Device clinic and follow-up

This chapter describes the device clinic. Requirements for a suitable facility, including maintaining patient dignity, are covered, and the development of remote follow-up is defined, including advantages and disadvantages. The follow-up schedule is covered, and history taking and examination are covered. Pacemaker testing and interrogation are shown, to aid the physician in management, diagnosis, and optimization of programming. Implantable cardioverter defibrillator (ICD) follow-up is also described, with all additional information required for follow-up described. Finally, cardiac resynchronization therapy (CRT) follow-up differences from standard pacemaker checks are covered.

System and lead extractions

This chapter covers system and lead extractions, including the principles and indications for decisions to explant or extract leads, methods of patient preparation, and techniques. The specific tools for lead extraction, such as a locking stylet, needle’s eye snare, and extraction sheaths are explained. The EDS and laser systems for described. The superior venous approach and femoral venous extraction are explained in a step-by-step method, including practical tips. Factors that increase the risk of complications are defined, along with the major and minor problems that can occur in a lead extraction.

Troubleshooting ICDs

This chapter covers the causes of inappropriate implantable cardioverter defibrillators (ICD) therapies, and then covers each response in detail. Breaking down the response by key information required, and the most common presentation of each problem, diagnosis and treatment are discussed in turn. The chapter covers tachycardias (atrial, supraventricular, ventricular, etc.), atrial fibrillation or flutter, committed shocks, undersensing, and oversensing. Mechanical issues that may occur at follow up, such as lead damage or battery life problems, are covered. Finally, problems to date and management issues are described.

Lifestyle issues, patient concerns, and devices

This chapter covers patient education about implants, including management of wound care, indications for seeking medical attention, and what to do in the event of shocks. Fitness to drive regulations in the UK are described, including for group 1 and group 2 licences. Questions that will commonly be asked by patients with a newly implanted device are answered to aid patient understanding, and finally the procedure in the case of an inappropriate shock are discussed.

Cardiac resynchronization therapy

This chapter examines some of the challenges of cardiac resynchronization therapy (CRT). The procedure continues to be technically difficult and in recent years there have been advances in technology that have helped successful implantation and response to the therapy. A methodical approach to left ventricular lead placement is described in the chapter, along with troubleshooting guidance for the difficult case. Technological developments such as quadripolar leads have changed practice and so this is described in detail. New concepts of CRT are emerging such as left ventricular endocardial pacing and left ventricular only pacing. Appropriate follow-up of patients following implantation is important. All of these clinical issues are described in this chapter, ensuring a comprehensive practical guide to all aspects of CRT.

Troubleshooting

This chapter covers the common reasons why a pacemaker can fail to work, then provides methods for fixing each problem. Complications with high threshold have the diagnosis, cause, and treatment for lead displacement, lead fracture, lead insulation break, and exit block. Complications with oversensing have the diagnosis, cause, and treatment for T-wave oversensing, far-field sensing, myopotential inhibition, lead fracture, and pacing lead interaction with old leads. Undersensing covers generator failure, the end of life battery failure, and problems with a runaway pacemaker. Finally, other, yet rare, problems are described.

Pacemaker programming and device interrogation

This chapter covers all areas of pacemaker programming and choices related to pacing. Methods of choosing rate limits, and related programming features are described for the lower rate interval, the upper rate interval, the atrioventricular interval, and refractory and blanking periods are described in detail. The anatomical and signal changes for each period are defined, and all descriptions are illustrated with example ECGs to show different programme outcomes. Rate response, programming rate response, and mode switching are covered. Automated functions and stored information are described, and algorithms to prevent atrial arrhythmias are explained. Finally, pacemaker-mediated tachycardia is outlined, including detection and methods of terminating the pacemaker-mediated tachycardia (PMT).

Pulse generator replacement

This chapter covers pulse generator replacement, from general principles to pocket revision. Indications for pulse generator replacement are briefly covered, including pre-operative checks such as lead configuration and underlying rhythms being confirmed prior to the operation. Patient preparation is described, and the operative technique for removing the old pulse generator and new implantation are described, including common pitfalls. Different techniques, including moving from dual to single chamber or the addition of new leads are outlined, rationales are provided, and methods for carrying out each technique are discussed. The opportunity for pocket revision is described.

Implantable cardioverter defibrillator principles

This chapter covers the principles of implantable cardioverter defibrillators (ICDs). Indications and potential problems for insertion of an ICD are described, including the evidence base for insertion based on randomized trials. International clinical guidelines are summarized. The mechanism and components of an ICD are defined, including diagrams to show the pulse generator, electrodes, and a section on which lead to choose. Arrhythmia detection, sensitivity, oversensing, and rate determination are all discussed. Supraventricular tachycardia (SVT) discriminators, pacing for anti-tachycardia and bradycardia, anti-tachycardia pacing (ATP) delivery, defibrillation, and configuration of shock vector are covered. The importance of avoiding inappropriate shocks is briefly outlined, and strategies for home monitoring are featured.

Implantable loop recorder

This chapter covers the use of insertable loop recorders (ILR) to provide extended rhythm monitoring for patients with syncope or presyncope but without arrhythmia. The cost effectiveness is noted. Indications and contraindications for ILR implantation are described, and positioning technique is illustrated. Implantation, from patient preparation to post-operative care is described. Programming and complications are briefly summarized, along with common pitfalls with ILRs. Finally, the interpretation and explanation of the output is discussed.