Different pathologies such as an infarct, valve disease and some viral infections can weaken the heart muscle, which can eventually lead to rhythm problems. One of these problems is a fast heart rate that is potentially life-threatening. In this case, an implantable cardioverter defibrillator (ICD) is implanted as a primary prevention measure in people who are at risk of developing ventricular tachycardia. If the fast heart rate continues for a prolonged period, it can cause ventricular tachycardia and discomfort.
The signs and symptoms most often described are:
- The sensation of having a weak heartbeat
- Dizziness
- Shortness of breath
- Fatigue
- Palpitations, i.e., a racing heart or tachycardia
- An irregular heart beat
Some of these symptoms can cause syncope (fainting) and can even result in cardiac arrest. In this case, a doctor will implant an ICD as a secondary prevention measure when ventricular tachycardia has already been diagnosed.
The risk of developing ventricular tachycardia is very real and unpredictable. This is why an ICD implantation is indicated so as to treat the arrhythmia right away. This device acts as a safety net, as it monitors the heart rate 24 hours a day.
The main functions of the ICD are to detect fast arrhythmias and then deliver electrical energy in the form of a shock or pulse to restore the rhythm to a normal speed.
Similar to a smoke detector, the ICD also plays the role of sentry, as it permanently monitors the heart. It also stores data about each arrhythmia episode that it detects. This data is checked with the help of a programmer.
The lifespan of an ICD is approximately 5 to 7 years depending on how often the device is used. The battery does not run out suddenly but rather loses its charge slowly, which leaves enough time to replace it.
The total procedure time is approximately 1 to 1.5 hours. The total hospital stay is approximately 24 to 48 hours.
(some tests may be done during pre-admission):
- ECG
- Blood tests
- Urinalysis
- Chest X-ray
- Pregnancy tests in fertile women
- Follow-up by a nurse
- Follow-up by a doctor (explanations, risks and benefits and signature of consent form)
- Take your usual medication according to your prescription
- Be fasting from midnight the night before the exam, but note that this does not apply to medication (follow your doctor's instructions)
- Shaving of the chest and groin area (to create a sterile area and better adherence for electrodes and dressings)
- Shower with an antiseptic soap
Recommendations to prepare for the procedure:
Bring your:
- Health insurance card.
- Montreal Heart Institute (MHI) card.
- An updated list of medications provided by your pharmacy.
- Your medication (not all medications are available at the MHI).
- Comfortable clothing: dressing gown, slippers, tissues, books, etc. However, do not bring jewellery, extra cash, credit cards or valuable objects.
- If you have sleep apnea, bring a continuous positive airway pressure (CPAP) machine.
On the day of the procedure:
- Remain fasting; however, this does not apply to certain medications.
- An IV line is inserted into the arm.
- Take the time to go to the bathroom and put on a hospital gown. Remove your underwear.
- You will be taken to the EPS room on a stretcher or in a wheelchair.
ICD implantation procedure
The procedure is conducted in the EPS room in an aseptic environment:
- Patients lie down on their backs on the exam table.
- The skin is disinfected with a liquid antiseptic and then covered with a large sterile field.
- The doctor starts by applying a local anesthetic to the region below the clavicle of the left or right shoulder. The doctor then makes an incision of approximately 5 cm or 2 inches. A small pocket or space is created between the skin and the muscle to make room for the ICD.
- Each lead is then inserted through a puncture in a nearby vein (generally the subclavian vein).
- In some cases, the doctor will conduct a defibrillation test, which is done under general anesthesia and lasts approximately 5 minutes. The doctor will trigger ventricular arrhythmia to check that the defibrillator is working properly.
- Once the device has been verified, the electrode is attached to the muscle with a suture and then connected to the ICD. The connected components are then placed in a small pocket under the skin. The pocket is closed with absorbable sutures. Staples are then used to close the incision and a protective dressing is applied over the area. The entire area is covered by a compression dressing to prevent the risk of bleeding or hematoma.
When you go back to your room:
- Stay in your bed until the next morning and keep your arm still so that the compress over the incision stays in place.
- Setup of a heart monitor.
- Vital signs are checked regularly (blood pressure, heart rate, temperature, breathing).
- The dressing is checked to see if there is any bleeding or a hematoma.
- If the patient is in pain, an analgesic is administered.
- A light meal is served one hour after the procedure.
- Medication is taken as per usual.
- Anticoagulants can be taken in the evening or according to doctor's orders.
The next day:
- A nurse helps the patient get up for the first time.
- The IV line is removed.
- The compression dressing is removed.
- A cardiologist comes to examine the wound, prescribe medication, assess the recovery time and sign the discharge.
- Since patients cannot drive, they must ensure that someone can take them home before leaving the hospital.
Documents given to patients before discharge:
- Temporary ICD identification card (a permanent card will be sent by mail).
- Information booklet about your ICD.
- Written recommendations for the week following the implantation.
Confirming an appointment at the Pacemaker and ICD Clinic
- Your appointment will be sent to you by mail.
- It is important that you keep the appointment at the clinic to ensure your ICD is working properly and to determine the date that it will be replaced.
Recommendations for the week following the implantation of an ICD:
- If you have PAIN: Take 1 to 2 tablets of Tylenol® (acetaminophen) every 4 hours (do not take aspirin UNLESS a doctor has already prescribed that you take it once a day).
- If you feel a shock:
- Stay calm.
- Sit or lie down.
- If you do not feel well or if you feel a number of shocks, call an ambulance or go to the nearest emergency room.
- If the ICD vibrates or emits an alarm, go the MHI emergency room to have it checked.
- DRESSING: Remove the transparent oval bandage and the small butterfly closures after 5 days. Even if there is blood under the dressing, leave the dressing in place for 5 days unless it becomes soaked with blood.
- Removing the dressing: Carefully remove the adhesive tape. If it is difficult to remove, press a piece of tape onto the side of the dressing to start an edge. Continue to remove the tape until all sides detach from the skin. Slowly remove the dressing. The small butterfly closures will come off at the same time. Clean the wound by dabbing it with a mild soap. Do not cover with another dressing unless the wound is seeping.
- Take a shower instead of a bath during the first week and avoid getting water directly on the wound.
- Avoid raising your arm closest to the pacemaker site above the level of your heart.
- PREVENTING INFECTIONS: Practise good hand hygiene; do not scratch the wound; clean the wound every day with water and mild soap; avoid wearing a chain or necklace; to look at the wound, use a mirror instead of looking down towards the wound (since the nose and mouth contain germs).
- SIGNS OF INFECTION: Redness, swelling, pain, heat, occasional weeping from the wound and fever.
- SIGNS OF HEMATOMA: Swelling of the wound and sometimes bleeding.
- If one or more of these signs appear, apply a dressing or towel over the wound and go to the nearest emergency room. Also advise the nurse in Routine Follow-Up for electrophysiology by calling:
514-376-3330, extension 2244 (Monday to Friday from 7:30 a.m. to 3:30 p.m.)
Or the Emergency Department at 514-376-3330, extension 3000
- Driving a car: Permitted 2 weeks after the implantation of the ICD or according to your doctor's orders.
- Physical activity: Do not perform any intense physical activity with the arm on the side of the ICD for 1.5 months. Note that the heart rate increases gradually during an activity, contrary to tachycardia, which starts suddenly.
- Sex: The same recommendations as for physical activity.
- Professional activities: Patients can return to work after recovering or according to the doctor's recommendations.
- Travel: When travelling abroad, show your pacemaker identification card to airport security.
- Daily activities: Avoid magnetic fields and industrial motors. If necessary, discuss this with your doctor.
- Use a cell phone on the opposite side of your ICD; do not put it in a pocket close to the ICD.
- Advise medical staff that you have an ICD during the following procedures: procedures using a radio knife, radiotherapy, magnetic resonance imaging, external electric cardioversion, and radiofrequency ablation.