Device change when dependent

My understanding

by Gemita - 2023-03-24 08:45:55

John, like you I haven't been through a device change so still got that to look forward to, but from what I have been told, the heart won’t stop even if you pace every beat.  Of course it depends on the underlying rate of a pacemaker dependent patient.  Usually a pacemaker dependent patient will have a high enough rate to manage without any back up temporary pacemaker which is why they check our intrinsic rate throughout our history to make sure that we have a back up support so that there are no nasty surprises.

Before they disconnect our old device at battery change, they will of course check to see what our heart is doing on its own.  My underlying rate for example is often around 30 bpm which should be enough to keep me going for the short time that the pacemaker is disconnected (takes seconds to minutes I believe) for a straight forward device change only. It seems that they have an external pacemaker handy in case our rate is too low, or connecting the new device takes longer than usual.  However, the actual amount of time a pacemaker is not connected is very minimal, since they get the new device programmed and placed beside the old one and all ready to be connected.

Sometimes, rarely, patients are put on a temporary pacemaker for the surgery, the kind that go through the femoral artery, but most surgeons use an external pacemaker but only if they need to

Dependency

by piglet22 - 2023-03-24 08:46:20

Hello John

I was 98% dependent when I had mine replaceed in 2016.

They got me ready for external pacing via lead in groin region.

In the end they decided to do it without, but boy, did I suffer.

One lab assistant had a tight grip on my wrist feeling for a pulse- I was fully covered by a shroud head to toe - and all I remember was an amazing light show like hallucinations, flashing patterns in my closed eyes.

I'm fully expecting to have external pacing the next time round as my condition has deteriorated recently after 18 years and the present pacemaker is struggling.

In my opinion, replacement was worse than the initial implantation.

Replacement

by piglet22 - 2023-03-24 09:45:13

There are practical considerations during replacement.

Firstly you have to get the old one out which might be adhered after 10 or so years.

Then there are the connectors which are designed to be ultra reliable, mechanically and moisture proof. The very nature of the signals being detected mean that a lot of care has to be taken in fixing and positioning leads.

It might be interesting to watch the procedure, but on the other hand, maybe not.

very quick swap

by Tracey_E - 2023-03-24 09:52:00

I'm on #5 and pace every beat so been through this a few times now. They will check before to see what my underlying rate is. Just because we pace every beat doesn't mean we don't have an underlying rate that will be ok for the changeout. Mine has been as low as 20, as high as 60. The amount of time between when they disconnect the old and connect the new is very minimal. They will have the new one all ready to go before they disconnect the old one. 

They can do a temporary pacer through the groin or external pacer which is huge pads for a back up. I've only had the pads, even when they relocated the pacer this last time and the time before when I got a new lead. 

I found replacements to be much much easier than the initial placement. They go in through scar tissue, and we don't have the restrictions after of new leads. The incision needs to heal, that's it. 

Device replacement

by Julros - 2023-03-24 12:06:22

Each case is approached differently. My underlying heart rate is about 30. For myself, they removed my RV lead, which my vein had scarred around. In an abundance of caution, they did thread temporary pacing wires through my groin, to my heart, while they were cutting out the scarred lead. 

As a nurse, I have seen people externally paced. Their body twitches with each pace, so I don't think that would be ideal for cutting and stitching. Plus, if you are conscious, you feel every shock. 

I'd be very unhappy with any EP-doc who put in a temporary pacing wire *just* to replace the box itself

by crustyg - 2023-03-24 13:48:41

Pardon me for disagreeing, but where a simple box change is required, it's easy enough to disconnect a pacing wire from the old PM and connect it via a sterile croc-clip pair to the sterile leads coming from a temporary pacer.  One beat - atrial lead driven by old PM, next beat driven by big box on the table near surgeon.  Ditto for the vent lead.  Every hospital that can do temporary pacing will have such a box.  And if you drop one beat and you're lying flat then your BP will stay up.  And if things get really desperate, infuse IV isoprenaline to drive the heart a bit while you fumble with the leads.  It's also what's done while a temp pacing lead is placed after an anterior infarct has caused CHB (as below).

Different if you're facing a PM box swap *and* a lead replacement, in which case I'd be delighted to have a temp pacing wire.  The ones that I've done (for patients with large anterior infarcts - tends to kill the AV-node) go in through the right arm, that nice big vein on the inside of the elbow.  Keeps the temp lead away from everything else while the EP-doc digs out the old PM and leaves the groin for the ring-laser cutter that will remove the old lead embedded in the heart muscle.

There's at least one contributor here who told the tale of their EP-doc being unable to remove an old lead from the PM (for each lead there's a primary connector *and* a locking grub-screw, and it's easy to overtighten the grub screw if you don't use the provided tool/read the instructions). Over time the plastic cold-welds itself and the main connector can't be undone.  Solution: place a new lead, cut and cap the old lead and carry on.  Not ideal but it gets the job done.

Pacemaker swap

by AgentX86 - 2023-03-24 17:23:49

My cardiologist talked about this when I brought up the subject of my recalled PM.  He said that, since I had no escape rhythm at all, they'd use external pacing of some sort.  He didn't get into it very far.  He made it sound like anoter pacer would be connected (to the leads but that may have been my assumption) while the switch was made.  I should have pushed it but I was interested in other things at the time.  That's a couple of years off (I hope) so didn't seem critical at the time.