PERMANENT PACEMAKER  -implantable cardiac device for patients with rhythm disorders like bradycardia, brady/tachy syndrome and tachycardia. It is also indicated for conduction defects like complete AV block, second degree AV block and Intraventricular conduction defects.  Some neurocardiogenic syndromes may also benefit from the device.

     SINGLE CHAMBER PACEMAKER-  a pacemaker generator is connected to one  lead in either right atrium or right ventricle.  Atrial pacing is designed to correct the heart abnormalities in SA Node or condition called Sick Sinus Syndrome.

      DUAL CHAMBER PACEMAKER- this has an Atrial lead and Ventricular lead and  is indicated for the treatment of  conduction disorders and require AV synchrony like the different degrees of AV Blocks.  It monitors and senses both atrial and ventricular activity to determine when pacing is needed.

      CRT-P (Cardiac Resynchronization Therapy-Pacemaker) is a type of pacemaker that has three leads, a right atrial lead, a right ventricular lead  and a left ventricular lead.  It is a treatment option for heart failure. CRT-P monitors the heart beats and deliver electrical impulses to the heart and coordinate contractions, thus improving the pumping action of the heart and cardiac output.

DEFIBRILLATORS  are implantable cardiac devices indicated for patients  at risk for sudden cardiac death usually due to VF or VT. The first ICD human implant was in 1980.
   
ICD (IMPLANTABLE CARDIOVERTER DEFIBRILLATOR) is a device that continuously monitors the heart's  electrical activity.  It is a treatment option for patients with atrial fibrillation with risk of ventricular arrhythmias because of its capability to detect episode and provide treatment. It can be either  a single chamber or a dual chamber. The device has programmable outputs and allows therapies  like  cardioversion, defibrillation, managed ventricular pacing in the presence of conduction loss, and anti-tachycardia pacing.
      CRT-D (CARDIAC RESYNCHRONIZATION THERAPY DEVICE CARDIOVERTER DEFIBRILLATOR):  This device  came out in the year 2001. It is a treatment option  for patients who continue to have signs and symptoms of heart failure not responsive to drug therapy.  During heart failure, the heart has uncoordinated contractions called dyssynchrony.  CRT device restores proper timing of contractions by delivering electrical impulses to the right and left ventricles reducing  symptoms of heart failure, reduce need for hospitalizations, prevents the progression of the disease and reduce the risk of death. Like the CRT-P, it has three leads; atrial, left ventricular, and the right ventricular lead as the defibrillator lead. The functions are similar, but CRT-D is capable of treating deadly arrhythmias.

     ICD's and CRT-D's uses one or more type of energy for treatment.  ATP or anti-tachycardia pacing  interrupts the arrhythmia by delivering a series of small rapid electrical pacing pulses. In cardioversion, low energy shocks are delivered to stop arrhythmia that are regular but rapid. With defibrillation, high energy shocks are delivered to abort deadly arrhythmias.

      LOOP RECORDER - This device is smaller than a pack of chewing gum and is implanted in the upper chest area beneath the skin  on patients  with recurrent fainting spells  possibly due to heart rhythm   problems.  It is a diagnostic tool that can provide answers  and lead to treatment. Like a block box in an airplane  it can continuously record  hear rate and rhythm  for  up to 14 months The device is removed when the physician is satisfied with heart rhythm-related causes can be determined.

          IMPLANT PROCEDURE AND TESTING

       All these devices are  implanted at the Electrophysiology Lab surgical suite  under sterile technique..  Fluoroscopic imaging is used , hemodynamic monitoring, moderate sedation by an RN and monitored anesthesia care as needed.  Patient is attached to an external defibrillator and external pacemaker with the use of booker pads or defibrillator pads. The incision is about 2 inches on the left or right subclavian area and a pocket is created to hold the device and leads.  After the procedure it will be tested  with a pacing system analyzer to verify good position and threshold and then attached to the  device generator.

     The ICD implant is just like a pacemaker procedure except for the implant of the ICD shocking lead. DFT's or  testing of the device includes inducing arrhythmia and have the device shock the patient.  The device is usually tested twice at an output determined by the physician at 5 minutes interval.   The  RN's has to be ready to provide rescue shocks in the event that the device fails to provide the shock.  After the procedure, an evaluation of the device using a programmer is established as a baseline.

POST PROCEDURE NURSING RESPONSIBILITIES/
                              TEACHINGS

1. Activity restriction includes placing an arm sling on the side of implant for 24 hours.  Patient is instructed  not to move the arm  or raise  elbow  above the shoulder for 4 weeks to prevent dislodgement of leads.
   
2. Telemetry monitoring for 24 hours, then patient is sent home the next day.  Watch for signs of loss of capture and high impedance..  EKG , Chest X-ray  and device evaluation  are done the next day prior to discharge.
   
3. Watch for other signs of dislodged leads like hiccups - a sign of diaphragmatic stimulation where the LV lead fell into the diaphragm.
   
4. Watch for signs of bleeding, hematoma, oozing at site.