Points of attention for patients with an implantable device (pacemakers, ICD, CRT)

Also read: Therapy with implantable devices ICD, CRT, LBBA Pacing

Considerations shortly after implantation of the device

The movements of the arm on the side of implant (usually the left) should be limited for 2 days. It is recommended not to carry heavy weights with this arm for the first 10 days. More extreme movements of this arm (above the shoulder level and backwards) should be avoided during the first month.
The bandage and wound should be kept dry, clean and sterile sealed for 10-14 days after implantation. If the bandage looks good, it should not be replaced. The wound must always be inspected by the GP, with the removal of stitches if necessary.
In case of unfavorable wound healing, the treating cardiologist should always be contacted to guide further management.
In case of bleeding/hematoma (pocket hematoma):
- It is best to consult with the treating cardiologist.
- Interrupt (D)OAC for a few days. Please note: if there is a risk of embolism, for example atrial fibrillation, it is best not to interrupt for more than 2 or 3 days.
- Apply local ice or a cold pack (twisted in a thin towel) to the skin.
- DO NOT puncture the swelling. This can introduce an infection.
- In case of severe pain and swelling, a revision with drainage of the hematoma can be done under sterile conditions in the hospital, if indicated by the cardiologist.
If infection is suspected (fever, local redness and pain around the battery):
- Always urgently check with the treating cardiologist (if necessary via the emergency department) for further management.
- Avoid blind initiation of empirical antibiotics. It is best to take hemocultures before starting antibiotics. Short-term use of antibiotics can also make hemocultures falsely negative and make correct diagnosis and treatment more difficult.
- Explantation of the device and the leads if they are infected. This has to be decided by the cardiologist.
The device must always be checked by the treating cardiologist 1 to 2 months after implantation, unless indicated earlier.

Considerations for a patient with an ICD

VVI-ICD

If the patient experiences a shock :
- 1 shock, without other complaints: wait and contact the treating cardiologist, the heart failure nurse or the rhythm clinic by telephone as soon as possible.
- 2 or more shocks in 24 hours or 1 shock with other complaints (angina, dyspnea, hypotension, etc.): urgent admission to hospital for monitoring and further examination.
- The patient cannot drive for 3 months after a proper shock for an arrhythmia.

The patient may sometimes experience a beeping or vibrating alarm signal from the ICD, usually at night or at the same time in the morning. This may indicate one of the following problems (according to the ICD settings):
- Low battery voltage: battery replacement required.
- Problems with the leads (fracture of a lead, poor functioning due to dyslocation of a lead, etc.).
- Exceeding the set limit for arrhythmias (atrial fibrillation, VT), anti-tachytherapy, congestion, etc.

It is best to have the ICD analyzed as quickly as possible during the consultation. In case of symptoms such as abrupt syncopes, > 1 shock, cardiac decompensation, etc., it is best to have an urgent check-up via the emergency department.

Considerations in a patient with a CRT

The goal of cardiac resynchronization therapy (CRT) is to achieve > 95% biventricular pacing. Biventricular pacing can drop below 95% due to many extrasystoles, an atrial arrhythmia with a too fast ventricular rhythm, suboptimal device settings, etc.
See figure. With biventricular pacing, the QRS complex normally becomes positive in V1 (right bundle branch block morphology), negative in lead I. The sudden change of the QRS complex back to a left bundle branch block pattern may indicate dysfunction of the CRT.

A. Before CRT implantation there is a left bundle branch block with negative QRS complex in V1-2.
B. After CRT implantation the QRS complex becomes narrower and positive in V1-2.

Possible complications / side effects after implantation:
- Dislocation of the LV lead with loss of biventricular pacing and recurrent symptoms of heart failure.
- Stimulation of the phrenic nerve with contractions of the left diaphragmatic dome ('hiccup', muscle contractions at the level of the left hypochondriac at 60-70 per minute (according to the set lower rate)). Sometimes this phenomenon is position-related, for example only when lying on the left side. This can often be remedied by adjusting the device settings.

Capability to drive a vehicle for patients with an implantable device (in Belgium)?

Pacemaker or CRT-P

Group 1 (= driving license A3, A, B, B+E) – max. driving capacity for 3 years : (KB 3/2011)
- New implant: 1 month unfit to drive.
- PM battery replacement: immediately ready to drive.
- PM lead replacement: 1 month unfit to drive.

Group 2 (driving license C, C+E, D, D+E) – max. driving license for 1 year : (KB 23 March 1998)
- New implant: unfit to drive for 3 months.
- PM battery replacement: 2 weeks unfit to drive.
- PM lead replacement: 3 months unfit to drive.

ICD or CRT-D

- Group 1 (= driving license A3, A, B, B+E) : (KB 3/2011)
  - Nieuwe implantatie: 1 maand rijongeschikt
  - Batterijvervanging: onmiddellijk rijgeschikt
  - Leadvervanging: 1 maand rijongeschikt
  - ICD-interventie (shock): 3 maanden rijongeschikt
- Group 2 (= driving license C, C+E, D, D+E) : permanently unfit to drive.

What is allowed and what is not allowed with a pacemaker / ICD?

Close contact with a strong magnetic source should be avoided.

The detection of a magnetic field will trigger a (temporary) reprogramming to VOO mode with a (resynchronization) pacemaker. This will cause the pacemaker to stimulate at a fixed, programmed magnetic frequency (for example at 80 or 90 per minute) without taking any notice of your own heart rhythm.
With a defibrillator, magnetic interference will (temporarily) disable the shock function, meaning that a patient will not receive intervention in the event of a rapid ventricular arrhythmia. When the magnetic field disappears, the ICD will work as before.
Examples of magnetic sources are:
- MRI examination
- Welding
- Magnetic strip of Ipad
- Induction stove (at a distance < 0.5 meters from the device)
- …

MRI examinations

MRI examinations used to be prohibited in patients with pacemakers or defibrillators. Current devices (implanted after 2010-2013) are normally MRI compatible. This should always be checked when planning an MRI examination. For devices that were implanted a long time ago, MRI incompatibility may remain despite a more recent battery replacement due to older, non-MRI compatible leads.

Despite the potential interference of the magnetic field of the MRI with the device, in many cases performing an MRI is still possible provided that precautions are taken.

Due to the scattering of the device itself, an MRI of structures in the chest will in any case provide less qualitative images.

The theoretical risk of an MRI examination in a patient with a device is:

Provoking a reprogramming of the device.
The induction of currents in the leads with heating and potential perforation of the lead tip or non-capture. The latter mainly occurs with old, no longer functional leads (that are no longer connected to the device).

The usefulness of the MRI must always be weighed against the potential risk.

Modern MRI compatible devices are programmed into an MRI compatible mode prior to the MRI and then programmed back to the original settings.

An MRI scan can also be performed on non-MRI compatible devices under strict conditions. Monitoring during the study is recommended. This must then be discussed with the treating radiologist and cardiologist/electrophysiologist.

Radiotherapy

Radiotherapy can potentially damage both the hardware and software of the pacemaker when the device is in the area to be irradiated. It is therefore recommended to shield the device with lead. If this is not possible, the device must be checked regularly during therapy. In rare cases, the battery can be moved to a place (just) outside the radiation field.

Perioperative management

The use of electrocautery can potentially interfere with the pacemaker function. The danger is that the pacemaker inhibits itself due to oversensing of the electrocautery. This can cause the pacemaker to stop pacing. This can be prevented by programming in VOO or DOO mode or by applying a magnet to the device.
In patients with an ICD, use of electrocautery can also cause false signals that can be interpreted by the ICD as ventricular tachycardia or fibrillation and can therefore provoke inappropriate ICD shocks. This can be prevented by applying a magnet to the device, which turns off anti-tachytherapy of the device while maintaining the pacemaker function. When you remove the magnet, the device will immediately be reprogrammed as before.

Air travel

Air travel is no problem. It is recommended not to go through the magnetic security check, but to be searched manually by showing a device identification card.

Sport

Sports are allowed for patients with a device.

It is best for the patient to wear a heart rate monitor. Peak efforts with a heart rate that is too high should be avoided. In patients with an ICD, the maximum heart rate must remain sufficiently below the set limit above which the ICD will deliver a shock. Otherwise the patient could wrongly receive an ICD shock.
It must always be determined whether there is a risk to the patient and his environment in the event of sudden presyncope or syncope during exercise.
However, contact sports such as rugby or martial arts should be avoided.
Rifle shooting where the butt of the rifle would be placed on the pacemaker battery is prohibited.

BWGHF

Points of attention for patients with an implantable device (pacemakers, ICD, CRT)

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Points of attention for patients with an implantable device (pacemakers, ICD, CRT)

Considerations shortly after implantation of the device

Considerations for a patient with an ICD

Considerations in a patient with a CRT

Capability to drive a vehicle for patients with an implantable device (in Belgium)?

Pacemaker or CRT-P

ICD or CRT-D

What is allowed and what is not allowed with a pacemaker / ICD?

Close contact with a strong magnetic source should be avoided.

MRI examinations

Radiotherapy

Perioperative management

Air travel

Sport