Treatments

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	Cardioversion Cardioversion is a treatment that involves the use of electricity to shock the heart back to a normal rhythm. Electricity is applied to the chest through paddles or adhesive pads.



	Cardioversion can be done in both emergency situations and can also be planned as an outpatient procedure. Virtually all of the fast rhythm disorders are amenable to treatment with cardioversion, although this is most commonly used for atrial fibrillation. Preparation for the Procedure Nothing to eat or drink overnight or at least 6 hours before the procedure. Remember to ask your physician for instructions about taking your scheduled medications especially if you are diabetic (on insulin or pills). If you have been placed on Coumadin (warfarin) for atrial fibrillation, this is usually continued at your usual dose. An electrocardiogram (ECG) and blood work may be obtained. An intravenous (IV) line will be inserted through which fluids and medicines can be given. Procedure. The procedure is usually performed on an outpatient basis in a monitored room or in the catheterization laboratory. You will be instructed to lie flat or with your head slightly elevated on a hospital bed or stretcher. Some chest hair may have to be shaved to ensure good contact. Electrodes and a blood pressure cuff will be attached to constantly monitor your vital signs. Prior to cardioversion, you will be heavily sedated. After adequate sedation is achieved, the shock/s will be delivered either through paddles or adhesive pads. Sometimes more than 1 shock is needed. An oxygen mask or cannula may be placed while you are sedated, so do not be alarmed if you awake and this is in place. If the cardioversion is unsuccessful, another drug may be given intravenously followed by an additional shock. After the Procedure You will be monitored for another hour or so. You will usually be discharged on the same day. Medication changes, if any, will be discussed with you by your physician. Be sure to ask him/her. Make arrangements to be driven home. You may experience some muscle soreness as well as skin irritation over the sites where electricity was applied. This is temporary and should go away within 1-2 days. If it is very painful and bothersome, let your physician know so that short-term medications can be prescribed.

Radiofrequency Ablation

Radiofrequency (RF) ablation is an invasive treatment option that is almost always performed in conjunction with an EP study. What it involves is the use of special catheters through which electromagnetic waves (much like radio waves) are used to heat the tissue beneath the tip of the catheter. By this application of heat, there is selective and controlled destruction of small amounts (1-2 mm X 1-2 mm) tissue.


	Example of an RF ablation system

With the EP study your physician can precisely locate down to the millimeter the heart tissue that your arrhythmia comes from or that your arrhythmia needs to keep on going. Application of RF energy (heat) to this specific area can cure you of your arrhythmia permanently; this is what we call "ablation" of the arrhythmia. RF ablation is the only procedure in cardiovascular medicine that can cure someone of a disease permanently.

Many arrhythmias are amenable to treatment with RF ablation. The following is a short list of arrhythmias with their respective long-term success rates:

AV nodal reentrant tachycardia 95 to 98%

Wolff-Parkinson-White Syndrome 93 to 95%

Atrial flutter 90 to 93%

Ventricular Tachycardia (normal heart) 80 to 90%

Ventricular Tachycardia (sick heart) 50 to 60%

Recently, it has been discovered that certain patients with atrial fibrillation can be treated successfully with RF ablation. For more information on RF ablation of atrial fibrillation, please proceed to the New Developments Section below.

Preparation for the Procedure

Essentially the same as with an EP study
Nothing to eat or drink overnight or at least 6 hours before the procedure.
Remember to ask your physician for instructions about taking your scheduled medications especially if you are diabetic (on insulin or pills) and/or are taking pills that can make you prone to bleeding (i.e. Coumadin or warfarin, Plavix or clopidogrel).
Your doctor may advise you to stop taking certain medications before your EP study to ensure more accurate results.
A chest x-ray, electrocardiogram (ECG) and blood work may be obtained.
An intravenous (IV) line will be inserted through which fluids and medicines can be given.
Your consent for the EP study will usually include a consent for RF ablation as well.

Procedure. If during the performance of the EP study, your physician was able to induce your arrhythmia or found evidence for a particular type of arrhythmia, he may proceed in the sitting to perform RF ablation. Alternatively, if your physician already knows the type of arrhythmia you have, he may proceed directly with RF ablation. As part of the EP study, your physician would have made a "map" of your arrhythmia. This electrical map indicates where the arrhythmia is coming from, what areas of the heart are necessary to keep the arrhythmia going and most importantly where to apply radiofrequency current to get rid of your arrhythmia!


	Example of a tachycardia (to the left of the image) terminating (middle of image) with RF ablation.

	Example of an electroanatomical map aiding in RF ablation. The red area shows where the arrhythmia originates. The brown dots show a single point of RF application that terminated the arrhythmia.

Application of RF energy (or ablation) requires the use of another catheter, so your physician may opt to insert another sheath in your leg. More commonly, however, they just remove a catheter that they no longer need and use an existing sheath placed at the beginning of the procedure. While RF current is on (while ablating), it is very important to hold still and be as quiet as possible. You may feel some pressure or burning in your chest, but this is temporary and should last only as long the ablation is ongoing. If the sensation very painful or uncomfortable, let your physician know. Normally, you will be very relaxed and heavily sedated during the ablation process. EP studies with RF ablation usually last from two to four hours.

After the Procedure

You will be brought to a holding area and then back to your room.

After the catheters are removed, pressure will be applied to the puncture site just long enough to stop the bleeding. No stitches are required but a sterile dressing will be applied and can be removed the next day.

Remain in bed with your leg straight for anywhere between 3-6 hours. Nurses will assist you when it is OK to get up.

Keep your head on the pillow.

Inform the nurse if you have any warmth, pain or swelling where the catheters were removed.

If you need to cough, sneeze or strain, hold the dressing down firmly before doing so.

You will be permitted to eat and drink.

Your vital signs and catheter insertion site will be checked frequently.

Your diagnosis and the level of complexity involved in the EP study and ablation procedure determine the exact length of your hospital stay. With a regular, uncomplicated EP study and ablation procedure, you can usually go home later the same day. If the procedure was long and complicated, your physician may opt to observe you overnight as a precautionary measure.

When the bandages are removed from the catheter insertion site, you may notice a small bruise no larger than a quarter. You may also feel a small lump there. The bruise may become slightly larger and/or darker after you return home. Both of these are part of the body's natural healing process and should disappear completely within two weeks. If you notice a discharge, or feel feverish or become very uncomfortable, please call our office immediately.

Some patients may require no further treatment and all medicines discontinued. Others may require additional EP study/RF ablation procedures (done in stages) and/or modification of their medications. Your physician will explain his/her findings and recommendations following your study. Don't be afraid to ask questions at any time before, during or after the procedure!

Implantable Cardioverter-Defibrillator (ICD)

An implantable cardioverter-defibrillator also known as an ICD is a device about the size of a deck of cards that is placed under the skin for the main purpose of delivering a life-saving electric shock directly to the heart in the event that it goes into a life-threatening arrhythmia such as ventricular tachycardia or ventricular fibrillation (most individuals who suffer from cardiac arrest have this arrhythmia). The delivery of an electric shock will correct the heart's rhythm by resetting and normalizing it. This is much like what is seen on television in the series 'ER' and in similar shows but this device is permanently a part of the body and gives the shock automatically. Embedded in the ICD is also a fully functional pacemaker. So the ICD is a 'pacer' and a 'shocker' rolled into one


	Like a pacemaker, the ICD system has 2 components: 1) the pulse generator, which is the brains of the system and includes a small computer chip, the battery and the capacitors needed to generate large amounts of electricity; and 2) the wires (or leads) which carry electrical signals to and from the heart. The pulse generator is what you feel under the skin. It determines how much electrical signal to send to the heart. The leads, which usually number 1 or 2, are inserted through an arm vein and attached to the heart's upper chamber (atrium), lower chamber (ventricle) or both. The lead which is placed in the ventricle has a shocking coil near its tip. When a shock is delivered, electricity courses between the device through heart muscle towards the coil.

ICDs are recommended for individuals who have suffered a cardiac arrest and have somehow survived it, for individuals with a documented fast arrhythmia originating from the lower heart chambers (ventricular tachycardia) and for those found to be prone to developing these arrhythmias (i.e. those with prior heart attacks, enlarged and poorly functioning hearts, lots of skip beats and those found to need an ICD during an EP study).

Recently, a new type of ICD called a biventricular ICD has been developed and approved for certain patients with heart failure. For more information on biventricular ICDs, please click on the highlighted tab: biventricular ICD. Another recent development has been the finding that patients with a prior heart attack and poor heart pump function are at high risk of life-threatening arrhythmias and may benefit from an ICD. For more information on this new indication for ICDs, please see the New Developments Section below.

Preparation for the Procedure

Nothing to eat or drink overnight or at least 6 hours before the procedure.

Remember to ask your physician for instructions about taking your scheduled medications especially if you are diabetic (on insulin or pills) and/or are taking pills that can make you prone to bleeding (i.e. Coumadin or warfarin, Plavix or clopidogrel).

A chest x-ray, electrocardiogram (ECG) and blood work may be obtained.

An intravenous (IV) line will be inserted through which fluids and medicines can be given.

An antibiotic will be given through your IV to reduce the possibility of infection.

Please make sure to inform someone if you are allergic to penicillin or have reacted to other drugs or IV contrast material in the past.

There is a video available on ICDs that you may want to view.

Procedure. The procedure is a same day admission following an EP study or can be done the next day. It is performed under sterile conditions in the catheterization laboratory or operating suite. You will be asked to lie flat on a cushioned table under a large, C-shaped x-ray machine. You will attached to a blood pressure cuff and heart monitor. The ICD is usually placed on the left upper chest. This area is shaved (if applicable), cleaned with antiseptic and covered with a sterile drape. It is then numbed with local anesthesia after which a small approximately 2 inch incision is made. Your arm vein is then carefully entered using a needle so that the leads (wires) can be threaded down to the desired location in your heart (atrium or ventricle or both). The pulse generator is then attached. Your physician will then deliberately put your heart into an abnormal rhythm to test the device. If this test is satisfactory, the incision is closed with stitches or staples. You will be exposed to intermittent low doses of x-rays during the procedure. X-rays are necessary to ensure the best placement of leads. An uncomplicated ICD procedure usually takes about 1 to 1 ½ hours. You will be kept relaxed and sedated throughout the entire procedure. During device testing, you will be completely 'knocked out," and will recall nothing of the incident.

After the Procedure

You will be admitted to the hospital and kept overnight.

The arm on the same side as the ICD will be placed in a sling overnight.

The same afternoon or evening after your procedure and the morning after, a chest x-ray will be taken to check on the leads (wires) and make sure they haven't moved or fallen out of place.

The following morning, you will be visited by the pacemaker clinic so that you ICD can be checked again (it was checked immediately after the procedure while you were still in the catheterization lab) prior to discharge. Additional ICD teaching will also be done here.

You will receive another 2 doses of antibiotics through your IV; you may be sent home on a short course of antibiotics by mouth.

You will be instructed not to raise your arm above the level of your shoulder for 2 weeks so as not to put undue strain on the wound and accidentally pull the wires out of the heart. If you play golf, this may be resumed in about 2 months time.

Specific guidelines exist for the resumption of driving after an ICD is placed. Ask you physician about this.

If you experience a shock, call your physician immediately. If you experience multiple shocks, proceed to your nearest emergency room.

You will be instructed on wound care. You may get the wound wet only after 5 days. Do not pick, scratch or attempt to manipulate the wound in any way lest this get infected. If you detect redness, swelling, warmth or drainage over the site, call your physician immediately.

After 10-14 days, an office visit will be scheduled to check the wound and remove stitches or staples.

Your ICD's battery should last approximately 5 years.

Your ICD will need to be checked at 1 month then every 3 months. These checks cannot yet be performed over the telephone and require you to visit the clinic. Do not worry, as this will be set-up before you leave the hospital.

Some Basic Pacemaker and Defibrillator Information

Microwave ovens and household appliances are okay and do not significantly affect your pacemaker, so long as you are not in the microwave!

Cellphones are generally safe, but as a precaution do not place your activated phone in the pocket overlying your pacemaker/defibrillator site, and try to listen using the other ear.

You should not go near any generators of electricity or magnetic fields: do not go near large electric generators, be in the same room with someone using a Ham radio, be in the vicinity of someone arc welding or arc weld yourself, and you can not have an magnetic resonance imaging (MRI) study performed on you.

Airport walk-through security points are okay so long as you don't lean on them or linger under the passageway for prolonged periods of time. Do not let airport security use the metal detector wand over your device; just tell them that you have the device and show them the ID card that comes with your ICD.

For other specifics, please ask you physician.

Pacemaker Therapy

A pacemaker is small device about the size of two-stacked silver dollars that is placed under the skin as treatment for a heart that is beating too slowly. As a result of beating slowly, one can feel tired, easily fatigued, dizzy or even pass out.

There are 2 components to a pacemaker system: 1) the pulse generator, which is the brains of the system and includes a small computer chip and the battery; and 2) the wires (or leads) which carry electrical signals to and from the heart. The pulse generator is what you feel under the skin. It determines how much electrical signal to send to the heart. The leads, which usually number 1 or 2, are inserted through an arm vein and attached to the heart's upper chamber (atrium), lower chamber (ventricle) or both.

Recently, a new type of pacemaker called a biventricular pacemaker has been developed and approved for certain patients with heart failure. For more information on biventricular pacemakers, please click on the highlighted tab: biventricular pacemaker.

Preparation for the Procedure

Nothing to eat or drink overnight or at least 6 hours before the procedure.

A chest x-ray, electrocardiogram (ECG) and blood work may be obtained.

An intravenous (IV) line will be inserted through which fluids and medicines can be given.

An antibiotic will be given through your IV to reduce the possibility of infection.

Please make sure to inform someone if you are allergic to penicillin or have reacted other drugs or IV contrast material in the past.

There is a video available on pacemakers that you may want to view.

Procedure. The procedure is a same day admission. It is performed under sterile conditions in the catheterization laboratory or operating suite. You will be asked to lie flat on a cushioned table under a large, C-shaped x-ray machine. You will attached to a blood pressure cuff and heart monitor. The pacemaker is usually placed on the left or right upper chest (depending on whether you are left or right handed, so as not to interfere with activity). This area is shaved (if applicable), cleaned with antiseptic and covered with a sterile drape. It is then numbed with local anesthesia after which a small 1-1.5 inch incision is made. Your arm vein is then carefully entered using a needle so that the leads (wires) can be threaded down to the desired location in your heart (atrium or ventricle or both). The pulse generator is then attached and the incision is closed with stitches or staples. You will be exposed to intermittent low doses of x-rays during the procedure. X-rays are necessary to ensure the best placement of leads. An uncomplicated pacemaker procedure usually takes about 1 hour. You will be kept relaxed and sedated throughout the entire procedure.

After the Procedure

You will be admitted to the hospital and kept overnight.

The arm on the same side as the pacemaker will be placed in a sling overnight.

The same afternoon or evening after your procedure and the morning after, a chest x-ray will be taken to check on the leads (wires) and make sure they haven't moved or fallen out of place.

The following morning, you will be visited by the pacemaker clinic so that you pacemaker can be checked again (it was checked immediately after the procedure while you were still in the catheterization lab) prior to discharge. Additional pacemaker teaching will also be done here.

You will receive another 2 doses of antibiotics through your IV; you may be sent home on a short course of antibiotics by mouth.

After 10-14 days, an office visit will be scheduled to check the wound and remove stitches or staples.

Your pacemaker's battery should last 5-7 years.

Your pacemaker will need to be checked at 1 month then every 3-4 months. These checks can be performed over the telephone. Do not worry as this will be set-up before you leave the hospital.

Some Basic Pacemaker and Defibrillator Information

Microwave ovens and household appliances are okay and do not significantly affect your pacemaker, so long as you are not in the microwave!

Cellphones are generally safe, but as a precaution do not place your activated phone in the pocket overlying your pacemaker/defibrillator site, and try to listen using the other ear.

For other specifics, please ask you physician..

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Please contact our WebMaster with any questions or comments