How do I prepare to have an ICD implanted?
Tell your healthcare provider all the medications you are currently taking. If you take a blood thinner, such as aspirin, warfarin (Coumadin), or clopidogrel (Plavix) you may be asked to stop taking it or to reduce your dosage before the procedure. You are not allowed to eat or drink after midnight the night before surgery.
What does the ICD procedure entail?
You will be awake during the procedure, but you will be given a sedative to help you relax and local anesthesia to numb the pain of the surgery. The sedative will be given through an intravenous (IV) line. You may feel the needle prick when the IV line is inserted into your arm. The surgical site near the left breast will be shaved if necessary and an antibacterial solution will be applied to the chest.
You will be hooked up to an electrocardiogram ( ECG) so that your heart rate and blood pressure can be monitored. For this, small sticky patches with wires attached will be taped to your body.
The surgeon will make a small incision into your skin. A tube called a catheter will be inserted into one of your veins, usually the large vein under your collarbone, the subclavian vein. Then the surgeon will insert the ICD wires into your heart through the vein. If the ICD will be placed in the abdomen, a different procedure is used. Once in place, the wires are tested to make sure they work and are in the correct spot. Through the same incision, the surgeon creates a small pocket that the ICD generator will be inserted into. Next, the ICD is attached to the lead wires and inserted into the pocket and the incision is closed. After implantation, the physician will test the ICD several times by causing the heart to fibrillate or “quiver” to make sure the ICD responds properly. Immediately after the procedure, an X-ray will be taken to confirm the proper placement of the device. The procedure takes about 1 to 2 hours.
What happens after the procedure?
You will rest in bed until the sedative has worn off completely. When you are fully awake, you will be allowed to eat and drink. The incision site may be sore and you can take pain medication if needed.
Depending on your age and overall health, a short hospital stay may be recommended. You will be given instructions regarding what level of activity is appropriate for you after the procedure. Your physician may also adjust the ICD by using a magnetic wand that is passed over the chest, a process that you should not feel. Your physician may also induce tachycardia or fibrillation (as they did during the implantation procedure) to program the ICD for maximum efficiency. This will also allow you to learn what an ICD shock feels like.
You may be instructed not to bathe or shower for at least 5 days. During this time, it will probably be all right for you to sponge bath, but you should not get the bandages wet. After 5 days or so, you can wash normally with soap and water, but be careful not to apply any unusual pressure to the site of catheter insertion.
Complete recovery from the procedure can take about 3 to 6 weeks. During that time, the wires will firmly take hold where they were placed. You should avoid contact sports, heavy lifting or pulling, or raising the arm on the side of the ICD above your head until your physician says it is all right for you to do so. You should be able to resume sexual activity once your incision has healed, unless your physician instructs you otherwise. Ask your physician when you can return to work, because the nature of your job, your health status, and your progress will determine how soon you can return.
You will probably also have a short restriction on driving. Episodes of ventricular tachycardia can cause you to temporarily lose consciousness because there may be a 5 to 15 second interval before the ICD delivers its shock.9 According to the National Highway Traffic Safety Administration, depending on the severity of your condition, you will need to be episode-free for 3 to 6 months before you can resume driving.15 This time may be shortened if you are also taking antiarrhythmic medication. When you do resume driving, you should not drive long distances or use your car's cruise-control setting.
Once healed, usually only a small bump is seen over the spot where the ICD was placed.
How often will the ICD need to be checked?
You will need to follow up with your cardiologist at regular intervals in order to monitor the device. This is done noninvasively, meaning it does not require surgery. If you have an ICD, your physician will see you every 1 to 3 months to see if any rhythm disturbances have been detected, what electrical treatments (such as any defibrillation shocks) have been delivered, and if these treatments need to be modified in some way.9 You may also have monthly monitoring over the telephone, known as transtelephonic monitoring. Signals from the ICD get converted into sound waves, which are sent over the phone, and received by a monitoring station at the other end of the phone, where they are reconverted back into the original signals so that your physician can interpret them. This cannot be done using cordless phones or cell phones, however, because of electronic interference.
The battery life will also be checked; ICD batteries can last from 3 to 6 years,9 depending on how many electrical shocks have been given. You do not need to worry about your ICD battery running out unexpectedly. When the battery is running low, the elective replacement indicator (ERI) is activated, and your physician can detect this activation during a routine office visit. Once the ERI is activated, your ICD will continue to function for 6 months, during which time you can schedule a replacement procedure.
Are there any special concerns for living with an ICD?
You will receive an identification card after your procedure that contains your name, emergency information, and the serial number and model of your ICD. You should keep this card with you at all times because you'll need this information if there are problems with the device, or if you are in an accident or need to avoid certain magnetic devices.
The following are some common concerns of people with ICDs:
- Airport security checks. You can pass through airport security metal detectors normally, but a handheld wand detector should not be held near the ICD9
- MRIs and X-rays. You should avoid MRIs, but X-rays are safe to have. In general, you should avoid strong electromagnetic fields (like those generated by an MRI)
- Magnets. You should avoid holding strong magnetic items (like stereo speakers) near your pacemaker. Small magnets, like refrigerator magnets, are safe because they produce very weak electromagnetic fields. As a general rule, if you are unsure about whether an item is safe to hold near your pacemaker, maintain a distance of 6 inches between yourself and the item
- Microwaves. All household appliances are safe to use with an ICD9
- Cell phones. You should hold cell phones at least 6 inches from the ICD, even when the phone is off. Don't keep your phone in clothing pockets near the ICD, and use the ear opposite the ICD when using your cell phone9
- Slot machines. You may be advised to avoid slot machines or to stay about 12 inches away from them
- Roller coasters. Some newer roller coasters are also controlled by large magnets; you should not ride these types or any roller coasters with shoulder harnesses
Talk to your healthcare provider about any other precautions that may be necessary.
What are the risks of ICD implantation?
Serious complications are rare, occurring in 1% to 2% of people undergoing ICD implantation. These complications include severe bruising or bleeding, formation of a blood clot, infection, or dying. Anxiety and depression are common in people who have an ICD implanted. Elevated levels of both conditions have been reported in about 20% to 60% of people after ICD implantation.16-19 Almost 40% of people with ICDs have the symptoms of an anxiety disorder.20 Because an ICD shock is painful, it's not uncommon to fear an ICD shock. If you have several shocks, you may experience increased anxiety and depression.21, 22 Cognitive behavior therapy, which is a form of therapy using imagery, self-instruction, and related techniques, has been shown help reduce depression and anxiety.23
References
1. Gregoratos G, Abrams J, Epstein AE, et al. ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee on Pacemaker Implantation). Available at: http://www.acc.org/clinical/guidelines/pacemaker/incorporated/Pacemakerclean.pdf.
2. Heart Disease and Stroke Statistics: 2005 Update. Dallas, Texas: American Heart Association; 2004.
3. Kannel WB, Wilson PW, D'Agostino RB, Cobb J. Sudden coronary death in women. Am Heart J. 1998;136:205-212.
4. Wood MA, Ellenbogen KA. Cardiology patient pages. Cardiac pacemakers from the patient's perspective. Circulation. 2002;105:2136-2138.
5. Brunner M, Olschewski M, Geibel A, Bode C, Zehender M. Long-term survival after pacemaker implantation. Prognostic importance of gender and baseline patient characteristics. Eur Heart J. 2004;25:88-95.
6. Schmidt B, Brunner M, Olschewski M, et al. Pacemaker therapy in very elderly patients: long-term survival and prognostic parameters. Am Heart J. 2003;146:908-913.
7. Trohman RG, Kim MH, Pinski SL. Cardiac pacing: the state of the art. Lancet. 2004;364:1701-1719.
8. Byrd CL, Wilkoff BL, Love CJ, Sellers TD, Reiser C. Clinical study of the laser sheath for lead extraction: the total experience in the United States. Pacing Clin Electrophysiol. 2002;25:804-808.
9. Reiffel JA, Dizon J. Cardiology patient page. The implantable cardioverter-defibrillator: patient perspective. Circulation. 2002;105:1022-1024.
10. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation. 2004;110:588-636.
11. Peters RW, Zhang X, Gold MR. Clinical predictors and efficacy of antitachycardia pacing in patients with implantable cardioverter defibrillators: the importance of the patient's sex. Pacing Clin Electrophysiol. 2001;24:70-74.
12. Greenberg H, Case RB, Moss AJ, Brown MW, Carroll ER, Andrews ML. Analysis of mortality events in the Multicenter Automatic Defibrillator Implantation Trial (MADIT-II). J Am Coll Cardiol. 2004;43:1459-1465.
13. A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators. N Engl J Med. 1997;337:1576-1583.
14. Shawl FA, Domanski MJ, Kaul U, et al. Procedural results and early clinical outcome of percutaneous transluminal myocardial revascularization. Am J Cardiol. 1999;83:498-501.
15. Allen KB, Dowling RD, Schuch DR, et al. Adjunctive transmyocardial revascularization: five-year follow-up of a prospective, randomized trial. Ann Thorac Surg. 2004;78:458-465; discussion 458-465.
16. Hegel MT, Griegel LE, Black C, Goulden L, Ozahowski T. Anxiety and depression in patients receiving implanted cardioverter-defibrillators: a longitudinal investigation. Int J Psychiatry Med. 1997;27:57-69.
17. Kamphuis HC, de Leeuw JR, Derksen R, Hauer RN, Winnubst JA. Implantable cardioverter defibrillator recipients: quality of life in recipients with and without ICD shock delivery: a prospective study. Europace. 2003;5:381-389.
18. Morris PL, Badger J, Chmielewski C, Berger E, Goldberg RJ. Psychiatric morbidity following implantation of the automatic implantable cardioverter defibrillator. Psychosomatics. 1991;32:58-64.
19. Schohl W, Trappe HJ, Lichtlen PR. [Acceptance and quality of life after implantation of an automatic cardioverter/defibrillator]. Z Kardiol. 1994;83:927-932.
20. Sola CL, Bostwick JM. Implantable cardioverter-defibrillators, induced anxiety, and quality of life. Mayo Clin Proc. 2005;80:232-237.
21. Heller SS, Ormont MA, Lidagoster L, Sciacca RR, Steinberg S. Psychosocial outcome after ICD implantation: a current perspective. Pacing Clin Electrophysiol. 1998;21:1207-1215.
22. Luderitz B, Jung W, Deister A, Marneros A, Manz M. Patient acceptance of the implantable cardioverter defibrillator in ventricular tachyarrhythmias. Pacing Clin Electrophysiol. 1993;16:1815-1821.
23. Frizelle DJ, Lewin RJ, Kaye G, et al. Cognitive-behavioural rehabilitation programme for patients with an implanted cardioverter defibrillator: a pilot study. Br J Health Psychol. 2004;9:381-392.
