Frequently Asked Questions about Electrophysiology Studies and Radiofrequency Ablation

1) Does the procedure hurt? The discomfort is minimal. Lidocaine (similar to what your dentist uses) is injected to numb up the skin before catheters are inserted. Once lidocaine takes effect, there should be no feeling in that area. Furthermore, sedatives are given in the vein to achieve a level of light anesthesia called "conscious sedation" where one is lightly asleep but remains arousable.  Without sedation, the actual application of radiofrequency energy can cause discomfort in the chest area, but this can be alleviated with appropriate level of conscious sedation.

2) Would I be asleep?  Conscious sedation (a level of light anesthesia) is all that is necessary for most of these procedures. Patients are sleepy but arousable within this stage of anesthesia. General anesthesia is unnecessary for these minimally invasive procedures, except in prolonged cases such as atrial fibrillation ablation..

3) How long does it take? In general, a routine EP study takes about 30 to 45 minutes. Radiofrequency ablation takes about 1 and ½ hours to 3 hours, depending on the difficulty of the case. One must also allow the preparation and recovery time (~2 hour) before and after the procedure.

4) How is it done? Multiple small-caliber catheters are inserted through the skin into the veins and advanced into the heart where they make recordings of the electrical activities within the heart.  The catheters can be used to stimulate the heart in order to uncover any electrical problems such as fast or slow heartbeats.

5) What is radiofrequency ablation?  Radiofrequency is a special form of energy that, when delivered through the tip of a special catheter placed inside the heart, results in laser-like precision destruction of abnormal electrical tissues. These tissues are nerve bundles that are responsible for you irregular heartbeats.

6) How does the doctor know where to ablate?  Before the procedure, your physician would have done an examination of you and had tests that give a general idea of the location of the culprit "extra nerve" responsible for your arrhythmia. However, only after "mapping" is performed inside the heart can one determine exactly where it is and where to perform ablation. In the process of mapping, the rapid heartbeat, or arrhythmia, is frequently reproduced by your physician (a process called "induction").  After ablation is performed and the nerve destroyed, one must then repeat the entire testing process to ensure that the culprit "extra nerve" indeed has been destroyed and that the rapid heartbeat is no longer "inducible."

7) When do I go home? Patients undergoing electrophysiology studies will go home on the same day after a few hours of observation. Most patients undergoing ablation can also be discharged the same day, with rare exception (see post-operative care section).

8) How long is recovery? After the procedure, only minor skin discomfort is expected at the site of catheter insertion. Aside from this, patient may feel groggy for a period of several hours.  The recovery time is usually a few hours and patients can go home the same afternoon. It is generally advisable that patient not engage in strenuous activities for 48 hours after the procedure.  Normal activities such as walking is not only acceptable, but encouraged, to facilitate recovery.

9) When can I get back to work? This depends on the type of work one does. Most patients can return to work within 24 to 48 hours (see post-operative care section) except for those who do heavy manual work, in which case time to return to work should be individualized.

10) Can I shower? Yes, on the same day of the procedure.  One simply needs to change the band-aid when wet for the next few days.

11) Does my insurance cover this procedure?  Today, electrophysiology study and radiofrequency ablation are commonly performed procedures that have become mainstream therapy for many types of arrhythmias.  Essentially every major insurance company covers these procedures.

12) Which hospital should I have my ablation done?  This is often a decision made by patients based on their own personal experience or general perception.  Sometimes it is based on the proximity of the hospital to patients' residence.  One thing to keep in mind is that different hospitals may have different equipments and this may be important when it comes to performing certain complex ablation procedures, notably ones that require the so-called "3-D mapping" study.. Please also note that your insurance may restrict you to using only certain "preferred" hospitals, in which case performing the procedures elsewhere may affect the amount of your co-payment or deductibles.

 

Frequently Asked Questions about Pacemakers and Defibrillators (before surgery)

1) Who needs a pacemaker?  A pacemaker is required for patients with slow heartbeat. (See sections on pacemaker and defibrillator). An exception is when one has a very rapid heartbeat where ablation is performed intentionally to slow down the heartbeat, in which case a pacemaker is inserted to keep the heart rate steady (as in atrial fibrillation).

2) Who needs a defibrillator?  A defibrillator is needed when the heartbeat is very fast and life threatening. It is implanted in patients already with these arrhythmias, or in patients at high risk for these arrhythmias (See sections on pacemaker and defibrillator).

3) Can I choose my own pacemaker/defibrillator? If you know of a certain company or certain type of devices that you feel strongly about, your physician can work with you in choosing the devices. Most often, however, your physician knows best the specific device that works best in your particular situation.

4) How and where is the pacemaker/defibrillator implanted?  One to three catheters (i.e., electrical wires) are implanted into the heart via the veins on the chest.  A pocked under the skin is made on the chest near the shoulder (most often on the left side) where the pacemaker or defibrillator is implanted. The skin is then closed with suture.  When the pocket is healed, one can not see any hardware externally (from the outside), only a slight bulge on the skin.

5) Does the procedure hurt? The discomfort is minimal. Lidocaine (similar to what your dentist uses) is used to numb up the skin before the pacemaker or defibrillation is inserted. Once lidocaine takes effect, there should be no feeling in the surgical area. Furthermore, light sedatives are given for conscious sedation (a light stage of anesthesia). Full general anesthesia is not always necessary but is at the discretion of your anesthesiologist.

6) Would I be asleep during surgery? Most often, conscious sedation (a light stage of anesthesia) should suffice during most procedures.  But for the more complicated cases, general anesthesia is used.

7) How long does the surgery take? In general, a pacemaker can take 20 to 45 minutes and defibrillator 30 to 60 minutes, depending on the complexity of the case. One must also allow the preparation and recovery time (~2 hour). Devices with Resynchronization therapy (CRT) capabilities may take longer (1-2 hours) because of the the additional work involved in implanting an extra wire.

8) Does my insurance cover this procedure?  Today, pacemakers and defibrillators are commonly performed procedures that have become mainstream therapy for many types of arrhythmias.  Essentially every major insurance company covers these procedures.

9) Can you just change the battery or do you have to change the whole pacemaker?  See below.

10) Which hospital should I have my surgery done?  This is often a decision made by patients based on their own personal experience or general perception.  Sometimes it is based on the proximity of the hospital to patients' residence.  One thing to keep in mind is that different hospitals may have different equipments and this may be important when it comes to performing certain complex ablation procedures.

Another very important factor to consider is the particular contract the hospital may have with various pacemaker or defibrillator manufacturers.  Depending on the contract, some hospital may restrict usage of devices to certain manufacturers only, or limit utilization to only "last year's" model in the name of "cost containment."  These factors may be important in deciding on which hospital you may want to have certain procedures done.

Please also keep in mind that your insurance may restrict you to using only certain "preferred" hospitals, in which case performing the procedures elsewhere may affect the amount of your co-payment or deductibles.

 

Frequently Asked Questions about Pacemakers and Defibrillators (immediately after surgery)

1) When do I go home after surgery? Most patients will be discharged the next morning unless their specific medical conditions require additional stay. Many patients who come in only for the change out of a previously implanted pacemaker or defibrillator can go home the same day.

2) What are my restrictions after surgery? The main limitation applies to the arm on the side of surgery. We generally advise that patients not lift the arm above the shoulder or engage in strenuous activities on that arm for several months.  Activities such as golfing, tennis, and weight-lifting should be avoided. There have been cases where the electrodes (wires) have been pulled outside the heart because of patient engaging in such activities too soon after surgery.

3) When can I get back to work? This depends on the type of work one is does. Except in the case where work involves strenuous activities, most patients can return to work within 24 to 48 hours.

4) Can I shower after surgery? Yes. A medical adhesive is often applied to the skin to seal the incision and make it waterproof. This is the shining layer on the incision, which will fall off by itself in about 2-4 weeks.  Without this adhesive, one must avoid shower for up to one week.

5) Can I lift my arm after surgery? Yes, but not above the shoulder level for 2 to 3 months. This is a precaution taken to avoid dislodgement (moving out of position) of the wires placed in the heart. Such dislodgement will almost always require a second. Therefore, after surgery, activities involving heavy swinging around the shoulder, such as tennis, golfing, swimming, and weight lifting should be avoided for 3 to 6 months, to be safe. Activities involving the other arm (away from the pacemaker and defibrillator) need not be restricted.

6) Can I sleep on my side of the pacemaker? No problem.

7) Can I drive? Generally yes, unless you have a history of fainting prior to the surgery, in which case your physician must evaluate how your are doing after surgery before allowing you to drive again.

 

Frequently Asked Questions about Pacemakers and Defibrillators (long term after surgery)

1) What kind of follow up do I need for my pacemaker/defibrillator?  Generally speaking, long term follow up for pacemaker is twice a year and for defibrillators four times a year. The exact frequency depends on the particular situation and is at the discretion of your physician.  Close follow-up is important so your physician can monitor the progress of your heart condition and detect malfunctions of the devices before serious consequences occur. When the battery voltage runs low, such follow up check can help determine when it is necessary to replace the battery of the pacemaker or defibrillator.  These follow up visits can also give your physician the opportunity to advise you on certain unexpected issues such manufacturer recall.

2) How long does the pacemaker/defibrillator battery last? Most pacemakers will last 5 to 8 years. Most defibrillators will last 4 to 6 years. Change out of the battery is a relatively simple outpatient surgery.

3) Can you recharge the battery?  No. This is a concept that had been considered in the past, but currently no manufacturers make a rechargeable pacemaker or defibrillator. The technology in this field is evolving so fast that it often becomes outdate within a few years.  Therefore, it makes little sense to recharge the battery just to save the old unit and the old technology.  The entire system, battery and hardware (except the wires which stay in place), is updated in one setting during change-out surgery.

4) How do I know if my battery needs to be changed?  You usually do not feel any symptoms, unless the battery is completely depleted and your heart rate is too slow without the pacemaker (i.e., "pacemaker dependent").  In certain units, an audible warning beep can be heard when the battery is running low.  Most often, battery depletion is discovered during routine office visit and evaluation of the pacemaker.  The unit gives advanced warning of 6 to 12 months before complete battery depletion so that you and your physician may have ample time to schedule an elective change-out surgery.

5) Can you just change the battery or do you have to change the whole pacemaker?  A pacemaker consists of two major parts, the "pulse generator" and the "electrode."  The pulse generator is the metal casing that contains the battery as well as the micro-electronics necessary for the working of the pacemaker.  The electrode is the wire that connects the pulse generator to the heart.  At the time of the "change-out" surgery (a.k.a. "replacement" surgery), the old pulse generator is taken out and a new one inserted in its place while the electrodes remain in place (for most cases).

During the surgery, the entire metal casing (the "pulse generator") is taken out and replaced, not just the "battery."  Many physicians may use the word "battery" interchangeably with "pulse generator," as the former is easier to understand for the patients.  This is technically incorrect and can be a source of confusion.  For, one can never change "just the battery" but the entire metal casing.  Essentially, the patients receives a brand new battery as well as new state-of-the art electronics.

As mentioned above, the electrodes (wires) usually do not have to be changed as they can last 10 to 20 years or more, unlike the "battery," which is generally good for 6 to 10 years.  However, at the time of surgery, your physician may choose to replace the electrode if it is found to be defective.

6) Can I have an MRI after pacemaker/defibrillator? No. Current devices are not MRI compatible (although futures ones are in development). Although in theory it is reasonably safe, rare but severe (sometimes fatal) consequences have been reported when someone with a pacemaker goes through an MRI. It is generally recommended that alternative imaging modalities, such as CT scanning, be used.

7) Can I go through airport security with my pacemaker/defibrillator?  Yes. It is generally safe. However, one may prefer hand-search instead of going through the metal detector because of personal preference.  Most importantly, one should never have the security personnel place the metal detector wand directly over the pacemaker or defibrillator.

8) Can I use a microwave oven with my pacemaker/defibrillator? No problem. This is an old wife's tale that just refuses to go away. Currently there are no contraindications (or warning label) for the use of a microwave with any implanted devices.

9) Can I use a cell phone? Cell phones are generally safe. New generations of devices have been cell-phone tested and cell-phone compatible since the mid 1990s. As a general rule, however, we advise that when a cell phone must be used that it be held on the side opposite your pacemaker of defibrillator in order to minimize any potential and theoretical interference.

10) Does the pacemaker/defibrillator tick?  Can I hear my pacemaker/defibrillator? Some patients are absolutely convinced that they hear their pacemaker of defibrillator tick. This is not possible. Pacemakers make absolutely no sound whether it is pacing or not pacing. Likewise, defibrillators do not make any sound when pacing or shocking the heart. The defibrillator, however, has a built-in warning system that will emit a beeping sound once a day (usually programmed to occur in the morning) if the over-night check-up performed during your sleep revealed an abnormality.  The defibrillator will also emit a beeping sound when a magnet is applied.

11) Can I take Viagra? Is there any limitation on sex?  Viagra is not contraindicated in patients with a pacemaker or defibrillator, per se.  However, precautions should be taken if you have severe heart conditions, in which case you should discuss with your general cardiologist.  Although pacemakers and defibrillators are compatible with most activities of a normal life style, including sex, sometimes the heartbeat can run too fast during sex so as to result in the discharge of the defibrillator.

12) Do I need antibiotics for dental work?  No. There is no specific indication for antibiotics related to your devices.  However, many patients may need antibiotics for other heart conditions, such as mitral valve prolapse.

13) Can a pacemaker/defibrillator be reused or recycled?  We get this question quite frequently.  There is currently no role for a used device in this country. FDA allows only brand new devices to be implanted in this country.

14) How do I know if I receive a shock from my defibrillator? A defibrillator shock is uncomfortable and will not be subtle. However, there have been occasional patients who did receive shocks but did not remember the event, especially if it occurred during sleep or if patient passes out as the result of the event.  If there is any doubt, one should make an appointment to have the defibrillator evaluated in the office.  The device keeps all its memory of any arrhythmias and the memory can be downloaded for your physician to review.