Jefferson University Hospitals

Frequently Asked Questions

What is a biventricular pacer?

Symptoms of congestive heart failure develop due to a weak heart muscle. Sometimes, the heart's ability to pump is further compromised if it is not contracting in a synchronized fashion. In such cases, implantation of a biventricular pacemaker, or pacer, improves the function of the heart by re-synchronizing, or re-coordinating, contraction.

A biventricular pacer is a small electrical generator powered by a battery with special wires called "leads"; that run to the heart. The device is implanted under the skin of the chest. Computer-like circuitry inside the device transforms the energy from the battery into tiny electrical pulses that travel to the heart through the leads. Electrodes on the tips of these leads touch the heart wall. One electrode is placed in the right ventricle of the heart; the other is placed through a coronary vein that stimulates the left ventricle. Simultaneous impulses down each lead cause the right and left sides of the heart to contract simultaneously, thereby re-synchronizing contraction of the chambers, making the heart work more efficiently.

Who should get a biventricular pacer?

With each heartbeat, the left ventricle, which is the main pumping chamber of the heart, squeezes or contracts, ejecting blood to the rest of the body. If the heart is simply beating weakly, a biventricular pacer will not help. The patients who will benefit the most from this new technology are those whose heart failure stems from a lack of synchrony in the heart's contraction. This occurs when there is a delay in the electrical impulse that signals the heart muscle to contract. The delay in electrical conduction causes one wall of the heart to contract before the other. The resulting lack of coordination, or dyssynchrony, reduces the pumping function of the heart and may lead to worsening heart failure.

An electrocardiogram (ECG) monitors the heart's electrical activity and can easily determine if there is a delay in electrical conduction to the left ventricle. The results of this painless test will determine if you are a good candidate for a biventricular pacer.

How does the biventricular pacer help?

A biventricular pacemaker improves the function of the heart by re-synchronizing contraction. One pacemaker lead is placed in the right ventricle and a second over the left ventricle. The leads are attached to a pacemaker battery that then sends impulses to both leads simultaneously. The heart is re-synchronized – both sides now contract at the same time. The physician programs the pacer according to what the patient's heart requires, making whatever adjustments are necessary to the strength, duration and speed of the electronic impulse.

Implanting the biventricular pacer in appropriate patients has been shown to reduce symptoms, hospitalization and mortality, compared to other treatments for congestive heart failure. Other benefits include improved exercise performance and quality of life.

How is the pacer implanted?

The pacer is implanted through minor surgery. Sedation and local anesthesia are used – not general anesthesia.

A local anesthetic is administered to numb an area on the chest wall, near the shoulder, where the device will be placed. A surgeon makes an incision, and a pocket (about three inches by two inches) is created for the pulse generator.

The pacemaker leads are introduced into a vein near the site of the pocket and then, guided by x-ray images, advanced through the large veins leading to the heart. Once proper function is confirmed, the leads are attached to the pulse generator, which is then placed in the pocket beneath the skin.

The resulting scar will be about three inches long. In very thin individuals, the pulse generator may be noticeable underneath the skin. In heavier people, there may be no outward evidence of a pacemaker at all.

What happens after the surgery?

The patient will generally spend one night in the hospital after pacemaker implantation. For comfort, many patients will wear a sling, or "immobilizer," on the arm during that time. The surgical site may be uncomfortable for one to two weeks. Analgesics (aspirin, acetaminophen or ibuprofen) can provide relief.

Before leaving the hospital, the patient will get a wallet ID card containing details about the pacemaker in the event of an emergency. The patient's activities may be limited the first two weeks after surgery because vigorous motion of the affected arm and hand could cause the leads of the new pacemaker to move or be dislodged.

Four weeks after the procedure, the patient will visit the surgeon, who will evaluate the pacemaker to make sure it is working properly.

Are there risks associated with this procedure?

Pacemaker implantation is a safe procedure. However, there is a minor possibility (less than 1 percent) of risks such as bleeding, blood clots, infection or a punctured lung. Device malfunction is rare, but patients with pacers should call their physicians if they experience any of these signs:

  • Pain at the pacer site
  • Swelling of the arm or hand where the pacemaker was placed
  • Shortness of breath
  • Signs of infection: redness, heat, oozing
  • Reappearance of congestive heart failure symptoms that had initially disappeared

How do I know if the pacemaker is working?

Patients generally do not know if their pacemaker is working properly. Therefore, they must return to their doctors' offices for regular appointments. During these appointments, your doctor will evaluate the function of your pacemaker and be able to non-invasively adjust its function using a computerized program.

Pacer batteries generally last from six to 10 years. During regular office visits, physicians evaluate patients' pacer battery status. When your battery reaches its elected replacement time, a minor outpatient surgical procedure will be necessary to insert a new battery and remove the old one.

Are there restrictions on living with a pacemaker?

Few precautions are necessary to protect the pacer. High magnetic fields can interfere with pacer function, so patients cannot have MRI scans. Inform screeners at airports so that you do not have to linger around security detectors any longer than necessary for a walkthrough, although this security measure need not be avoided. Everyday devices such as cellular telephones and microwave ovens pose no threats. Your physician will provide instructions about any particular hazards.

Today, people are more aware than ever of the risks of having a high blood cholesterol level.

High cholesterol levels can lead to clogged arteries, heart attack or stroke. So if you have high cholesterol, you should take steps to lower it. Simple dietary and lifestyle changes can reverse your course and set you back on the path of good health. For those who have coronary artery disease, or are at unusually high risk for it, lowering your lipid levels can reduce further coronary events and the possible need for interventions such as surgery or angioplasty.

What is cholesterol?

Cholesterol is a waxy substance produced by the liver that is also found in animal foods such as red meat and whole milk dairy products, which are usually high in fat as well. (Plant sources do not contain cholesterol.) Your body uses cholesterol to build cell walls and other necessary tissues. High-fat diets stimulate the liver to produce excessive cholesterol. As a result of the amount your body manufactures normally and in response to a fat-laden diet, you can accumulate too much cholesterol in your blood. That is when trouble occurs in the form of cardiovascular disease.

Cholesterol travels through the blood in packages called lipoproteins. Low-density lipoproteins (LDL), or bad cholesterol, have a tendency to cling to the inner walls of the arteries as plaque. This plaque restricts the flow of blood to the heart or brain, which can lead to heart attack or stroke. High-density lipoproteins (HDL), or good cholesterol, whisk surplus cholesterol from the blood and arterial walls, thus lowering the odds of developing cardiovascular disease.

What do my cholesterol numbers mean?

Total blood cholesterol is the number most people are familiar with. Doctors no longer measure just the total cholesterol level in your blood, because that only provides part of the picture. Your doctor should do a complete lipid profile, which includes measuring your levels of good (HDL) and bad (LDL) cholesterol and triglycerides. (Although completely different from cholesterol, triglycerides likewise are fats found in foods and manufactured in the body. Most of the fat we eat is in the form of triglyceride.) Other lipid tests are also available, if needed, to help your doctor and you define your risk level.

Ideally, your LDL cholesterol should be below 100; a desirable HDL level is 45 of higher. The lower the LDL and the higher the HDL, the more protected you are from cardiovascular disease. Most pre-menopausal women have high levels of HDL because of the female hormone estrogen, which offers added protection against heart disease. After menopause, though, a woman's risk for heart attack jumps until she is 65, by which time it is almost as great as a man's.

Triglyceride levels above 150 mg/dl are abnormally high. A high triglyceride level often accompanies a higher total cholesterol and LDL cholesterol level, and especially a lower HDL cholesterol. The combination of high triglycerides and low HDL levels in concert with disorders such as diabetes or high blood pressure is termed "metabolic syndrome." Metabolic syndrome is strongly associated with abdominal obesity, which itself has been shown to put you at risk for coronary artery disease. Whatever your cholesterol counts, keep in mind other important risk factors as well. Age, heredity, family history, high blood pressure, diabetes, smoking and lifestyle should all be considered when evaluating your risk of cardiovascular problems.

How can I lower my cholesterol level?

You can take control of your cholesterol by making lifestyle changes. Eating a heart-healthy diet is often an effective way to bring your blood cholesterol within a normal range. Limit saturated fat to no more than 7 percent of your daily calories and trans fat to no more than 1 percent, and substitute more whole-grain and high-fiber foods.

Load up on fish, fruit, vegetables, beans, rice and other whole grains in place of meat or baked goods. Switch to low-fat or skim milk dairy products. When you must cook with fat, choose the monounsaturated varieties, such as olive or canola oils. Don't overdo your use of even these oils, however, as they are still high-fat foods. Fat in the diet stimulates the liver to raise blood cholesterol levels; it is not just eggs that elevate blood cholesterol.

Additionally, since regular exercise has been shown to increase the level of good cholesterol, get active. Because smoking reduces the level of good cholesterol, smokers should quit. Everyone should maintain a normal body weight, as above-normal weight and obesity contribute to abnormal lipid levels, as well as diabetes, high blood pressure and other disorders. The rewards of changing your habits are well worth it; for every 1 percent drop in bad cholesterol, you get a 2 percent drop in cardiovascular risk.

Are foods labeled 'Cholesterol Free' safe bets?

Don't be fooled by food labels that say "cholesterol free." Foods bursting with saturated fat are sometimes disguised with these healthier-sounding labels. Likewise, products made with hydrogenated vegetable oils may seem good for you but are actually rich in fat. Current U.S. Food and Drug Administration regulations cut down the hype surrounding terms used on food labels, such as "cholesterol free." To prevent being misled, however, read nutrition labels to learn the amount of fat in a serving. A truly low-fat product contains three grams or less of fat for every 100 calories.

Should I consider cholesterol-lowering drugs?

Drugs that can help normalize blood cholesterol may be necessary for people at higher risk who can't control their levels through diet. Dietary changes should often be tried before medication, however. Within three months of following a low-fat diet, you should notice a reduction in your cholesterol count. If this self-care method doesn't lower your cholesterol to an acceptable level, you may need to add medication to your regimen, particularly if you have other risk factors for cardiovascular disease. Since drugs that lower cholesterol can have side effects, however, you should consult your physician before deciding if medication is appropriate.

Do I need to worry about my child's cholesterol levels?

Research indicates that one out of four children and teenagers has a high cholesterol level. Clearly, it's never too early to start thinking about your child's cholesterol. Although the American Academy of Pediatrics does not recommend universal screening of all children, it's wise to test children over two years of age who have a family history of early heart attacks or elevated cholesterol. Overweight children or those with high blood pressure, diabetes or other risk factors for heart disease should also be screened. An abnormal level warrants dietary modifications, but it is best to consult your doctor in individual cases.

Eating habits are established at a young age, and regardless of whether your child has a clean bill of health, you should set an example for a healthy future by serving low-fat meals to children over two years old. Remember, though, that children need some fat in their diets to help them grow.

How can I ensure an accurate cholesterol test?

It's usually better to get tested at your doctor's office rather than at a mass screening at a mall. To obtain a correct measurement of blood cholesterol, you need to fast for 12 hours prior to an HDL/LDL/triglyceride workup for a total profile.

How often should cholesterol be checked?

A high cholesterol level produces no warning symptoms, so it makes sense to test periodically. The American Heart Association recommends a lipid profile by age 20 or earlier in some cases. If your levels are acceptable, return to your doctor every five years for subsequent checks until age 45; after that, screenings should be scheduled every three years.

Before menopause, some degree of protection is afforded to most women, but they should still be tested. After menopause, all women should have their cholesterol measured every three to five years.

Can a cholesterol level ever be too low?

Usually, a low cholesterol level is a good health indicator. In other cases, it may point to a systemic disease that needs treatment. Ask your family physician to discuss your cholesterol measurement with you.

 

Any discussion on small-vessel stents requires background information on coronary artery disease – a condition in which fatty deposits accumulate in the cells lining the wall of the artery and obstruct blood flow. The inadequate supply of blood to the heart muscle damages the heart. Untreated, patients may experience angina – chest pain that occurs when the heart isn’t receiving enough oxygen. Blocked arteries can also lead to a heart attack.

Cardiologists treat coronary artery disease by opening up these blocked blood vessels. In the past, open-heart surgery was the only way to accomplish this. Today, however, there are innovative medical strategies and technologies that do not require surgery. If symptoms of heart disease do not respond to drugs, diet and lifestyle changes, a cardiologist may recommend an angioplasty and stent. The combination of these two non-surgical procedures – the medical term for which is percutaneous coronary intervention (PCI) – has been highly successful in opening up blocked blood vessels and diminishing the chance that a blockage will recur.

What is a stent?

Balloon angioplasties have been the most common non-surgical technique for opening clogged arteries in patients since the 1980s. More recently, though, studies have shown that patients who also receive an implanted device called a stent were less likely to require additional angioplasties or bypass surgery in the future.

A coronary stent is a mesh tube the size of a spring in a ballpoint pen. The stent is placed in the artery to hold it open after the angioplasty balloon has cleared the blockage. About 70 percent of patients receiving balloon angioplasties today are now treated with stents as well to improve their odds of a successful outcome.

How does a stent help?

A stent can be used alone but is typically inserted following an angioplasty procedure. Placing a stent in a cleared vessel has been shown to cut the risk of subsequent blockages in half by keeping the arteries wide and reducing the incidence of re-closure. The device usually relieves the chest pain of angina, and the benefits are longer lasting than an angioplasty on its own.

Another significant advantage is that only a small incision is required for a stent as opposed to invasive bypass surgery. The non-surgical stenting procedure entails less pain and a shorter recovery time. While helping to restore normal blood flow, stents also keep the artery open if any damage occurs from the catheter during the angioplasty. Overall, the complication rate of angioplasty goes down too when a stent is used.

What is the advantage of the new small-vessel stent?

First introduced in the early 1990s, stent design has steadily improved to offer greater effectiveness, more variety in size and minimal trauma.

Jefferson cardiologists have pioneered the use of small-vessel stents for tiny and hard-to-reach heart vessels. These compact stents being used by top cardiologists today have the ability to reach lesions in small blood vessels which were previously difficult to access. The ultra-smooth surface of the small-vessel stents also promotes proper blood flow, thus reducing the possibility of thrombosis (blood clots), a particular risk when stenting small vessels.

How is a stent inserted?

A physician trained as an interventional cardiologist performs the procedure, which usually starts with the angioplasty. An incision the size of a pencil tip is made. Guided by X-ray images, the doctor threads a balloon-tipped catheter through the arterial system and into the obstructed coronary artery. At the end of the catheter is the stent, a small flexible tube made of plastic or mesh.

Next, the physician inflates the angioplastic balloon to force the plaque against the arterial wall; in the large majority of cases, this opens up the obstructed artery. This balloon inflation also causes the stent to expand and press against the
vessel wall.

Once the angioplasty balloon is deflated and removed, the stent stays in place permanently to hold the blood vessel open.

New cells and tissue slowly grow over the stent and eventually cover the surface.

Are there any risks or possible complications associated with stents?

Stenting is a safe procedure with a small risk of complications such as blood clots (which may cause heart damage) and scar tissue (causing restenosis, or recurrent blockage). In all, the medical risks of the angioplasty and stent are usually lower than for heart bypass surgery (which is more difficult for small arteries).

Are stents beneficial for anyone with coronary artery disease?

Stents are used to treat a wide variety of patients with narrowing or clogged arteries. The indications for using a stent can be angina (chest pain) or a heart attack. Or sometimes, stents are inserted as a temporary measure for cardiac patients who are not fit for surgery.

The size of the obstructed artery and location of the blockage will determine whether a stent is a suitable treatment and what size is required. Most, but not all, patients with blocked arteries are candidates for stents.

What should I expect after the procedure?

Most people stay in the hospital for only one night following an angioplasty and stent. Full recuperation may take several days. Patients may feel mild chest pain initially from the stretched artery. After stenting, patients also must take blood- thinning agents to help prevent re-closure of the artery. Aspirin is recommended indefinitely and an anti-platelet agent – clopidogrel (Plavix®) – is prescribed for up to one year.

Are there alternatives to a VAD for heart failure?

For patients who are sick enough for a VAD, the only other options are chronic inotropes (intravenous medications that push the heart to work harder), transplantation and hospice. Inotropes are not good for long-term use because patients usually do not survive more than a year. Transplantation is limited by the availability of donor organs. In addition, some patients do not qualify for transplantation. Hospice is reserved for patients who cannot get any of the other therapies or who do not desire to have them.

Can my heart recover on a VAD?

While there are some people whose heart gets better after placement of an LVAD, this is not common. However, we monitor all patients on a VAD for signs of recovery. If recovery occurs, the removal of the device is a possibility.

Can I live at home on a VAD?

Our goal is to get every VAD patient home again living the life they want to live. After recovering from the VAD placement, patients are usually able to return to a fairly normal life at home. Some patients require inpatient rehab before going home. Your doctors will assess your need for this prior to discharge.

Which doctors will take care of me while I’m on the VAD?

You’ll require special care by physicians who are experts in the care of VAD patients. The physicians at Jefferson will provide care for you as long as you have your VAD. Patients on VADs also will need to be at a VAD-capable hospital for any admission or procedure requiring anesthesia.

How long does the surgery take?

The VAD surgery usually takes 4 to 8 hours.

How long will I be in the hospital after a VAD implantation procedure?

Patients are usually in the hospital for two weeks or more after implantation. Your health prior to the surgery will factor in to the length of stay.

Is it better to have a VAD or Total Artificial Heart?

VAD is almost always a better option for people who only need support of the left side of the heart. For those with severe failure of both sides of the heart, a total artificial heart or bi-ventricular assist devices are the best options. Your cardiologist and surgeon will determine which device is best for you.

If I cannot shower with a VAD, how will I stay clean?

Our team will educate you about how to stay clean with sponge baths. In addition, many VAD patients are willing to share their tips.

What will be expected of my family/support?

You should plan for someone to be with you at all times for about six weeks after you are discharged home. Most patients need support to perform sterile dressing changes of the driveline (wire coming out of the abdomen) site; to assist with filling a medication box and making changes to the pill box when needed; to accompany you to the laboratory and office visits; and to assist with monitoring symptoms and calling when needed.

How will I wear the external equipment?  

You will be provided with a vest and a bag to carry the equipment. Many patients create other alternatives and most VAD patients are eager to share tips.