Latest advances in Pacemaker Technology – Dr. G. Ramesh

Latest Advances in Pacemaker Technology

What is a pacemaker?

Most of us after a certain age would have a basic heart rate of 50-100. Childrens generally have very high heart rates more than 100 to 120. In older people, as they reach the age of 60-70 their heart comes down. After a certain extent, the heart rate becomes so low that we need to put in a pacemaker so that the basic heart rate of 60-70 is maintained. So these patients who will need a pacemaker will most commonly develop symptoms like dizziness, shortness of breath and are more likely to lose balance and fall, particularly in old age patients and patients with multiple comorbidities such as renal disease. For these patients, we need a pacemaker to maintain the heart rate at 70-100.

What are the types of pacemakers available?

Pacemakers are of 2 types:

1. Single chamber pacemaker
2. Dual-chamber pacemaker

We have got 2 chambers, one is the atria and the other is the ventricle. The heartbeat starts from the atria and goes till the atrium. This is a natural physiological phenomenon for all of us.

In a pacemaker also ideally a dual-chamber pacemaker, the pacing starts in the atria and goes till the ventricle. Atria is the above chamber and the ventricle is the lower chamber. 

Single chambered pacemaker is needed for a few people where a pacemaker is put in the lower chamber ventricle. Mostly we try to put a dual-chamber pacemaker because it works in the best physiological way where there are 2 lead pacemaker batteries followed by 2 leads, one is in the atria and the other one in the ventricle. So the conduction starts from the battery, goes to the atria and then goes to the ventricle. 

What is a leadless pacemaker and its advantages?

The basic components of the pacemaker would be a battery and a lead. Leads could be a single lead or double lead. In a single chamber pacemaker, the lead is in the atria and the lead is in the ventricle and there’s a battery which is put just above the shoulder area. 

But in the case of leadless pacemakers, this is on some indications.

Particularly in old age patients with comorbidities or if there’s no venous connection where we are unable to access the vein near the shoulder plates we need to put in a leadless pacemaker. Another indication would be, the patient has got a very irregular heartbeat in the atria. This is again an indication of the leadless pacemaker.

A leadless pacemaker is a pacemaker where you put a pacemaker directly into one of the chambers of the heart that is into the ventricle with no lead. There’s a lot of advantages of leadless pacemakers, the most important advantages is, as there’s no lead, there’s no risk of lead fracture, there’s no risk of the disc of lead moving, also avoiding the risks of lead of these patients.

The second point is, there is no cut. We do this leadless pacemaker through the femoral root or through the leg so there’s no risk of infections to the patients. Generally, when we do a pacemaker we generally make a cut of 1 inch or 1 1/2 inch just below the shoulder blades. So for these patients, there’s a little risk of infections, it’s very less but there’s still a chance. In a leadless pacemaker since there are no leads, there is no risk of a lead fracture or lead displacement, no risk of infections particularly because there’s no cut at all. For these patients, we access through the leg and put a pacemaker and the next morning the patient can be discharged.  

Latest case study details:

Recently we have had an 87-year-old male patient who has complained to us about a lot of episodes of giddiness and fall. This patient was a diabetic and had chronic kidney disease for the last 6 months and has been having a lot of falls (nearly 7-8), so he was consulting a neurologist and due to some renal issues, he had follow-ups with a nephrologist as well. So somehow they missed doing an ECG. When the patient came to us, we did an ECG and found his heart rate was around 30-35. So the possible cause of the patient’s falls was his low heart rate. But considering the patient was having a lot of comorbidities particularly neurological, as he was diagnosed with Alzheimer’s disease and due to renal failure, he was getting dialysis and was very obese weighing 100kg. So we thought he definitely needs a pacemaker and possibly a leadless pacemaker would be good for him considering two factors.

One because the patient is on dialysis we did not have good venous access to this patient so we planned a leadless pacemaker.

Secondly, because the patient was having multiple comorbidities and he wasn’t very alert so we thought that the leadless pacemaker is a short procedure so he could get discharged the next day and the risk of infections to the patients will also be less.

So the patient we are putting a leadless pacemaker in, we access him from the femoral/groin artery which takes around five minutes. We go through the groin artery, into the vena cava and then into the right atrium and the right ventricle. And once we go there we deploy this leadless pacemaker. It is a very small pacemaker of around 1inch and we put it there. This has got some spikes, once we put this pacemaker there, spikes will get attached to the cardiac chamber. And then we recheck if the spikes are deployed well and then we recheck if the pacing is done properly, once this is put into the right ventricle the pacing starts and the heart rate will be around 70-100. So this is a patient for whom we did a leadless pacemaker once. The next day we observed him and discharged the patient. If the patient was having multiple comorbidities, we would discharge him in a couple of days and when he comes for follow up, the patient’s mental alertness is far better than before and the patient is able to walk and come inside.

Initially, when he was brought he was brought on a wheelchair and later he improved dramatically with the pacing and there’s no risk of infection. He was still on dialysis but his mental alertness certainly improved with this pacemaker.

To summarize, a leadless pacemaker is used in a specific suspect of patients particularly where there’s no venous access, where there’s irregular heart rate or patients with multiple comorbidities where you’d feel that a dual-chamber pacemaker with skin cut is not ideal for this patient. We got all these high-end facilities and technologies at Yashoda Hospitals and we do use it whenever there’s a need for it to our patients.