Cardiac pacemaker. Installation of a heart pacemaker

In medical practice Increasingly, there are patients for whom a cardiac pacemaker is a vital necessity. The device helps to cope with heartbeat disorders that previously would have led to disability and early death patient.

Cardiac dysfunction inevitably leads to loss of functionality of other internal organs, including the central nervous system, due to lack of oxygen. The pathological condition can develop when the pulse rate is too slow (bradycardia), arrhythmia complicated by tachycardia, and organ blockade, in which the conduction of electrical impulses fails.

The need for a pacemaker and indications for installation arise in the following diseases:

• Sick sinoatrial node syndrome, in which the heart rate drops to 40 or below. It also includes sinus block, bradycardia and bradyarrhythmia (attacks of decreased rhythm followed by episodes of tachycardia).
• Atrioventricular block (impaired atrioventricular conduction) 2-3 degrees.
• Pathologies of the carotid sinus – sharp drop heart rate when irritating the site of expansion of the internal carotid artery. May be provoked active movement head or by squeezing the neck with clothing. Manifests severe dizziness and fainting.
• Need for drug therapy(for example, "Amidarone") for normalization contractile function hearts with various blockades and arrhythmias.
• Other types of bradycardia, which are accompanied by convulsions and/or loss of consciousness due to a short-term complete stop of the electrical system of the heart (asystole).
• Paroxysmal ventricular tachycardia.

• Atrial fibrillation.
• Regular cases of extrasystoles with high probability transition to ventricular fibrillation, left ventricular failure, often resulting from a heart attack.

Installation of a pacemaker is indicated in cases where it is impossible to cope with life-threatening conditions of the patient. using medicinal methods.

What types of pacemakers are there?

To have an understanding of the installation method and types of devices, you need to understand what a pacemaker is and what the principle of its operation is.

A pacemaker (pacemaker), also called an artificial pacemaker, is a device that supports or imposes normal frequency heart contractions, suppresses other sources of impulse excitation and monitors the patient’s own pulse.

EX structure

Modern models of artificial pacemakers resemble mini-computers: they consist of electrodes, a complex microcircuit and a battery that allows them to work on average for about 10 years. New pacemakers are designed to last longer – up to 12-15 years.

Using a microcircuit, the device recognizes the electrical potential of the myocardium - in other words, a cardiogram. Electrodes with sensitive head are implanted into the thickness of the heart muscle, transmitting information about impulses and returning electric charges, normalizing the rhythm of beats.

Appliance dimensions vary depending on model and features, and average weight is about 50 g. The pacemaker is configured by a computer programmer within the medical institution where the operation to implement it was carried out.

Classification

Pacemakers are divided by purpose and number of electrodes. By purpose they are classified into:

• Pacemakers (pacemakers), which are used for bradycardia to ensure a normal frequency of blood emissions.
• Cardioverter-defibrillators, which, in addition to the function of a pacemaker during rare contractions of the heart, are capable of recognizing the state of fibrillation and restoring the normal frequency of beats using a strong electrical discharge of 12-35 J or special stimulation schemes.

According to the number of electrodes, ECS are divided into:

• Single-chamber. The stimulator electrode is located in the left ventricle and initiates contraction of other cavities. It is rarely used, since if the atrial and ventricular rhythms coincide, the blood circulation of the heart is disrupted. Useless for supraventricular arrhythmias.
• Two-chamber. Equipped with two electrodes, which are placed in the ventricle and atrium. They control and coordinate the rhythm of cavity contractions well.
• Three-chamber. They are the most optimal and physiological. Three electrodes are located in the two ventricles and the right atrium, respectively. Such models are actively used for dyssynchrony of contractions of the left and right ventricles.

Pacing is also classified by duration. EX is installed for the following types impacts:

• Permanent. Epicardial implantation is performed only on open heart special devices.

• Temporary. Used before installing a permanent pacemaker, when drug overdose or temporary failure heart rate. To stabilize the patient's condition if resuscitation is necessary, external or endocardial cardiac pacing is used. Placing electrodes on the sternum is less effective than placing them along the central venous catheter directly into the atrium or ventricle.
• Diagnostic. Transesophageal stimulation is used to eliminate attacks of atrial arrhythmias, as well as to check the functionality of the heart if paroxysmal tachycardia, pathology is suspected sinus node, atrioventricular conduction disorder, coronary artery disease.

The ability to select an external rhythm allows you to use a pacemaker as a replacement for bicycle ergometry and treadmill test when diagnosing the causes of angina pectoris.

Labeling of pacemakers

For short designation Three-letter (ICHD) and five-letter (NBG) codes are used. The marking indicates the number of electrodes and the presence of additional functions. The letters of the code sequentially indicate:

1. Localization of implanted electrodes (A – atrial, V – ventricular, D – both cavities).
2. Detectable camera.
3. Response to a received impulse (stimulation – I, suppression – T, both functions – D, no response – O).
4. Adaptation to the patient’s body requirements for contraction frequency (load). Rate-adaptive pacemakers are labeled with the letter R.
5. Presence and parameters of other functions in tachycardias.

Contraindications

There are no absolute contraindications for implantation of a heart pacemaker, either based on age or vital signs. The decision is made by surgeons and cardiologists regarding each clinical case. Surgery may be recommended even for patients who are already in the intensive care unit due to a heart attack. This is possible if the cessation of blood supply to a section of the heart muscle is accompanied by complete atrioventricular block or severe arrhythmia.

The date of intervention can be postponed due to several clinical circumstances (indications), if the patient does not need immediate installation of a pacemaker. These include:

• Fever or symptoms of infectious diseases.
• Exacerbation chronic pathologies internal organs (asthma, peptic ulcers Gastrointestinal tract).
• Mental disorders that exclude normal contact with the patient and reduce the likelihood of successful rehabilitation.

Preparation and tests before intervention

List of necessary diagnostic procedures varies depending on the urgency of the operation and the standards of a particular clinic. Standard preoperative cardiac tests and studies are usually performed:

Preparation for surgery includes consultation with the following doctors:

• Arrhythmologist.
• Otolaryngologist and dentist (they exclude or treat foci of infection).
• Other specialists if available chronic diseases kidneys, central nervous system, endocrine system.

A few days before the intervention, doctors may require you to stop therapy with NSAIDs and anticoagulants. In parallel with this, it is necessary to lighten the diet, and on the day of the procedure, starting from midnight, do not eat or drink anything.

How is implantation performed?

The cardiac pacemaker is installed with local anesthesia of the sternum, less often - under general anesthesia. The entire procedure lasts 1-2 hours and includes the following steps:

1. After all diagnostic procedures, the patient is taken to the operating room. Local anesthesia is applied to the sternum above the left clavicle.
2. An incision is made into the skin and vein under the collarbone. The electrodes are passed through the vessel to the cavities of the heart. The progress of the detectors is monitored using x-rays.
3. When they reach the desired chambers, the surgeon looks for the best place to stimulate by checking the heartbeat parameters on the ECG. Upon completion of the search, the electrodes are fixed in the wall of the organ with “antennae” or a corkscrew-like fastening.
4. After installing the detectors in subcutaneous tissue the bed for the ECS body is being prepared. Having placed the device, doctors connect electrodes to it, stitch the wound and apply sterile bandage. A noticeable scar later remains at the site of the suture.

After the operation, the arrhythmologist programs the pacemaker, setting the modes for recording the cardiogram, stimulating the heart muscle, parameters for analyzing the load and choosing the degree of stimulation activity. Also in the settings you can set an emergency mode, which operates when the battery charge is low.

For 6-10 days, the patient is observed in the hospital, receiving therapy with analgesics, anticoagulants and antibacterial drugs.

How long does the stimulator last?

The pacemaker is installed forever, but the duration of uninterrupted operation of one pulse source does not exceed ten years. The service life of the ECS is on average 8-10 years: it is determined by the battery capacity. After complete discharge or failure of the stimulator due to non-compliance with safety standards or manufacturing defects, the device must be replaced. Electrodes often last longer than electrical pulse generators, so when reoperation can only install a new titanium case with a microcircuit and battery.

The warranty covers the first 3-5 years of operation of the device.

What is the cost of the operation?

If it is necessary to implant a heart pacemaker, the cost of the operation can be paid according to a quota, that is, the patient can do it free of charge, excluding the cost of travel, stay in a medical facility and accommodation during preparation for the procedure and rehabilitation. Due to the high demand for ECS, scheduled installations are carried out on a rolling basis.

The price of electrical stimulators varies depending on the manufacturer and configuration of the device. Single-chamber pacemakers will cost the patient 10-70 thousand rubles, two-chamber pacemakers - 80-200, three-chamber pacemakers - up to 450. The cost of electrodes, as well as the cost of implantation itself, are often calculated separately.

Complications

Side effects after surgery that may worsen the patient's condition are uncommon. According to statistics, complications are observed in 6.2% of elderly patients (over 65 years of age) and 4.5% of people under this age. The probability of fatal consequences is orders of magnitude lower than these values. When installing an pacemaker, there is a risk:

• Infectious infections - suppuration of the incision, fistula formation, sepsis.
• Displacements of detector electrodes.
• Intracardiac bleeding.
• Stimulation of extracardiac muscles, diaphragm.
• Loss of the analyzing function of the pacemaker, leading to stimulation failures.
• Swelling of the upper limb.
• Pneumothorax.
• Block up large vessels.
• Detector fracture.
• Early end of battery life.

Most of these complications can be avoided with proper implantation of the device, the use of quality equipment and adequate postoperative care. To protect yourself, you should pay attention to patient reviews of heart pacemakers from a particular manufacturer, as well as about operations performed by a particular doctor.

Lifestyle after surgery

Life with a pacemaker is full and differs from the reality of a healthy person only in a number of aspects. By following the recommendations, the patient can work, do household chores, and even get involved in sports.

In this case, it is necessary to observe safety precautions:

• Visit a cardiac surgeon and arrhythmologist once a quarter for 1 year after implantation of the stimulator, once every six months during the second year and annually thereafter.
• Monitor your health status (well-being, blood pressure, pulse rate).
• Refuse bad habits(alcohol, nicotine), establish a balance between work and rest.
• Avoid certain diagnostic methods (ultrasound of the sternum, MRI) and physical therapy (exposure to magnetic fields heat).
• Consult a cardiologist before minimally invasive interventions (electrocoagulation, operations with electric scalpel incisions, crushing stones in internal organs).
• Do not stay near high-voltage power sources for long periods of time.
• Avoid blows to the sternum and falls.
• Mobile phone and sources electromagnetic radiation(including household ones) when used, it is advisable to place it on the other side of the body relative to the device, at a distance of more than 25-30 cm from it.

The patient needs to carry with him a document confirming the installation of the pacemaker: this will avoid detector checks that are dangerous for the operation of the device.

The patient’s performance is determined medical commission, taking into account the presence or absence of complications (IHD, CHF). A patient may be given a disability group if work at a specific workplace can cause serious harm to him or the device (contact with electric welding equipment, steel-smelting machines).

Having a pacemaker is not absolute contraindication for bearing a fetus. But the patient must be observed by a cardiologist throughout the entire pregnancy and follow all the doctor’s recommendations on nutrition and exercise. Childbirth takes place only through caesarean section, the operation is scheduled.

Physical activity should be moderate, without straining the sternum. During the rehabilitation period (up to 3 months), sports are prohibited along with any other intense loads upper body.

Banned for life martial arts due to the risk of impacts to the area of ​​the device, extreme sports, football, rugby, basketball, hockey, shooting, bodybuilding with weights on the pectoral muscles.

Baths and saunas are allowed only after consultation with a doctor in the absence of complications, after the end of rehabilitation. Visits should be infrequent and gentle.

Forecast

The use of pacemakers in medicine has significantly increased the life expectancy of patients with arrhythmia, heart block and sinus node weakness. For bradyarrhythmias and supraventricular tachycardias, the effectiveness of device installation reaches 100%. With atrial and ventricular fibrillation, pacemaker helps 80-99 patients out of 100.

Knowing not only your own indications for installing a pacemaker, but also what it is, what advantages and disadvantages the operation to implant it carries, you can accept with greater confidence the right decision. EX allows you to eliminate unpleasant symptoms heart pathologies and promptly stop life-threatening conditions.

In clinics, doctors are increasingly encountering patients for whom life with a pacemaker has become normal everyday problem. They do not complain about their health, continue to work in their specialty, and cope with moderate physical activity.

It is wonderful when a person who was previously bedridden due to arrhythmia attacks receives a pacemaker to get rid of the pathology.

Purpose of the device

U healthy people contraction of the heart muscle occurs under the influence of transmission nerve impulses. The path runs from the sinus node in the right atrium to interventricular septum and then with fibers diverging deeper. This is how we ensure correct rhythm.

The coordinated activity of the main node with the sympathetic and vagus nerves makes it possible to adapt the number of contractions to specific situation: during physical work and stress, the organs and brain need more oxygen, so the heart should beat more often; during sleep, a slower rhythm is sufficient.

Arrhythmias occur for various reasons. Electrical impulses change direction, additional foci appear, each of which “claims” to be a pacemaker.

Medicines do not always lead to successful result. There are cases when combined pathology in a person precludes the use of medications. In such a situation, installing a pacemaker comes to the rescue. He is capable of:

• “force” the heart to contract at the desired rhythm;
• suppress other sources of excitation;
• monitor a person’s own heart rhythm and intervene only in case of violations.

How does the device work?

Modern types of pacemakers can be compared to a small computer. The device weighs only 50 g. The coating is made of titanium compounds. A complex microcircuit and battery are built inside, providing autonomous power to the device. The service life of one battery is designed for 10 years. This means that the pacemaker will have to be replaced with a new one. The latest modifications of the device last from 12 to 15 years.

The device comes with durable electrodes for direct contact with the myocardium. They transmit the discharge to muscle tissue. The electrode is equipped with a special sensitive head for sufficient interaction with the heart muscle.

All materials from which the device is made are suitable for the body, do not have allergic properties, and do not deteriorate due to body movements or heart contractions.

Pacemaker operation

To understand how a pacemaker works, imagine an ordinary battery that we often use in everyday life. We always set it depending on the charge poles. In the device, a discharge occurs only when the heart’s own contractions become rare with bradycardia or chaotic with a disturbed rhythm.

The force of the discharge imposes the necessary rhythm on the heart, which is why the device is also called an artificial pacemaker. In older models, a significant drawback was the setting of a constant number of contractions, for example, 72 per minute. Of course, this is enough for a calm, measured life, slow walking. But it is not enough in cases of acceleration of movements, if you have to go for a run, or in case of excitement.

A modern heart pacemaker “does not offend”, adapts to its needs and physiological fluctuations in contraction frequency. Conductors not only transmit impulses to the myocardium, but also collect information about the established heart rhythm. The attending physician can check the effect of the device in specific situations.

Types of devices

The need for an artificial pacemaker can be temporary or permanent. Temporary installation of a pacemaker is necessary for the duration of the patient's hospital stay to treat short-term problems:

• bradycardia after heart surgery;
• eliminating overdose medicines;
• relieving an attack of paroxysmal fibrillation or ventricular fibrillation.

Pacemakers for the treatment of long-term problems with arrhythmias are produced by different companies and have their own differences. Practically, they can be divided into three types.

There are no obstacles to blood outflow when installing electrodes in 2 chambers

Single-chamber - characterized by one single electrode. It is placed in the left ventricle, but it cannot influence atrial contractions; they occur independently.

Disadvantage of the model:

• in cases where the rhythm of contractions of the ventricle and atria coincides, blood circulation inside the heart chambers is disrupted;
• not applicable for atrial arrhythmias.

Double-chamber pacemaker - equipped with two electrodes, one of them is located in the ventricle, the second in the atrium cavity. Compared to single-chamber models, it has advantages because it is able to control and coordinate both atrial and ventricular rhythm changes.

Three-chamber is the most optimal model. It has three electrodes that are implanted separately into the right chambers of the heart (atrium and ventricle) and into the left ventricle. This arrangement results in maximum proximity to physiological pathway the passage of the excitation wave, which is accompanied by the support of the correct rhythm and the necessary conditions for synchronous contraction.

The choice of the desired model is determined by the type of arrhythmia and the patient’s condition. The attending cardiac surgeon can always advise the patient and relatives on the optimal therapeutic effect device in a specific situation.

Why are devices coded?

For convenient use different models without detailed descriptions purpose, a letter classification is used, proposed jointly by American and British scientists.

• the value of the first letter determines in which parts of the heart the electrodes are implanted (A - in the atrium, V - in the ventricle, D - in both chambers);
• the second letter reflects the camera's perception of an electrical charge;
• the third is the functions of triggering, suppressing, or both;
• fourth - indicates the presence of a mechanism for adapting contractions to physical activity;
• fifth - includes special functional activity with tachyarrhythmias.

The most common models are VVI and DDD types

When encoding, no attention is paid to the last two letters, so you have to additionally find out the functions of the device.

Indications for artificial pacemaker implantation

Persistent heart rhythm disturbances have many causes. Most often, severe heart attacks and widespread cardiosclerosis lead to failures. These changes are especially severe in old age, when the body no longer has enough strength to restore and compensate for losses.

No less often, cardiac surgeons have to deal with dangerous attacks without a clear cause (idiopathic arrhythmias).

• confidence in the weakness of the sinus node;
• the presence of such types of arrhythmias as extrasystole, paroxysmal tachycardia, atrial fibrillation, if they develop frequent attacks ventricular fibrillation;
• complete with attacks of loss of consciousness;
• the need to take drugs against the background of blockade to support myocardial contractile function in cases of heart failure.

Surgery is indicated if it is not possible to cope with medication. There are no contraindications for this manipulation.

How is temporary pacing performed?

There are simplified models for temporary pacing. Depending on the location of the place where the electrodes are placed, types of stimulation are distinguished:

• endocardial,
• epicardial,
• outer,
• transesophageal.

The most effective is the endocardial option. The device is placed next to the patient, the electrode as a probe is inserted through a catheter into subclavian vein under the control of X-ray or ultrasound equipment. On the electrocardiogram at correct installation a rise in the ST interval is recorded. Bursts of energy and the ECG pattern are monitored on the monitor.

In case of external stimulation, adhesive electrodes are applied to the patient's skin. It is carried out if it is impossible to use the intracardiac method.

Epicardial installation - made with special electrodes only on an open heart during cardiac surgery

Intraesophageal stimulation is limited to temporary relief of supraventricular arrhythmias.

After the patient is removed from dangerous condition The electrodes are removed and the heart is allowed to operate at its own pace.

Progress of the permanent pacemaker implantation surgery

The operation to install a pacemaker for a long time is performed without opening the chest. Use local anesthesia. Using an incision in the subclavian region, the electrodes are inserted through the subclavian vein into the heart chambers, then under the skin to pectoral muscle hem the device itself.

The correct installation is checked using X-ray control and a cardiac monitor. In addition, the surgeon needs to make sure that the pacemaker is working and fully captures atrial impulses in the specified mode.

At the end, several stitches are placed on the skin and the incision site is covered with a sterile napkin.

The pacemaker is replaced after the device's service life has expired according to the same principle as the initial installation.

How to evaluate the correct operation of a pacemaker?

The frequency of the imposed rhythm is monitored on the monitor; it must correspond to the programmed one. All artifacts (vertical bursts) must be accompanied by ventricular complexes. Insufficient frequency is possible when the battery is discharged. Contractility The heart can be easily checked by a clear pulse in the ulnar artery.

When identifying the natural rhythm frequency higher than programmed, use a reflex increase in tone vagus nerve(massage of the carotid area or Valsalva maneuver with straining while holding the breath).

During the operation, some actions of the medical staff are important:

• Carrying out electrocoagulation of blood vessels to stop bleeding may affect the operation of the pacemaker, therefore it is recommended to monitor the short pulse effect of the coagulator;
• anesthesiologists know a list of medications that can mask electrical impulses from the myocardium and block cardiac stimulation;
• if the patient's condition is accompanied by a violation of the concentration of potassium in the blood, the electrophysiological properties of myocardial cells are disrupted and the threshold of sensitivity to stimulation increases, this should be taken into account when selecting parameters.

How is the postoperative period going?

During the rehabilitation period after implantation of the stimulator, the patient needs to get used to slight restrictions in physical activity, movements involving the muscles of the shoulder girdle, and constant “listening” to the heart.

If the skin at the suture site is inflamed, moderate pain and fever are possible. Problems in setting up the device may be indicated by increased shortness of breath, pain in the chest, increasing weakness.

It is difficult to predict in advance how long a patient will live with the device installed. You need to use the average deadlines specified in the instructions.

Indications for installing a cardiac pacemaker (or artificial cardiac pacemaker, IVR) are absolute and relative. Indications for installing a heart pacemaker are discussed every time there are serious interruptions in the rhythm of the heart muscle: long pauses between contractions, rare pulses, atrioventricular blockades, syndromes hypersensitivity carotid sinus or sinus node weakness. Patients with such diseases are those who definitely need to have a pacemaker installed.

The cause of such deviations may be a violation of the formation of an impulse in the sinus node ( congenital diseases, cardiosclerosis). Bradycardia usually occurs due to one of four possible reasons: pathology of the sinus node, pathology of the AV node (AV block), pathology of the legs (fascicular blockades) and autonomic depression nervous system(manifested by neurocardial syncope).

Absolute indications for surgery to install (use) a pacemaker include: the following diseases:

• bradycardia with clinical symptoms(dizziness, fainting - syncope, Morgagni-Adams-Stokes syndrome, MAS);
• a recorded decrease in heart rate (HR) to values ​​less than 40 during physical activity;
• episodes of asystole on the electrocardiogram (ECG) lasting more than 3 seconds;
• persistent atrioventricular block II and III degree in combination with two or three-bundle blocks or after myocardial infarction if present clinical manifestations;
• any types of bradyarrhythmias (bradycardia), life threatening or the health of the patient and in which the heart rate is less than 60 beats per minute (for athletes - 54 - 56).

Indications for installing a pacemaker are rarely heart failure, in contrast to cardiac arrhythmias that accompany it. In severe heart failure, however, we may be talking about asynchronous contractions of the left and right ventricles - in this case, only the doctor decides on the need for surgery to install a pacemaker.

Relative indications for pacemaker implantation:

• atrioventricular block of the second degree, type II, without clinical manifestations;
• atrioventricular block of the third degree at any anatomical site with a heart rate under load of more than 40 beats per minute without clinical manifestations;
• syncope in patients with two- and three-fascicle blocks not associated with ventricular tachycardia or complete transverse block, with the impossibility of accurately identifying the causes of fainting.

Subject to availability absolute readings For implantation of a pacemaker, the patient’s operation is performed as planned after examination and preparation, or urgently. in this case no. Subject to availability relative readings The decision to implant a stimulator is made individually, taking into account, among other things, the patient’s age.

The following diseases are not indications for installing a heart pacemaker based on age: atrioventricular block of the first degree and atrioventricular proximal block of the second degree of type I without clinical manifestations, drug blockades.

It should be noted that each country in the world has its own recommendations for installing heart pacemakers. Russian recommendations largely repeat those American Association cardiologists.

In what cases is a pacemaker placed on the heart?

A heart pacemaker is installed only in cases where there is a real risk to the patient’s life and health. Today, both single-chamber and dual- and multi-chamber devices are used. Single-chamber “drivers” are used (to stimulate the right ventricle) and for sick sinus syndrome, SSS (to stimulate the right atrium). However, more and more often they put it in SSSU.

SSSU manifests itself in one of four forms:

• symptomatic - the patient has already lost consciousness or had some kind of dizziness;
• asymptomatic - the patient has bradycardia on the ECG or daily monitoring(on “holter”), but the patient does not express any complaints;
• pharmacodependent - bradycardia is present only against the background usual doses drugs with negative chronotropic effect, (antiarrhythmic drugs and beta blockers). When the drugs are discontinued, the symptoms of bradycardia disappear completely;
• latent – ​​there is no clinical or bradycardia in the patient.

The last two forms are recognized initial stage sinus node dysfunction. The patient can wait up to several years with implantation of the pacemaker, but it is only a matter of time before the operation becomes an emergency planned one.

What other heart conditions require a pacemaker?

In addition to the heart diseases described above, a pacemaker is installed to treat dangerous arrhythmias: ventricular tachycardia and ventricular fibrillation for the prevention of sudden cardiac death. In the presence of atrial fibrillation, the indications for installing a pacemaker are emergency (the patient in this case already loses consciousness or has tachybradyform). And the doctor cannot prescribe drugs to increase the rhythm (risks of fibrillation attacks) and cannot prescribe antiarrhythmic drugs(the brady component is enhanced).

Risk sudden death in case of bradycardia with attacks, MAC is considered low (according to statistics - about 3% of cases). Patients diagnosed with chronic bradycardia also have a relatively low risk of syncope and sudden death. With such diagnoses, the installation of a pacemaker is largely preventive in nature. Such patients, due to adaptation to their heart rate, rarely complain of dizziness or fainting, but have a whole layer concomitant diseases, from which the installation of IVR will no longer get rid of.

Timely implantation of a pacemaker helps avoid the development of brady-dependent heart failure, atrial fibrillation, arterial hypertension. According to experts, currently up to 70% of operations are carried out for preventive purposes.

In case of transverse blockade, pacemaker implantation is mandatory regardless of the cause, symptoms, nature of the blockade (transient or permanent), and heart rate. There are risks here fatal outcome for the patient are extremely high - IVR installations can increase the survival rate of patients to values ​​close to those of healthy people. And the operation is emergency.

In two cases:

• complete blockade that appeared during acute heart attack myocardium;
• complete blockade resulting from cardiac surgery

it is possible to wait up to 2 weeks (it is possible to resolve the problem without installing an pacemaker). With congenital complete blockade, indications for pacemaker implantation already exist in adolescent children. Congenital blockade develops in utero (the cause is mutations of chromosomes 13 and 18). In this case, children do not have MAS attacks, because they are completely adapted to their bradycardia.

Unfortunately, bradycardia only intensifies with age, by the age of 30 (the average lifespan of a patient with similar disease) Heart rate may decrease to 30 beats per minute. Installation of a stimulator is mandatory and is planned. Emergency implantation is carried out in case of fainting. If the heart rate is critical, then the operation is performed even at the age of several days or months.

Treatment of blockage in a child depends on whether it is congenital or not. If it is congenital, it is registered in the maternity hospital, and the diagnosis is known even during pregnancy. If acquired, then it is considered to be obtained as a result of the myocardium. In the second case adolescence not expected - pacemaker is implanted regardless of age.

The beginning of the 20th century was marked by the rapid development of technology in all sectors of human life.

Innovative medical research, carried out in the 1920s, showed the ability of the myocardium to contract under the influence of electrical current pulses.

The essence of the research was capable of revolutionizing the treatment of certain heart diseases, as proven by the external rhythm device created in 1927.

However, due to the large dimensions and relatively short service life of electronic components of that time, the development of pacemakers was frozen for decades.

The device in its modern sense was created only in 1958 by Swedish scientists and was named Siemens-Elema. Since then, the design and operating principle of pacemakers have been improved every year - the devices have become more functional, reliable and durable.

Purpose and design of the device

To understand how a modern pacemaker works, you need to understand what it is. An electric pacemaker (ECS), or, as it is also called, an artificial pacemaker (APM), is a microprocessor device equipped with an independent power source and located in a sealed metal case, most often made of titanium alloy.

The design of the device includes:

1. Frame– serves to accommodate the internal elements of the pacemaker and isolate them from body tissues.
2. Control and communication unit– necessary for coordinating the operation of modules and exchanging information with control and diagnostic devices.
3. Memory block– stores statistical information about the operation of the device.
4. Sensor block– is able to detect changes in the functioning of the heart and correct the effects of the pacemaker.
5. Working block– forms and transmits electrical impulses to the heart.
6. Battery– serves as a power source for the remaining elements of the pacemaker, is equipped with mechanisms for saving energy and disabling non-basic functions when the charge drops below a threshold level.

The functions of a pacemaker are to sense the heart’s own rhythm, detect pauses and other failures in its operation, and eliminate these failures by generating impulses and transmitting them to the appropriate chambers of the heart.

If your own rhythm is stable and corresponds to the needs of the body, impulses are not generated.

An optional feature of some high-tech stimulators is the prevention of arrhythmia, tachycardia and other disorders through special work programs.

What types of pacemakers are there?

IN present moment There are many types of pacemakers, differing from each other in design, functionality and other criteria. Classification of devices can be carried out according to various signs, but the main ones are the design features that characterize the specifics of stimulation.

Depending on them, they are distinguished:

• Single-chamber pacemakers - affect one atrium or one ventricle;
• Two-chamber – act on the atrium and ventricle simultaneously;
• Three-chamber – affect both atria and one of the ventricles;
• Cardioverter-defibrillators (ICD, IKVD) - used in cases of high risk complete stop of blood circulation.

To understand in what cases a specific pacemaker model should be used, its letter code, which takes into account design features and functionality of the device.

It includes 3-5 letters of the Latin alphabet, which, depending on serial number in the labeling indicate:

1. Camera stimulated by the device.
2. The camera detected by the device.
3. The nature of the heart's response to an impulse.
4. Device frequency adaptation parameters.
5. Type of device response to tachycardia.

The main letters used in the marking of a pacemaker are the first letters English words: Atrium (atrium), Ventricle (ventricle), Dual (two, both), Single (one), Inhibition (suppression), Triggering (stimulation), Rate-adaptive (frequency adaptation). The final code used to mark types of pacemakers may look like this: AAI, VVIR (aka PEX), DDDR, etc.

When considering the classification of IVR, one cannot ignore the temporary pacemaker. It is an external device that is connected to the patient’s heart by a resuscitator in the event of a sudden cessation of natural cardiac activity or frequent dangerous fainting.

Indications for installation

The most common heart conditions for which a pacemaker is recommended are:

• Arrhythmia;
• Sick sinus syndrome;
• Atrioventricular block.

Arrhythmia is pathological condition, which is characterized by a change in the frequency and sequence of stages of excitation and contraction of the heart. With arrhythmia it is disrupted normal functioning organ and a number of serious complications arise.

Arrhythmias can be caused for various reasons, but the most common are:

• Coronary heart disease;
• Heart failure;
• Cardiomyopathy and myocarditis;
• Heart defects (both congenital and acquired);
• Mitral valve prolapse;
• Toxic effects, including smoking, alcoholism, drug use;
• Mixed effects, manifested by atrial fibrillation or ventricular arrhythmia (heart rate increases to 250 beats/min or more).

Not everyone has a pacemaker implanted. listed cases. Some violations allow you to do without surgical intervention, affecting the source of the problem medicines or other factors.

Sick sinus node syndrome (SSNS) reflects disturbances in the sinoatrial mechanism that controls heart rate.

Arrhythmias and blockades associated with SSSS include:

• Fall minimum heart rate up to 40 beats/min. and lower, and heart rate under load is up to 90 beats/min. and below;
• Pauses between contractions exceeding 2.5 seconds;
• Alternating bradycardia and tachycardia;
• Severe sinus bradycardia;
• Bradysystolic mitral arrhythmia;
• "Migration" of the atrial driver;
• Sinoauricular blockade, etc.

Features of the operation

The operation to install a pacemaker is a minor surgical procedure and is performed in the X-ray operating room. The first step is to determine the installation location.

The most common options are:

• Left subclavian region– for right-handers, left-handers with tissue damage right side breasts;
• Right subclavian region - for left-handers, right-handers with tissue damage on the left side of the chest;
• Other places connected by veins to the chambers of the heart - if classic options for some reason are not possible.

Let's see how the operation goes. The algorithm usually includes the following sequence of actions:

For an experienced surgeon, 20-30 minutes will be enough for all this, but if the installation site is atypical or several cameras are connected at once, the surgical intervention time may increase.

Device installation cost

There is no clear answer to the question of how much such an operation costs - it all depends on the reputation and prices of the clinic, and the features of the technologies used in it. In Moscow heart health clinics, the cost of the operation will be from 100 to 600 thousand rubles, in St. Petersburg the price ranges from 60 to 300 thousand. Provincial clinics are ready to do the work for 25-100 thousand rubles.

But it is important to understand that these amounts only take into account the installation of the device. For the pacemaker itself you will need to pay another 2500-10000 dollars.

Patients treated under a quota can receive a full range of services for $3,500-$5,000.

This amount includes:

• Accommodation and maintenance in the clinic;
• Cost of a pacemaker;
• Cost of consumables;
• Payment for the work of doctors and medical staff.

For patients with serious heart rhythm disorders who have general health insurance, a pacemaker is installed free of charge.

How to live with a pacemaker?

Despite the opportunity to return, in fact, to their previous life, a patient with a pacemaker should still adhere to some rules.

The first and most important thing is regular, timely visits to a doctor who carries out further monitoring of the patient.

The following sequence of visits is usually prescribed:

1. Three months after the pacemaker was installed.
2. Six months after the first postoperative visit.
3. Once every six to twelve months, by agreement with your doctor for a routine examination.
4. Unscheduled - in cases of sensation of electrical discharges, return of symptoms of the disease, appearance of signs of inflammation at the site of installation of the device.
5. After the pacemaker’s service life, as stated by the manufacturer, has expired (usually 6-15 years).

Like any implantable medical device, a pacemaker has its pros and cons. About the advantages, that is positive impact A lot has already been said about the device on the functioning of the heart and the body as a whole. But it's important to remember that living with a pacemaker after surgery means paying attention to details that previously seemed unimportant.

You will have to refrain from the following types of work and actions:

Being close high-voltage power lines, powerful wireless communication translators;

Checking with a metal detector and passing through magnetic frames at the airport, shops;

Carrying out MRI, lithotripsy, physiotherapy, as well as ultrasound in the immediate vicinity of the device installation site.

There will also be a number of restrictions in everyday life. Particular care should be taken when working with electrical appliances, and especially with powerful power tools, to avoid any electric shock. The mobile phone should be kept at a distance of no closer than 20-30 cm from the place where the pacemaker is installed.

It is also recommended not to bring a camera, player or other portable electronics near the device. Otherwise, patients with a pacemaker live life to the fullest, getting rid of problems associated with heart rhythm disturbances.

In what cases is it necessary to replace the device and how is it carried out?

During a routine visit to the doctor, the pacemaker is diagnosed and, if necessary, reprogrammed. However, in some cases it may be necessary to replace the device.

Such cases include:

• End of warranty period;
• Low remaining battery charge;
• The occurrence of fatal faults.

A special case is replacing the stimulator to install a more modern and functional model. The process of replacing a pacemaker is similar to the process of installing it; it is also carried out under local anesthesia. During the operation, the condition of the electrodes is monitored and, if necessary, new ones are installed.

Video