2023a

PACEMAKER IMPLANT,
CARDIOVERTER-DEFIBRILLATOR
IMPLANT THREE-DIMENSIONAL
PACEMAKER
A N G U I E H E R R E R A , N I C
O L E F L O R E Z , S E R G I O
DANIEL FELIPE GÓMEZ ESPARZA, JULIETH GAMBOA,

GUERRERO, YULETSY JAIMES Y CATALINA JAIMES

PAREDES
 PACEMARKER
IMPLANT

BASIC CONCEPTS:

HEART RATE:

THE HEART RATE IS THE REGULAR SUCCESSION

OF SYSTOLES AND DIASTOLES OF THE HEART
MUSCLES.

CARDIAC ARRHYTHMIA:

ARRHYTHMIAS ARE RHYTHM DISTURBANCES THAT MAY

BE DUE TO THEIR ACCELERATION (TACHYCARDIA), THEIR
SLOWING (BRADYCARDIA) OR THEIR ABSENCE (ASYSTOLE
OR HEART BLOCK).

PACEMARKER
DEFINITION

is an electronic device that delivers a repetitive

electrical stimulus to the right atrium (RA),
right ventricle (RV), or both in the case of
sequential atrioventricular (AV)

Pacemakers initiate and maintain the heart

rate when the natural pacemaker, the
sinoatrial (SA) node, fails, is late, or does not
regularly drive the ventricles. The latter causes
AV block.

Tomada de: https://medlineplus.gov/spanish/ency/article/007369.htm



PACEMARKER'S
PARTS
THE LEADS
. wires that connect the
heart to the generator and
THE GENERATOR
carry electrical messages to
said organ.
contains the battery and the
information to control the
heartbeat.
is a more resistant material
than steel, although less heavy
than steel and which does not
cause rejection.

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P09320

WHY IS THE PACEMAKER IMPLANTATION

PROCEDURE PERFORMED?

PACEMAKERS CAN BE USED FOR PEOPLE WHO HAVE HEART PROBLEMS

THAT CAUSE THEIR HEART TO BEAT VERY SLOWLY (BRADYCARDIA) OR
QUICKLY (TACHYCARDIA), WHAT THIS PACEMAKER WILL DO IS REGULATE
THE HEART RATE TO A SUITABLE ONE.

 TYPES
.
SINGLE CHAMBER DUAL CHAMBER TRICAMERAL
PACEMARKER

PACEMARKER PACEMARKER
Affect only the atrium or
Affects the atrium and right
ventricle they affect the atrium and and left ventricles.

ventricle, normally right.

There is a type of pacemaker

that is the VDD. It is the only
exception to this scheme. It
is a model that, through a
single electrode, detects in
both chambers (atrium and
ventricle) but only stimulates
in the ventricle.

 DIAGNOSTIC METHODS
.

ELECTROCARDIOGRAM:

measures the electrical activity of the heart. Adhesive patches

(electrodes) are placed on the chest and sometimes on the arms and
legs. They have wires that connect the electrodes to a computer that
displays the results

MONITORING OR HOLTER:

It is a small portable device that tracks your heart rate. Your doctor may ask
you to wear a Holter monitor for 1 to 2 days. During that time, the device
records every heartbeat. Holter monitoring is especially helpful in diagnosing
heartbeat-related problems that occur at unpredictable times.

ECHOCARDIOGRAM
This noninvasive test uses sound waves to produce images of the size,
structure, and motion of the heart.

STRESS TEST :
An electrocardiogram is done before and immediately after
walking on the treadmill or riding a stationary bike. Sometimes a
stress test is done along with an echocardiogram or nuclear
medicine imaging.
 CARDIOVERTER-
DEFIBRILLATOR
IMPLANT

Small, battery-powered device to detect and

stop arrhythmias, continuously monitors the
heartbeat and delivers electrical shocks,
when necessary, to restore normal heart
rhythm.
TYPES
• THE TRADITIONAL IMPLANTABLE CARDIOVERSER
DEFIBRILLATOR
is inserted into the chest, and wires (leads) are connected to the
heart. The implant placement procedure requires invasive surgery.

THE SUBCUTANEOUS IMPLANTABLE CARDIOVERSER

DEFIBRILLATOR:
is another option that is implanted under the skin on the side of the
chest, under the armpit. It is connected to an electrode that runs
along the breastbone. It is larger than the traditional implantable
cardioverter-defibrillator and does not connect to the heart.
 IMPLANTABLE DEFRIBILLATOR'S
PARTS
.
THE GENERATOR
contains the battery and the
information to control the

heartbeat.
is a more resistant material
than steel, although less heavy
than steel and which does not
cause rejection. THE LEADS

wires that connect the
heart to the generator and
carry electrical messages to
said organ.

Tomada de: https://www.stanfordchildrens.org/es/topic/default?id=pacemakerinsertion-92-

P09320

 WHY IS IT DONE?

IF YOU HAVE HAD SIGNS OR SYMPTOMS OF A CERTAIN TYPE OF

IRREGULAR HEARTBEAT CALLED SUSTAINED VENTRICULAR
TACHYCARDIA, INCLUDING FAINTING.
CORONARY ARTERY DISEASE AND HEART ATTACK THAT HAS
WEAKENED THE HEART.
AN ENLARGED HEART MUSCLE.

 DIAGNOSTIC METHODS
.

ELECTROCARDIOGRAM:
measures the electrical activity of the heart. Adhesive patches
(electrodes) are placed on the chest and sometimes on the arms and
legs. They have wires that connect the electrodes to a computer that
displays the results

MONITORING OR HOLTER:
It is a small portable device that tracks your heart rate. Your doctor may ask
you to wear a Holter monitor for 1 to 2 days. During that time, the device
records every heartbeat. Holter monitoring is especially helpful in diagnosing
heartbeat-related problems that occur at unpredictable times.

ECHOCARDIOGRAM
This noninvasive test uses sound waves to produce images of the size,
structure, and motion of the heart.
 THE IMPLANTABLE CARDIOVERTER-
DEFIBRILLATOR COULD BE
PROGRAMMED TO:

Low energy pacemaker. You may feel nothing or a

painless fluttering in your chest when the ICD reacts
to slight changes in your heart rhythm.

A higher energy shock. For more serious heart

rhythm problems, the implantable cardioverter-
defibrillator can deliver a higher-energy shock.

RUTHSTON MEDICAL CENTER | 2020

 PRECAUTIONS

Cell phones and other mobile devices. avoid placing it less than 15
centimeters from the site of the implantable cardioverter-defibrillator

Security systems. the defibrillator could trigger airport security alarms.

Some procedures, such as magnetic resonance imaging, magnetic

resonance angiography, and radiofrequency or microwave
ablation,

Stand at least two feet away from welding equipment, high-voltage

transformers, or motor-generator systems.

Keep headphones and wireless chargers at least 6 inches apart

CHECK LIST
COMMERCIAL HOUSE
INTRODUCER KIT

 PROCEDURE

1. Application of local anesthesia, infiltrating the subclavian puncture area, at the same time
making a subcutaneous bubble in the area where the pacemaker bag will be made.
2% lidocaine with epinephrine, 20mm needle

2. Subclavian vein puncture depending on the number of electrodes to be placed.

2% lidocaine with epinephrine, 20mm needle

3.A subcutaneous or submuscular pocket (as appropriate) is made for the implantation of the
device, trying not to break the fascia of the muscle.

Blunt dissection, Metzembaum or Kelly scissors for dissection, 2/0 silk fixation points of
the electrodes (one point for each electrode) and another fixation point to hold the
pacemaker or cardioverter defibrillator.

This pocket is where the pacemaker generator will be stored.

4.Once the bag is made, a topical antibiotic will be applied, soaked in gauze.
Cefazolin 1 g or gentamicin 80 mg, radiopaque gauze.

5. After this, the 6, 7 or 9 Fr introducers are passed, as appropriate.

Introducer of the commercial house (consisting of the sleeve and the dilator)

RUTHSTON MEDICAL CENTER | 2020

 PROCEDURE

6. The vein is dilated if necessary

Dilator
7.The surgeon proceeds to remove the guide.
In this maneuver, care is taken to prevent air from entering and causing an embolism

8. A stylet will be passed through the introducer, which will give the shape for the electrode to
be positioned.
The electrodes will come from this stylet.

9.The implantation of the electrodes will be guided by fluoroscopy.

*Active or passive fixation ventricular electrode (if ventricular)
*Auricular electrode (active fixation in all cases)

10.The electrode has a thread and the electrode kit has a butterfly which will screw on and
remain fixed together with the cardiac tissue.
Butterfly.

11.The generator will be fixed to the muscle

Polyester 0 CHR

12.The fascia is sutured Polyglactin 910 3/0 needle ½ round circle

13.Monocryl 3/0 skin is sutured sharp curved needle\

Verification of the parameters of: sensing, impedance and stimulation threshold, after
fixing the electrodes. RUTHSTON MEDICAL CENTER | 2020
 THREE DIMENSIONAL MAPPING
It is the technique that allows delimiting an area of ​the
endocardium and/or epicardium, considered of diagnostic and/or
therapeutic interest, where an arrhythmia is circumscribed, its
origin or critical region that promotes it.

useful in patients
who have already
had previous
ablations and also in
pediatric patients
They allow the three- For its performance,
dimensional electrocatheters are traditionally
creation of inserted into the endocardium
anatomical and/or epicardium, through a
structures venous, arterial or pericardial
route with the help of "X" rays.

The creation of
voltage maps locating
To serve as a radio-
the points that must anatomical reference
be ablated, without
this implying a longer Electrocatheters have
procedure time. two main functions, he capture, amplification,
recording and
reproduction of electrical
signals from specific areas
of the heart
 HOW DOES IT
WORK?

Recording and characterization of electrical signals It is done by means of the

alphabet that allows understanding and diagnosing cardiac arrhythmias.

These signals are correlated during an arrhythmia with the waves and intervals of the
electrocardiogram, which makes it possible to determine their origin or establish
relationships between atrial and ventricular signals, their position or order in time,
facilitating their identification and diagnosis.
 TYPES
.
BASED ON THE
ELECTROMAGNETIC FIELD
PRINCIPLE (CARTO®):
It is based on the use of 3 magnetic fields
generated by an emitter external to the
patient and which is located under the
operating table.
The catheter takes the data for the
anatomical reconstruction and at the same
time records the activation times.
The time elapsed between the electrogram
recorded by the catheter and the activation
of the chosen reference is compared. It can
be early, simultaneous or late, and is
automatically calculated by the system.
BASED ON THE VOLTAGE
GRADIENT PRINCIPLE
(ENSITE NAVX):
It is a diagnostic aid system in electrophysiology
procedures
functions:
1. Navigation:
Displays electrophysiology catheters in real time in a
three-dimensional (3D) manner.
2. Modeling:
Create surfaces that model the anatomical structures
of the heart and register the navigation field for models
based on tomography or magnetic resonance imaging.
3. Mapping:
Record cardiac electrical activity as waveform traces,
collect these electrical data, and display their
representation on color maps
 COLOR MAPS

Color scale used for different purposes

to recreate a three-dimensional map.

If used to correlate the voltage of a

specific point.
Red, green and yellow color: It will
be the lowest voltage.
Lilac color: High voltage
Gray color: Absence of voltage.

HOW IS THE THREE-DIMENSIONAL MAPPING AND

INTEGRATION OF IMAGES CARRIED OUT?

3D image is taken the days preceding the procedure.

These images are stored on a magnetic medium and later

reproduced in the computerized system (CARTO or Ensite).

The images are processed and their limits are debugged.

Critical structures are recognized.

In the procedure, a puncture will be made in the left atrium

and an ablation catheter will be used to perform the 3D
reconstruction.
 STRENGTHS

Reduction of Integration of
the use of “X” Better anatomical complementary
rays recognition images

Mapeo y
Recognition and
70.7%
ablation of difficult-
to-manage
ablación del
substrato
Heart-related deaths in males
arrhythmias arritmogénico
 2023a

CARDIAC ABLATION

IT IS A PROCEDURE USED TO ELIMINATE SMALL AREAS

I N T H E H E A R T T H A T C A U S
E D E F I C I E N C I E S I N T H E
CARDIAC RHYTHM, ALLOWING TO RECONSTITUTE THE
NORMAL ELECTRICAL PATHWAYS OF THE HEART AND
RESUME ITS RHYTHM.


WHY IS IT
PERFORMED?

Cardiac ablation is a procedure used to correct

heart rhythm problems.
When the heart beats, the electrical signals that
cause it to contract must follow an exact
pathway through the heart. Any interruption in
the signaling pathway can trigger an irregular
heartbeat (arrhythmia).

Tomada de: https://medlineplus.gov/spanish/ency/article/007369.htm

 PROCEDURE

1. The procedure is performed under conscious sedation (in

order to reduce anxiety), and vital signs are monitored
during the procedure (heart rate, blood pressure).

2. A puncture is performed on the femoral vein (groin), for the

introduction of the catheters into the cardiac cavities.

3. An electrophysiological study (study of the arrhythmia) is

performed, with programmed electrical stimulation of the
atrium and ventricle inducing the arrhythmia.
The ablation lines are performed using an irrigated
monopolar radiofrequency system, advancing in the atrium at
a rate of 1 cm of tissue every 10 seconds, with a maximum
energy of 25 Watts and a continuous irrigation system with
saline solution in an infusion pump at a rate of 5 to 8 mL/min.

RUTHSTON MEDICAL CENTER | 2020

 PROCEDURE

4. The ablation lines were performed continuously,

always maintaining contact of the device (catheter)
with the tissue and avoiding at all times the
presence of radiofrequency free spaces between
one line and another.
Once the catheter is in place, the cardiologist will
place small electrodes in different areas of the
heart.

5. These electrodes are connected to monitors that

allow the cardiologist to determine which area in
the heart is causing problems with your heart
rhythm.
Once the source of the problem has been found,
one of the catheter leads is used to send electrical
energy to the problem area.

RUTHSTON MEDICAL CENTER | 2020

 PROCEDURE

6. Once the operation was completed, four epicardial pacing electrodes

were placed, two atrial and two ventricular, and cardiac cavity deaeration,
hemostasis and conventional closure were performed.

COMPLICACIONES
DURANTE LA ABLACIÓN

pseudoaneurysms,

arteriovenous fistulas,
phlebitis,
thrombosis of the punctured vessels.
if there is a lesion in any
atrioventricular
atrioventricular node, the
patient would require the implantation
implantation of a definitive pacemaker.

RUTHSTON MEDICAL CENTER | 2020

 CRIOABLATION

CRYOABLATION IS PERFORMED TO RESTORE NORMAL HEART RATE AND

PERMANENTLY ELIMINATE CARDIAC ARRHYTHMIAS.
THE MAJOR BENEFIT OF THIS TECHNIQUE LIES IN THE FACT THAT THE
TREATMENT IS PERFORMED BY FREEZING, IN A SINGLE ENERGY IMPACT,
AND IN A FASTER AND MORE EFFECTIVE MANNER.

RISKS

Allergic reactions to drugs or contrast material

Pre-existing heart or lung conditions
Recent or chronic serious illnesses
Bleeding disorder

ANESTHESIA

Local anesthesia

will receive
During the procedure, you
intravenous fluids and medications fluoroscopy,
anesthesia and a sedative to help you feel more
relaxed.

Tomada de: https://medlineplus.gov/spanish/ency/article/007369.htm

 PROCEDURE

1. A special ablation catheter is inserted and guided into the heart through the blood vessels.
The surgeon will watch the progress on a fluoroscope, an x-ray machine that provides
continuous, real-time images of the inside of the body.

2. Once the catheter reaches the heart, the surgeon will use another catheter tipped with an
electrode to reproduce the presenting arrhythmia. When the approximate location of this
arrhythmia has been identified, the surgeon will first test the area by cooling the tip of the
ablation catheter to 30°C. If correctly positioned, this arrhythmia will be reproduced. If properly
placed, this temperature will temporarily stop the arrhythmia and, at the same time, generate
enough heat to avoid causing permanent damage to nearby tissues, which will recover their
temperature and recover.

3.Once the exact location of the arrhythmia is confirmed, the physician will cool the tip of the
ablation catheter by another 100°C, to -70°C. This extreme cold will freeze and scar the tissue.
This extreme cold will freeze and scar the heart tissue, eliminating the arrhythmia. Your surgeon
will then try to reproduce the arrhythmia again and treatment will continue until the arrhythmia
does not reproduce.

RUTHSTON MEDICAL CENTER | 2020

 2023a

MAZE SURGERY
TREATMENT FOR ATRIAL
FIBRILLATION

IRREGULAR AND OCCASIONALLY RAPID HEART RATE,

O F T E N R E S U L T I N G I N P
O O R B L O O D S U P P L Y .


ATRIAL
FIBRILLATION

Atrial fibrillation is more prevalent in patients

with mitral valve disease compared to other
heart diseases and has a two-fold increased risk
of causing cerebrovascular accidents (CVA).
types of AF:
Paroxysmal AF
Persistent AF
Permanent AF

Tomada de: https://medlineplus.gov/spanish/ency/article/007369.htm

SIGNS AND SYMPTOMS
Disney
Fatigue
Dizziness
Syncope
Chest pain

DIAGNOSTIC METHODS
EKC
Echocardiogram

Chest X-ray

Physical exam

RUTHSTON MEDICAL CENTER | 2020

 PROCEDURE

1. General anesthesia (non-EC procedure)

2. bilateral totally thoracoscopic access to perform a "box lesion" connected to the left atrial
appendage and with additional lesions in the right atrium performed with radiofrequency.
3. ports are introduced in the right thoracic wall and a videothoracoscopy camera is used, CO2
insufflation to facilitate lung collapse preserving the pleural space pressure at 10 mmHg.
4. The pericardium is opened on the right side, separated about 2 cm from the phrenic nerve,
and traction is applied with 3 silk stitches to allow better exposure.
5. After meticulous dissection of the oblique and transverse sinus, isolation of the right
pulmonary veins is started with the Isolator Synergy bipolar clamp.
6. A) Subsequently, the roof and floor lines of the left atrium are made with the Coolrail Linear
Pen (Fig. 1B and C) as well as the line to the right atrial appendage and a bicave lesion in the
right atrium.

RUTHSTON MEDICAL CENTER | 2020

 PROCEDURE
7. Once these lesions have been made, the bidirectional block of the lesions is checked with the
Isolator Transpolar Pen® (Fig. 2A).
8. The pericardium is closed and a 32 F angled chest drain is placed.
9. The right lung is expanded and the left lung is collapsed to perform the contralateral lesions.
10. Three ports are placed in the left chest wall, CO2 is insufflated and the pericardium is opened.
11. Isolation of the left pulmonary veins is performed with the Isolator Synergy® bipolar clamp
(Fig. 2B) after sectioning the ligament of Marshall and the roof and floor lines are completed with
the Coolrail Linear Pen®.
12. Finally, the left appendage is excluded with the AtriClip Pro® device (fig. 2C) inserted through
the inferior port incision and the lesion block is rechecked with the Isolator Transpolar Pen®.
13. The pericardium is closed, the 32 F chest drain is placed and the left lung is expanded.
14. A transesophageal echocardiogram is routinely performed in the operating room to ensure
exclusion of the left atrial appendage.

RUTHSTON MEDICAL CENTER | 2020



BIBLIOGRAPHY
Hernández-Estefanía, R., Martín Trenor, A., Levy
Praschker, B., & Rábago, G. (2011). Cirugía de la
fibrilación auricular. Anales Del Sistema Sanitario
de Navarra , 34 (1), 83–95
https://doi.org/10.4321/s1137-66272011000100009

Montero-Cruces, L., Pérez-Camargo, D., Torres-

Maestro, B., Carnero, M., Cobiella-Carnicer, F. J., &
Maroto-Castellano, L. C. (2020). Tratamiento de la
fibrilación auricular mediante toracoscopia (TT-
MAZE). Cirugía Cardiovascular, 27(6), 246–250.
https://doi.org/10.1016/j.circv.2020.09.003

Ignacio, F. L. (1998, November 1). Técnica de

MAZE para el tratamiento de la fibrilación
auricular: experiencia inicial. Revista Española De
Cardiología. https://www.revespcardiol.org/es-
tecnica-maze-el-tratamiento-fibrilacion-articulo-
X0300893298003757

Tomada de: https://medlineplus.gov/spanish/ency/article/007369.htm