New Comprehensive Guide to Pacemaker Implantation: Interview With Dr. Jeffrey Williams

This is great new work — very well written! What prompted you to write this book?

The fastest growing population segment in the United States, seniors commonly undergo pacemaker implantation. Although doctors’ offices typically provide short pamphlets on pacemaker implantation, there is rarely any comprehensive yet understandable reference material for the patients to obtain. The hectic pace of today’s doctors has shortchanged the information sharing process for patients undergoing pacemaker implantation. Patients and their families are often unaware of many critical issues involved in pacemaker implantation especially when implanted urgently or emergently. Though pacemaker implantation can usually be performed with minimal risks, any surgery entails risks that are particular for each procedure and patient. I have found it increasingly difficult to provide a complete consultation, physical exam, and discussion about the risks, benefits, and alternatives of pacemaker therapy in a typical 45-minute session. Since starting our Heart Rhythm Center in 2008, I have developed several iterations of written and online patient education materials to complement our office discussions, culminating with this new What is a Pacemaker? book.

What are your main goals for this book? What audience is the book intended for?

What is a Pacemaker? is a comprehensive summary of the steps involved with pacemaker implantation from the initial evaluation and implant procedure to the possible post-operative complications and required long-term follow-up care for patients and their caregivers (both professional and layperson alike). Furthermore, many of my extremely elderly patients rely upon their spouses and families for help with the decision making process and long-term care of their device; this book serves as a thorough means to ensure that all family members understand the roles, risks, and required follow-up for pacemaker patients.

Readers will also find more complex information such as pre-operative management issues as well as complications of pacemaker implantations and their associated x-ray findings. I’ve included detailed discussion of these more complex issues to provide health professionals in their clinical training a solid footing on pacemaker therapy; medical residents/students/fellows, nurses, allied health professionals, and physician extenders will all find this book very informative. The sections on indications for pacemaker therapy and complications of pacemaker implantation are at a level that primary care providers will find useful and informative.

What was the writing process like? What unique features did you want to include in the book?

The skeleton of this book was developed several years ago. The writing process started at that time while I added “meat on the bone.” The majority of the final writing and polishing occurred throughout 2012 and the final draft was submitted in January 2013. It took a good 6 months of editing and revision to get the final proof. I approached this book as if I were a patient under evaluation for pacemaker therapy. The book starts by introducing some basic cardiac coronary and electrical anatomy which lays the foundation to discuss indications for pacemaker therapy. These first several chapters are definitely the most challenging for patients as I attempt to distill a lot of information without “dumbing it down” too much. The book then covers the preoperative evaluation and the implant procedure and takes the reader through the post-operative course and long-term follow-up issues. I customized stock photography to provide readers with clearly illustrated and detailed figures. 

What do you feel are the most common misperceptions patients have about pacemaker implantation?  

The most common misperception I encounter is whether or not one can carry on a normal life after a pacemaker implantation. When I was finishing my training and starting a new EP program, I asked colleagues what activity, bathing, and driving limitations they advised their pacemaker patients. Interestingly, not one EP gave the same answer regarding post-operative activity limitations, so it serves to reason that patients would have questions about this. There are obviously certain activities (e.g., arc welding) that pacemaker patients may not be able to participate in, but by and large, most patients can resume their usual routine 4 weeks after implantation. 

One of the most interesting situations I encountered was an extremely elderly gentleman in his late 80s who wanted to be sure he could shoot a rifle after pacemaker implantation. He and I discussed the need to wait 4 weeks after the implant and use the contralateral shoulder for the rifle. He had an uneventful biventricular pacemaker implant/recovery, and went on a successful alligator hunt in Florida!

In the book, you write that you have been treating a surprising number of patients with symptomatic chronotropic incompetence. Tell us more about this. 

Chronotropic incompetence can affect 20-40% of patients, is an important cause of exercise intolerance, and an independent predictor of major adverse cardiovascular events and mortality.^1-3 Practicing EP in a small community, I see a more elderly and ill population than typically seen at larger medical centers similar to where I completed my EP training.⁴ I have learned to have a high suspicion for chronotropic incompetence in my patient population. Several times per month, I encounter elderly patients with progressive exertional dyspnea despite relatively normal echocardiograms and ischemic evaluations. Close inspection of the Holter monitor often reveals symptomatic chronotropic incompetence, which I confirm in the office after stopping any beta blockade. Though it is very common, Brubaker and Kitzman lament that a “barrier to progress in studies of (chronotropic incompetence) and its clinical management has been a lack of consistent methodology for determining CI.”³

A special emphasis in the book is placed on complications that can occur. Tell us a little bit more about what is covered in this chapter. 

A friend of mine from fellowship once joked that I had a “shock and awe” consent process because I very bluntly described percentages and descriptions of major and minor complications. All joking aside, I often find patients are under-counseled on risks of (both interventional and EP) cardiac procedures. Chapter 7 of What is a Pacemaker? describes the possible complications that may result from a pacemaker implantation. This chapter was adapted from a book chapter geared toward health professionals that Dr. Bob Stevenson and I coauthored (https://www.intechopen.com/books/current-issues-and-recent-advances-in-pacemaker-therapy/complications_of_pacemaker_implantation, or https://bit.ly/1anKJzY). The chapter was made less complex for this book and discusses the incidence and features of pacemaker implant complications. It also covers the techniques used to detect these complications, including associated imaging such as chest x-rays. I really feel this chapter is an important addition to the patients’ informed consent process. It also provides referring providers a nice review of possible complications they may encounter when they see the patient in follow-up.

Which implant location do you most commonly use to implant pacemakers? Also, describe your use of the left cephalic vein cut down approach. 

The most common implant site for pacemaker implantation in our Heart Rhythm Center is the left infraclavicular position using the first rib approach.⁵ Actually, an interesting debate is whether or not this technique can be classified as an axillary approach; the basilic vein forms the axillary vein, which then forms the subclavian vein at the lateral border of the first rib. Since the vein is punctured near the middle of the first rib, it is reasonable to infer that the subclavian rather than the axillary venous access is obtained. In any event, this first-rib approach is used for the majority of our patients as well as a preceding left subclavian venography to assess patency prior to making an incision.

Direct subclavian venous punctures are associated with increased rate of pneumothorax,⁶ while cephalic vein cut down has been associated with the lowest rate of pneumothorax and lead damage.^7,8 In patients I consider at elevated risk for implant complications (e.g., extremely elderly, thin, female smokers), I generally attempt cephalic vein cut down for vascular access. The more superficial and lateral cephalic vein courses in the deltopectoral groove and joins the axillary vein near the coracoid process. I often get a good idea of the cephalic vein caliber and course during the subclavian venography. Blunt and bovie dissection is then carried out in the deltopectoral groove fat pad to isolate the cephalic vein. A distal tie is used to tether the vein, and a micropuncture kit is then used to get wire access. If the vein is too small for multiple leads (as can happen in extremely elderly patients), I can use the first wire to guide a first-rib approach for the second access wire.

Why was it important to include information on Twiddler’s Syndrome? How often do you see these types of cases in your lab? 

Originally described in 1968,⁹ twiddling refers to patient manipulation of the pacemaker can or leads that may lead to malfunction. It has a reported incidence of 0.07% in a series of 17,000 patients,¹⁰ and I see a case every few years. I use the Twiddler’s syndrome example as more of a lesson for patients to avoid complications and repeat procedures.

Will this book also be available to your patients at the Heart Rhythm Center? What types of patient education materials are currently offered to patients? 

All of our patients undergoing pacemaker implantation are given a free copy of What is a Pacemaker? to review (hopefully) before the implantation. We continue to offer the traditional short pamphlets to patients undergoing defibrillators and EP studies. I also have online patient educational materials (www.heart-rhythm-center.com) that I will often reference during office visits when describing implant procedures and EP studies.

Where will the book be available for purchase?

What is a Pacemaker? is available at online and offline retailers such as Amazon.com and Barnes & Noble. It is also available as an e-book for Kindle readers. Text-to-Speech is available for Kindle Fire HD, Kindle Touch, Kindle Keyboard, Kindle (second generation), and Kindle DX. It is available to distributors such as Ingram and NACSCORP. Finally, What is a Pacemaker? is available through Baker & Taylor to libraries and academic institutions.

What’s next for you? What projects do you have coming up?

I typically keep a few “irons in the fire” and am working on a summary of radial intracardiac echocardiography during EP procedures. Also, I am drafting another book, What is a Defibrillator?, that is similarly geared to patient education. I am hoping to have the next book completed by the end of 2014. I have started planning our yearly Lebanon Valley Cardiovascular Symposium featuring local and national faculty that is geared toward primary care provider cardiovascular education. Finally, I stay very active with the Pennsylvania and National Chapters of the American College of Cardiology.

References

1. Lauer MS, Okin PM, Larson MG, Evans JC, Levy D. Impaired heart rate response to graded exercise. Prognostic implications of chronotropic incompetence in the Framingham Heart Study. Circulation. 1996;93:1520-1526.
2. Kawasaki T, Kaimoto S, Sakatani T, et al. Chronotropic incompetence and autonomic dysfunction in patients without structural heart disease. Europace. 2010;12:561-566.
3. Brubaker PH, Kitzman DW. Chronotropic incompetence: causes, consequences, and management. Circulation. 2011;123:1010-1020.
4. Williams JL, Lugg D, Gray R, Hollis D, Stoner M, Stevenson R. Patient demographics, complications, and hospital utilization in 250 consecutive device implants in a new community hospital electrophysiology program—implications for ‘niche’ hospitals. Am Heart Hosp J. 2010;8:33-39.
5. Belott P. How to access the axillary vein. Heart Rhythm. 2006;3:366-369.
6. Link MS, Estes NAM, Griffin JJ, et al. Complications of dual chamber pacemaker implantation in the elderly. Pacemaker Selection in the Elderly (PASE) Investigators. J Interv Card Electrophysiol. 1998;2:175-179.
7. Parsonnet V, Bernstein AD, Lindsay B. Pacemaker-implantation complication rates: an analysis of some contributing factors. J Am Coll Cardiol. 1989;13:917-921.
8. Wiegand UKH, Bode F, Bonnemeier H, Eberhard F, Schlei M, Peters W. Long-term complication rates in ventricular, single lead VDD, and dual chamber pacing. Pacing Clin Electrophysiol. 2003;26:1961-1969.
9. Bayliss CE, Beanlands DS, Baird RJ. The pacemaker-twiddler’s syndrome: a new complication of implantable transvenous pacemakers. Can Med Assoc J. 1968;99:371-373.
10. Fahraeus T, Höijer CJ. Early pacemaker twiddler syndrome. Europace. 2003;5:279-281.