16837 Cardiac Implantable Electronic Device Replacement

Overview

A cardiac implantable electronic device (CIED) is a small computer placed under the skin of your chest to watch over your heart and step in when it needs help. The most common types are a pacemaker (which sends tiny electrical signals to keep your heart beating at the right speed), an ICD (implantable cardioverter defibrillator — a device that can give a shock to stop a dangerous heart rhythm), and a CRT device (which helps the two sides of your heart beat together in heart failure). Every device runs on a battery sealed inside a metal box called the generator. That battery cannot be recharged, so after several years it runs low and the whole generator is swapped for a new one. This is what 'device replacement' means. Sometimes one of the thin wires (called leads) that run from the device to your heart is also repaired or replaced at the same time.

Yes. Because devices have a limited battery life, almost everyone who has one will need at least one replacement eventually. Device replacement is a routine, well-practised procedure done in hospitals every day.

It affects anyone living with a pacemaker, ICD or CRT device. That includes older adults with slow or irregular heart rhythms, people with heart failure, people who have survived a dangerous heart rhythm, and children born with heart problems or heart block. Younger people, and children, are more likely to need several replacements over their lifetime simply because they live longer with a device.

Symptoms

Common symptoms

• There are usually no symptoms at all — most replacements are triggered by a low battery reading at a routine device check.
• Your device may make a beeping or vibrating sound or feel like a gentle buzz in your chest, which is an alert set by your clinic.
• Feeling more tired, dizzy or breathless than usual can sometimes mean the battery is nearly empty and the device can no longer support your heart fully.
• Your own original heart symptoms (such as blackouts or a racing heart) coming back after a long gap.
• Sometimes the clinic notices a problem with a lead on a remote download before you feel anything.

Symptoms in children

• Children often show tiredness, poor feeding or slower growth rather than saying they feel unwell.
• A child may need a replacement sooner because they have grown and the leads or device pocket no longer fit well.
• Children may be more aware of, or frightened by, the device beeping or buzzing.
• Teachers, carers and school nurses may notice changes in energy levels or play before a child does.

Symptoms in older adults

• Older adults may put tiredness or dizziness down to 'just getting older' — it is always worth mentioning to the device team.
• Memory problems can make it harder to remember device check appointments, so a family member or carer can help keep track.
• Falls or near-falls may be a sign the device is no longer supporting the heart as well as it should.
• Other health conditions can make recovery from the procedure slower, so planning ahead with the care team helps.

Causes

Main causes

• Battery running down — by far the most common reason for replacement.
• A problem with a lead, such as a break or worn insulation, found on a device check.
• A device that has been the subject of a manufacturer's safety notice or recall.
• Infection in the device pocket or on a lead, which means the device has to be taken out and a new one fitted later.
• Your heart needs changing care — for example moving from a pacemaker to an ICD, or adding a third lead for heart failure (an 'upgrade').
• In children, growth making the original device or leads an unsuitable fit.

Risk factors

• Simply having a device — every device has a battery that will eventually run out.
• A device that is working hard, for example pacing your heart most of the time, uses its battery faster.
• Having had your device implanted at a young age, which means more replacements over a lifetime.
• A previous device infection or a history of skin problems over the device pocket.
• Some device settings and features use more battery power.

When to see a doctor

See a doctor urgently if:

• Your device alerts you with beeping or vibration.
• You get a shock from your ICD and feel unwell, or get more than one shock.
• You have a fever, or the wound becomes red, hot, swollen or leaks fluid.
• You faint, or feel dizzy or breathless in a way that is new for you.

Book a routine appointment if:

• Your routine device check or remote download shows the battery is getting low.
• You are planning a long trip or moving abroad and want to check your device schedule first.
• You are due to have an MRI or other scan, or another operation, and need advice about your device.
• You have questions about driving, exercise or travel with your device.

Diagnosis

The decision to replace a device is made from regular device checks rather than from an illness you feel. At each check, a small wand or computer is placed over your chest (or your device sends information remotely) and it reads the battery level, how the leads are working and any stored heart rhythm information. Your team combines this with how you feel and your overall health to choose the right time for replacement — early enough to be safe, late enough to get full use from the battery.

Tests that may be done

• Device interrogation: a painless check with a programmer machine that reads battery life, lead function and stored heart rhythms.
• Remote monitoring download: data sent from your device at home to your clinic.
• Electrocardiogram (ECG): a tracing of your heart's electrical activity.
• Chest X-ray: to look at the position of the device and leads.
• Blood tests: to check for infection or other health issues before the procedure.
• Echocardiogram (heart ultrasound): to see how well your heart is pumping and whether your needs have changed.

What to expect at your appointment

You will usually be told at a routine check that a replacement is due, with a date planned for weeks or months ahead. Before the procedure you may have a short appointment for blood tests and to talk through the plan, including any blood-thinning medicines you take. Most people are asked not to eat for a few hours beforehand, and you should arrange a lift home in case you feel sleepy after sedation.

Treatment

Replacement means swapping the old generator for a new one, and sometimes repairing or changing a lead at the same time. It is a planned procedure, usually done under a local anaesthetic (the area is numbed but you stay awake), sometimes with light sedation to help you relax. The team opens the skin over the old scar, disconnects the leads from the old device, connects them to the new one, tests everything, and closes the skin. Many people go home the same day; some stay in overnight for observation.

Self-care at home

• Keep the wound clean and dry, and follow your team's advice on when you can shower or bathe.
• Avoid lifting heavy things and avoid lifting the arm on that side above your head for the time your team advises — often a few weeks.
• Wear loose clothing over the wound while it heals, and check the wound daily for redness, swelling or discharge.
• Carry your device ID card with you at all times.
• Follow the driving advice you are given — rules vary depending on your device and why you have it, and on local licensing laws.
• Go to every device check and remote-monitoring appointment, even when you feel completely well.

Medical treatments

No medicine can recharge or replace a device battery, so the procedure itself is the treatment. Around the time of the procedure you may be given antibiotics through a drip to lower the risk of infection, and pain relief afterwards if you need it — your team will explain what is suitable for you. Your device settings may be adjusted to help the new battery last longer. If you take blood-thinning medicines, your team will give you clear instructions about when to stop and restart them; never change these on your own. Some people also need changes to their heart medicines after the procedure — this is decided by your own doctor.

When is surgery considered?

Replacement is recommended when the battery has reached the level where it can no longer be relied on, when a lead is faulty, when there is an infection, or when your heart's needs have changed and a different device would help. If you have a serious infection, the device and leads may need to be removed first and a new system fitted once the infection has cleared. Your team will always explain the timing and the reasons clearly before you decide.

Living with this condition

Most people carry on with life much as before after a replacement. You will have regular device checks — often once or twice a year — plus remote monitoring that sends information from home. Everyday electrical items such as phones, microwaves and computers are safe, but keep your mobile phone a short distance from the device and avoid holding strong magnets against your chest. Tell staff at airports, dentists and any hospital appointments that you have a device, and show your ID card.

Lifestyle tips

• Stay active — walking, swimming and most sports are fine once your wound has healed; ask your team about contact sports.
• Tell your team before starting any new vigorous exercise programme.
• Avoid strong magnets, and keep headphones and phones away from the device pocket.
• Check with your team before using arc welders, powerful speakers or other strong electrical equipment.
• Carry your device ID card and let someone close to you know you have a device.

Diet and exercise

There is no special diet for having a device, but eating a heart-healthy diet — plenty of vegetables, fruit, whole grains, beans and fish, and less salt and processed food — supports your heart in general. Gentle movement in the first weeks after the procedure helps healing, and your team will tell you when you can return to your usual exercise. Build up gradually rather than all at once, and stop and rest if you feel dizzy or breathless.

Mental health and emotional wellbeing

It is very common to feel anxious before a replacement, or to worry about becoming dependent on the device, about shocks, or about what happens if the battery runs out. Some people feel low for a while afterwards or find the wound uncomfortable and unsettling. These feelings usually ease, and talking about them helps. If worry is affecting your sleep, mood or daily life, tell your doctor or device nurse — support such as talking therapies is available. If you ever feel you cannot cope or have thoughts of harming yourself, contact your local emergency number or a crisis line in your country straight away.

Prevention

You cannot stop a battery from running down, but you can make replacement safer and better timed by keeping every device check, using remote monitoring if it is offered, and reporting alerts or new symptoms straight away. Good wound care after any device procedure, and prompt treatment of any infection, helps prevent the more serious problems that sometimes lead to early replacement.

Vaccines

Ask your doctor or nurse which routine vaccinations are recommended for you. Flu and pneumonia (chest infection) vaccines are often suggested for people with heart conditions, because infections can put extra strain on the heart.

Screening programmes

There is no screening test for needing a replacement. Instead, your regular device checks and remote monitoring act as ongoing monitoring, catching a low battery or a lead problem long before it becomes a problem for you.

Complications

If left untreated

• If a low battery is left too long, the device can stop working — a pacemaker may stop supporting your heart, leading to dizziness, fainting or falls.
• An ICD may no longer be able to give a life-saving shock when it is needed.
• A faulty lead can cause inappropriate shocks or fail to deliver treatment.
• An untreated device infection can spread along the leads towards the heart and becomes much harder to treat.
• Rarely, a device or lead can wear through the skin, which needs urgent treatment.

Long-term outlook

For most people, device replacement is a straightforward, low-risk procedure with a good recovery. The wound usually heals within a few weeks, and most people are back to their usual activities soon after. Many people have several replacements over their lifetime and live full, active lives. Your team will talk you through the small risks of the procedure — such as infection, bleeding or a problem with a lead — and how they are managed, so you can make a confident decision.

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