In certain cases, arrhythmias may be induced allowing them to be studied in a controlled fashion. This will aid in determining the proper effective treatment. The EP study is a sterile procedure performed in a laboratory equipped with x-ray equipment and electronic recording equipment. In general, the patient is awake and only given light sedation. A local anesthetic is used to numb the groin area where the catheters are inserted. Positioning the catheters within the heart is painless. The risks of diagnostic EP study is extremely low, lower than that of a diagnostic heart catheterization. The information learned is used to guide further treatment as indicated. In general, what is recommended depends upon the specific results of the study.

Success rates for this procedure depend on the type of arrhythmia treated, but can be greater than 95%. Complications are infrequent and again are dependent upon the pathway location, but usually is considered less than 1 - 2%. Radiofrequency ablation is an alternative to drug therapy in many patients with certain heart rhythm disorders.

The tilt table test is a simple, non-invasive method of evaluating people who have syncope, or loss of consciousness. There is a syndrome which is characterized by transient loss of consciousness, often preceeded by nausea, lightheadedness or diaphoresis which has several names: vasodepressor syndrome, neurally mediated syncope or neurocardiogenic syncope. It is characterized by either marked bradycardia, a slowing of the heart, or hypotension, a fallen blood pressure or both. During a tilt table test, an intravenous needle is inserted prior to beginning. The patient lays on a table which is tilted up to around 70 degrees. The patient is then allowed to stand there for 30 to 45 minutes while the blood pressure and pulse are carefully monitored. In people who are prone to the syndrome, this will often precipitate syncope. In some instances, medications may be given to increase the sensitivity of the test. Treatment for neurally medicated syncope may include medications or in extreme cases, a pacemaker may be useful. Overall a tilt table test is a very safe procedure which helps in determining the etiology of syncope and guide in it's management.

The implantation of a permanent pacemaker is a relatively minor surgical procedure done with a local anesthetic and usually light sedation. An incision is made below the collarbone and a pocket formed under the skin. The pacemaker leads are passed to the heart through a large vein under the collarbone. The other end is connected to the pacemaker pulse generator which is placed in the pocket. The entire procedure usually takes less than an hour. The risk is low, but possible complications include bleeding, infection or collapse of the lung. The pacemaker will be programmed appropriately prior to discharge from the hospital.

Most routine daily activities can be resumed in several days, but heavy lifting, running, or contact sports should be avoided. An office visit will be scheduled in approximately two weeks following the procedure at which time the wound will be inspected and the pacemaker fully evaluated. Arrangements will also be made for transtelephonic surveillance. The patient is given a transmitter which allows the pacemaker to be checked over the telephone. This is done every other month for the first four to five years and then monthly thereafter. A more complete evaluation is done in the office once or twice a year.

Overall, implantation of a pacemaker is a safe procedure which allows a relatively normal lifestyle to be resumed.

An automatic implantable defibrillator, AICD, is a device used to treat the life threatening heart rhythm disorders called ventricular tachycardia or ventricular fibrillation. Patients with these arrhythmias usually have some structural heart disease. Most commonly these people have coronary artery disease and a previous heart attack resulting in significant damage to the heart muscle. This predisposes the heart to develop electrical instability and deadly arrhythmias. Symptoms occur precipitously and include shortness of breath, dizziness, lightheadedness, loss of consciousness or a cardiac arrest.

Patients with this problem are evaluated extensively with an echocardiogram and a cardiac catheterization. An electrophysiology study is also usually done which is an invasive procedure to evaluate the heart's electrical system.

An ICD is a very sophisticated device which detects arrhythmias and terminates them either by pacing or delivering a shock. Previously, the patient's chest had to be opened to permit the application of patches and leads directly to the heart itself. However, the technology has advanced to the point where these devices are now implanted very much like a pacemaker. The patient is either put under general anesthesia or heavily sedated. An incision is made below the collarbone and a pocket formed. One or more leads are passed to the heart through a large vein under the collarbone. The leads are connected to the ICD generator which is placed into the pocket. The system is tested to insure that it functions appropriately. The entire procedure should last about an hour. Despite the fact that most patients who need these devices have very sick hearts, the procedure is relatively safe with a low risk. Potential complications include bleeding, infection or collapse of the lung. Prior to discharge from the hospital the device will be programmed appropriately.

An office visit will be scheduled about two weeks after surgery at which time the wound will be inspected and the ICD evaluated thoroughly. Periodic office visits will be required to ensure that the device is functioning normally and to assess battery life. The battery lasts from four to seven years and when it reaches the replacement indicator it must be replaced.

What restrictions are recommended depend on each patient's individual problem and underlying heart disease. In general, the implantation of a transvenous ICD is well tolerated and very effective in treating life threatening arrhythmias.

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