I am a trainee in Cardiac Electrophysiology based in Colombo, Sri Lanka. The idea for this site was born after a futile internet search for hands on material on cardiac pacing. Although there are excellent text books on the matter, I could not  find a comprehensive hands on practical guide for pacing. In this age of selfies, instagrams, snapchats & 4k video, couldn’t find a single hands on video for pacing (although there were some patient oriented videos aka “this how a pacemaker is done…” ). This happened before starting training – as I wished to have some sort of idea of what to do.

Out of cardiac interventions, pacing has another unique aspect : it makes a patient permanently yours to care. It’s something that can be seen and felt from outside and it can hurt, it can come out, it needs regular followup and most terribly – it needs replacements – therefore  it can haunt you if things go sour. If things are very well and ok, you have a happy patient for life and you would be glad that you made a real difference.

National Hospital of Sri Lanka, the institution where I train, is the largest center for cardiac pacing in Sri Lanka. In the last few years, an average of 800 devices are implanted annually. Additionally, pediatric pacing done by our team at nearby Lady Ridgeway Hospital accounts for about 30 devices implanted on kids per year. Cardiac pacing has been in place for more than 15 years now at NHSL

Being in a high volume center gives the rare luxury of doing and seeing many cases – because experience matters a lot – especially when faced with difficult situations and complications. I personally believe that the morbidity and mortality of elective pacing should be near 0%. Most problems are operator dependent and preventable and therefore it’s an achievable goal if one practices safe and sound technique

Once I commenced training basically – I didn’t have a problem in getting hands on teaching – my trainers ensured that I got it from them – So a big thank you to Dr. Asunga Dunuwille and Dr. Rohan Gunawardena imparting me with their expertise and experience for cardiac pacing.  However, with progressive experience and seeing occasional complications – I realized that others could benefit from what I had learned and therefore came up with the idea of creating this resource.

Cardiac rhythm device therapy is gaining ground fast – as devices prices come down along with increased awareness even in developing countries like ours, more and more patients are referred for pacing. Apart from electrophysiologists, cardiologists too have a stake at implantation and more and more cardiologists are taking up pacing. Therefore I assume this site would help learn the basics for anybody foraying in to pacing.

This entire endeavor would have not been possible if not for the dedicated staff of the NHSL Cardiac Pacing Theater (affectionately called “Room 8”). Collectively (Nursing, Radiography and Cardiography Staffs) they shared a trove of experience spanning more than a decade that helped me learn the craft – so a big thank you goes for them too!

The techniques that are demonstrated in this site were all recorded in the pacing theater of  NHSL. I used a Go-Pro4 Hero Black mounted on a head strap. The GoPro style recording is exactly what is done from an operator’s perspective. I would like to hereby inspire other surgeons in any field to contribute to surgical education by creating GoPro style videos. The stills were photographed with a Canon 100 F2.8 macro and 10-18 mm STM lense. For procedures, verbal consent was obtained filming but recordings started only  after fully draping the patient. All audio data was deleted from the recordings. No-personally identifiable artefacts were recorded or photographed. The model for anatomical demonstrations was a staff member of the department who happily consented to be photographed.

Unfortunately our C-arm in the pacing theater is of low resolution and cannot save cine sequences. We do not have access to the sophisticated cath lab for pacing  – where fluoroscopic recordings would have been possible to demonstrate certain concepts and principles – this may change in the future – and I hope to update the site with recorded fluro sequences.

Being a developing country, we don’t have the luxury of throwing things around – we reuse lot of stuff – for example operating drapes, instruments, analyzer cables etc. (The green garb that is seen all over are a hospital characteristic – blue drapes are yet to come to our theaters). We also don’t have steri-drapes, fancy waterproof transparent dressings and tissue glue.

The goal of this website is to demonstrate techniques relevant to cardiac pacing with an emphasis on safety and efficacy. From a training – perspective I hope it will be of use for fellow trainees to reduce their complication rate and increase efficacy.

The following textbooks are highly recommended for sound theoretical knowledge

1. Cardiac Pacemakers and Resynchronization Step by Step: An Illustrated Guide 2nd Edition by S. Serge Barol. Although this book is not of pacemaker implantation, it has everything on pacemaker physics, functionality  & programming concepts presented in a highly digestible compendium of illustrations.
2. Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy: Expert Consult 4th Edition by Kenneth A. Ellenbogen et al. The “Braunwald” of pacing – no need of further explanation
3. Cardiac Pacing for the Clinician 2nd Edition by Fred M. Kusumoto. An excellent read for various practical aspects of cardiac pacing.

This site is a work in progress. Currently it reflects my level of experience and hope that it will help fellow trainees and others who wish to see whats happening during a pacing procedure.

This is the first set of recordings (they were done during usual work – no special preparation was done)  – and now I am in the process of filling the gaps. Depending on availability of resources and time, I will re-record and refine the videos when possible.

The next major goals :

1. Add fluoroscopic motion sequences
2. Record and add topics on advanced devices.
3. Hands on device programming
4. Expand on nut and bolt matters (e.g various hardware, leads, sheaths, accessories)
5. Device extraction
6. Section on gross cardiac anatomy (real dissected tissues and CT / MRI  reconstructed)
7. Visual library of complications