Published on November 06, 2009

A New Way to Implant Heart Rhythm Devices

Placement under the breast can avoid visible scars and discomfort for women

Alicia WhiteAlicia White has a pacemaker, but it's
not evident by a scar or lump on her
upper chest. Instead, her pacemaker
was implanted under the breast in a
pioneering procedure by Michael Giudici,
M.D., at Genesis Medical Center. This
unique placement means the world to
White, who loves to dress up in
eveningwear and doesn't want to have
to worry about a scar.

At work, nurse Alicia White wears a uniform. It's after work when she likes to unleash her inner fashionista.

One of her favorite pastimes is to pull out her array of sparkly eveningwear -- and an impressive collection of vintage purses, jewelry and hats -- and go out on the town in style.

So five years ago, when the 41-year-old White learned she needed a pacemaker, her thoughts immediately turned to those evening fashions that show off a woman's bare shoulders. Could she ever again wear strapless gowns, dresses with halter straps or even tank tops if she had an incision scar and the telltale lump from an implanted pacemaker?

"I knew I would benefit greatly from a pacemaker," says White, whose heart was injured as the result of a serious accident in 1994. "But the vanity in me couldn't help but think about how the neckline comes into play when you wear something to a nice, black-tie dinner. I'm like that Toby Keith song where 'the girls next door dress up like movie stars.' I really didn't want to be out on a date, looking like I had a deck of cards on my chest from the pacemaker."

An emergency department nurse at Genesis who also works on the cardiac unit, White was caring for a young female pacemaker patient when she immediately noticed what she didn't see. "When you looked at her, you saw no sign that she had a pacemaker," White says.

First in the nation at Genesis

That's when she learned that electrophysiologist Michael Giudici, M.D., had pioneered a procedure to implant pacemakers and implantable cardioverter-defibrillators (ICDs) under a woman's breast. His goal was to avoid the unique complaints of women who had traditional device placement, ranging from irritation and discomfort from purse and bra straps to changes in body image and cosmetic issues with visible scars.

"I started doing this 10 years ago after, in a short period of time, we had three young women who needed implantable heart devices," explains Dr. Giudici, a member of the Genesis Heart Institute. "In young women, there's a lot of tension in the skin in the upper part of the chest. Even if I did the most meticulous incision, and they left the hospital with this tiny scar, it would eventually stretch into an ugly scar. I thought, 'There's got to be a better way for women.' "

That better way came when he devised a way of implanting pacemaker and ICD leads in the natural crease where the arm meets the body, or the anterior armpit. The heart device is then implanted at the bottom of the breast, just above where the bra sits.

"That way, the incision has no tension on it," Dr. Giudici says. "It heals beautifully, and bra straps, purses and seatbelts won't rub on it. You can wear whatever you want. Mammograms also are OK because the device is not in the breast, but sits between the chest muscle and the ribs. That position also locks the device in place, so it doesn't move, as do some of the devices implanted in the traditional spot on the upper chest. It's a longer procedure, but we think it's worth it."

So did 49 women who had the procedure at Genesis over a nine-year period. This year, an abstract authored by Dr. Giudici, Kent Van Why, M.D., Jacqueline Carlson, RN, Roselyn Krupa, RN, and Cynthia Meierbachtol, RN, found that 97 percent of women felt they made the right choice with a submammary implant.

Nearly 75 percent had the procedure for cosmetic reasons and 95 percent would recommend the procedure to others.

"We concluded that submammary implants have a high patient acceptance and long-term satisfaction, with very few complications," Dr. Giudici says. "Especially if you're a younger woman, you don't want the world to know you have a pacemaker or a defibrillator. You just want to be normal like everyone else, and that's the purpose of these devices -- to allow you to be more normal. But if you put in the device the traditional way, and you end up with a big scar that marks you as different, that's not necessarily desirable."

Dr. Giudici would like to get the word out across the nation. Now, he estimates 95 percent of doctors have no idea such a procedure exists. Some of his own patients with submammary devices have moved away to other parts of the country, only to be very dissatisfied when they have subsequent devices placed in the traditional way.

He shows a photo of the beautiful Michaela Gagne, Miss Massachusetts 2006, a heart patient with an ICD and a very visible scar on her shoulder. "She didn't have to have that scar," he says. "We're trying to get this procedure more widely known and used."

A patient success

Dr. Giudici performed the submammary procedure on Alicia White in 2005, and she hasn't been disappointed. Her heart rhythm difficulties stemmed from damage to the heart sustained when a fully loaded grain truck going 55-mph collided with her car. She recovered from limited use of her left arm and leg caused by two fractured vertebrae but nerve damage to her heart caused arrthymia that eventually required her to have a pacemaker.

"Before I got my pacemaker, I was moving so slow," she recalls. "I'd go to work, come home and go to bed -- that was all I had the energy to do," she says. After the procedure, she recalls the joy she felt when she could again play 18 holes of golf -- and walk the course carrying the bag. "It was like, 'I have arrived!'"

Today, as a nurse in the Emergency Department and while working per diem on the cardiac units, she likes to talk to female patients who have reservations about getting a pacemaker or ICD. "I like to tell them that I have a pacemaker, and I can do anything and everything and am still going strong," White says.

About a year ago, she had to go to the Emergency Department because of an elevated blood pressure and was hooked up to a telemetry monitor. "The doctor came into see me and said, 'I can see a pacemaker spike, but I'm not feeling a pacemaker,' she recalls. "I joked, 'It's in a spot you'll never find.'"

She concludes, "I've been so pleased with Dr. Giudici and the cardiac staff, and I don't think I could have gone anywhere else in the country and received better care."

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