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Pacemaker implantation

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Pacemaker implantation



 Introduction  

Pacemaker implantation is a surgical procedure where a small electrical device called a pacemaker is implanted in your chest.

The pacemaker sends regular electrical pulses that help keep your heart beating regularly.

Having a pacemaker fitted can greatly improve your quality of life if you have problems with your heart rhythm, and the device can be lifesaving for some people.

Pacemaker implantation is one of the most common types of heart surgery carried out in the UK. During 2012-13 in England, more than 40,000 people had a pacemaker fitted.

 How does a pacemaker work? 

The pacemaker is a small metal box weighing 20-50g. It is attached to one or more wires, known as pacing leads, which run to your heart.

The pacemaker contains:


a battery, which usually lasts six to 10 years depending on how advanced the device is (more advanced pacemakers tend to use more energy so have a shorter battery life)

a pulse generator

a tiny computer circuit that converts energy from the battery into electrical impulses, which flow down the wires and stimulate your heart to contract


The rate at which these electrical impulses are sent out is called the discharge rate.

Almost all modern pacemakers work on demand. This means that they can be programmed to adjust the discharge rate in response to your body's needs. If the pacemaker senses that your heart has missed a beat or is beating too slowly, it sends signals at a steady rate. If it senses that your heart is beating normally by itself, it does not send out any signals.

Most pacemakers have a special sensor that recognises body movement or your breathing rate. This allows them to speed up the discharge rate when you are active. Doctors describe this as rate responsive.

 Why do I need a pacemaker? 

The heart is essentially a pump, made of muscle, which is controlled by electrical signals.

These signals can become disrupted for several reasons, which can lead to a number of potentially dangerous heart conditions, such as:


an abnormally slow heartbeat (bradycardia) or an abnormally fast heartbeat (supraventricular tachycardia) – caused by damage to part of the heart called the sinoatrial node

heart block – where your heart beats irregularly because the electrical signals that control your heartbeat are not transmitted properly 

cardiac arrest – when a problem with the electrical signals in the heart causes the heart to stop beating altogether


An implantable cardioverter defibrillator (ICD) is a device similar to a pacemaker. This sends a larger electrical shock to the heart that essentially reboots the heart to get it pumping again. Some devices contain both a pacemaker and an ICD.

ICDs are often used as a preventative treatment for people thought to be at risk of cardiac arrest at some point in the future. If the ICD senses that the heart is beating at a potentially dangerous abnormal rate, it will deliver an electrical shock to the heart. This can often help return the heart to a normal rhythm.

 What happens during a pacemaker implantation? 

Having a pacemaker implanted is a relatively straightforward process. It is usually carried out under local anaesthetic, which means you will be awake during the procedure.

Most commonly, the generator is placed under the skin near the collarbone, on the left side of the chest. The generator is attached to a wire that is guided through a blood vessel to the heart.

The procedure usually takes about an hour and most people are well enough to leave hospital the day after surgery.

 After pacemaker surgery 

You should be able to get back to normal physical activities very soon after surgery. As a precaution, it is normally recommended that you avoid strenuous activities for around four to six weeks after having your pacemaker fitted. After this, you should be able to do most activities and sports.

You will be able to feel the pacemaker, but you will soon get used to it. At first, it may seem a bit heavy and may feel uncomfortable when you lie in certain positions.

You will need to attend regular check-ups to make sure your pacemaker is working properly. Most pacemakers store information about your natural heart rhythms. When you have follow-up appointments, doctors can retrieve this information and use it to check how well the pacemaker and your heart are working.

Most ordinary household electrical equipment is safe to use and will not interfere with your pacemaker. This includes microwaves, as long as they are in good working order.

 Safety 

Having a pacemaker implanted is usually a very safe procedure with a low risk of complications. The biggest concern is that the pacemaker loses the ability to control the heartbeat, either because it malfunctions or the wire moves out of the correct position.

Sometimes it is possible to "reprogramme" the pacemaker to fix a malfunction by using wireless signals. However, further surgery may be required if the pacemaker moves out of position.

 Are there any alternatives? 

In some cases, it may be possible to control an abnormal heartbeat (arrhythmia) without having a pacemaker fitted.

For example, atrial fibrillation can sometimes be treated with a type of medication called a beta-blocker, or a non-surgical procedure called catheter ablation.

However, not all people with an arrhythmia can be treated in this way, and in many cases a pacemaker is considered to be the most effective option available.

If your cardiologist recommends having a pacemaker fitted, talk to them about why they think it is the best option and discuss any possible alternative treatments you could have.

 Why pacemakers are used  

Pacemakers are sometimes recommended for people with conditions that cause the heart to beat abnormally.

When the heart beats, the heart muscle contracts (pulls inwards) in preparation for pumping blood around the body. The contractions are triggered by electrical pulses. These are generated by a group of specialised cells known as the sinoatrial node (SA node).

The SA node is often referred to as a natural pacemaker because it generates a series of electrical pulses at regular intervals.

The pulse is then sent to a group of cells known as the atrioventricular node (AV node). The AV node relays the pulse to the two lower chambers of the heart (the ventricles).

A pacemaker or implantable cardioverter defibrillator (ICD) is required when something disrupts this process and causes an abnormal heartbeat.

Having an abnormal heartbeat is called arrhythmia. Some of the most common causes of arrhythmias are described below.

 Sick sinus syndrome 

In sick sinus syndrome, the SA node no longer works as it should. This can lead to an abnormally slow heartbeat (bradycardia), an abnormally fast heartbeat (supraventricular tachycardia) or a combination of both.

Symptoms of sick sinus syndrome can include:


feeling tired all the time

fainting

a dull, heavy or tight pain in the chest that is usually triggered by physical activity or stress (the medical term for this sort of pain isangina)


It is thought that most cases of sick sinus syndrome are related to age. Over time, the tissue that makes up the SA node can become hardened and scarred. This can disrupt the normal pattern of electrical pulses released by the SA nodes.

Some types of medication can also trigger sick sinus syndrome as a side effect. These include calcium-channel blockers and beta-blockers.

 Atrial fibrillation 

Atrial fibrillation is a condition in which the heart beats abnormally fast. This is usually defined as 140 beats or more a minute.

Most cases of atrial fibrillation can be treated with medication, but a small number of cases do not respond to treatment. In these cases, a pacemaker may be recommended.

 Heart block 

A heart block is where the pulse that needs to be sent from the SA node to the AV node is either delayed or absent.

Heart block can be caused by damage to the heart (known as acquired heart block). Alternatively, it can occur if a baby is born with one or more defects that affect their heart (known as congenital heart block).

If you have heart block and it's causing symptoms that trouble you, having a pacemaker implanted is usually recommended.

 Cardiac arrest 

A similar device to a pacemaker, called an implantable cardioverter defibrillator (ICD), is mainly used to prevent cardiac arrest.

A cardiac arrest is a potentially fatal condition where the electrical activity that controls the heart becomes so disrupted that the heart stops beating. Unless it is treated quickly, a cardiac arrest will be fatal. 

An ICD is designed to detect abnormal electrical signals that could suggest that a cardiac arrest is about to happen.

If it detects these types of signal, it sends a powerful electrical shock to the heart. This basically "reboots" the heart. After the shock, the heart should start beating again normally.

You may be recommended to have an ICD implanted if you have previously had a cardiac arrest or if it's thought that you have a significant risk of having one in the future.

Factors that increase the risk of a cardiac arrest include:


coronary heart disease – where the main blood vessels that supply the heart with blood become narrowed and hardened, reducing the supply of blood

having a heart attack

congenital heart disease – where a person is born with one or more defects affecting their heart



 

 



Pacemakers can be used to correct an abormal heartbeat 

Types of pacemaker

There are several different types of pacemaker.

The main types of pacemaker are:


single-chamber pacemakers – this has one wire, which is connected to either the right atrium (upper heart chamber) or right ventricle (lower heart chamber)

dual-chamber pacemakers – this has two wires, which are connected to the right atrium and right ventricle

biventricular pacemakers – this has three wires, which are connected to the right atrium, right ventricle and left ventricle


The type of pacemaker you need depends on your heart problem.

 How a pacemaker is fitted  

Before having a pacemaker fitted, you are likely to have a pre-operative assessment. The team looking after you will check that you are fit for surgery. You can also discuss the operation and ask any questions you have.

Tests, such as blood tests and X-rays, can be arranged at this stage so that there are no delays when you are called into hospital. You will be asked about your general health, your heart problems and how these affect you. You'll also be asked about any additional medical problems and previous operations you've had, as well as any problems or reactions you or your family have had with anaesthetics.

Taking steps to improve your fitness and health, such as stopping smoking if you smoke and eating a healthy diet, should help speed up your recovery time and reduce the risk of complications.

You will usually be told when you have to stop eating or drinking before surgery during the pre-operative assessment.

 Your specialist 

The procedure will be carried out by a heart specialist, known as a cardiologist, who will probably have a special interest in pacemakers.

If you are being treated in a large heart hospital, the operation will often be carried out by an electrophysiologist. This is a cardiologist who specialises in heart rhythm disorders.

 Fitting the pacemaker 

The most widely used method to fit a pacemaker or an implantable caridoverter defibrillator (ICD) is known as transvenous implantation.

 Transvenous implantation 

During transvenous implantation, the cardiologist makes a 5-6cm cut just below the collarbone (usually on the left side of the chest) and inserts the wires of the pacemaker (pacing leads) into a vein.

The pacing leads are guided along the vein, into the correct chamber of your heart, using X-ray scans. They then become lodged in the tissue of your heart.

The other ends of the leads are connected to the pacemaker, which is fitted into a small pocket created by the cardiologist between the skin of your upper chest and your chest muscle.

Transvenous implantation is carried out under local anaesthetic, which is given as an injection. This means the area where the incisions are made is numbed, but you remain awake during the procedure.

You will feel an initial burning or pricking sensation when the cardiologist injects the local anaesthetic. The area will soon become numb, but you may feel a pulling sensation during the operation.

A thin tube, called an intravenous (IV) line, will be attached to one of your veins before the procedure. Medication to make you drowsy will be given through the IV line to keep you relaxed while the procedure is carried out.

The procedure usually takes about an hour, but it may take longer if you're having a biventricular pacemaker (with three leads) fitted or other heart surgery at the same time. You will usually need to stay in hospital overnight and have a day’s rest after the procedure.

 Epicardial implantation 

Epicardial implantation is an alternative and less widely used method of fitting a pacemaker.

In this method, the pacing lead or leads are attached to the outer surface of your heart (epicardium) through an incision in your abdomen (below the chest). Epicardial implantation is often used in children and people who have heart surgery at the same time as the pacemaker implantation.

The procedure is performed under general anaesthetic, so you will be asleep while it is carried out. 

The surgeon attaches the tip of the pacing lead to your heart and the other end of the lead to the pacemaker box. This is usually placed in a pocket created under the skin in your abdomen.

This usually takes between one and two hours, but can take longer if you are having other heart surgery at the same time.

Recovery after epicardial implantation usually takes longer than after transvenous implantation.

 Testing and setting the pacemaker 

Once the leads are in place and before they are connected to the pacemaker, the cardiologist will test them to make sure they work properly and can increase your heart rate (called pacing). Small amounts of energy are delivered through the leads into the heart, which cause it to contract.

When the leads are being tested, you may feel your heart beat faster. Tell the medical team what symptoms you feel.

Your doctor will determine the settings of your pacemaker after deciding how much electrical energy is needed to stimulate your heartbeat.

 Waiting times 

How long you will have to wait to have a pacemaker fitted will depend on why surgery is required.

If it is needed to treat a potentially serious condition such as severe heart block or cardiac arrest, surgery is often performed as an emergency.

If the reason for surgery is not thought to be life-threatening, you may have to wait up to 18 weeks.

In most cases, surgery is carried out as soon as possible once it has been decided that you would benefit from a pacemaker.

Recovering from pacemaker implantation FAQs 


How will I be monitored?

Will I be in pain after the procedure?

When can I leave hospital?

How soon can I drive?

Will I be able to feel or see the pacemaker?

How soon will I be back to normal?

When can I do exercise or play sports again?

How can I care for my wound?

Will I have to have my stitches removed?

What check-ups will I need?

What problems should I look out for?

Will my pacemaker be affected by electrical equipment?

Will I need to have another pacemaker?

How often will I need a follow-up?

Will my sex life be affected?


 How will I be monitored? 

You will be attached to a special monitor so the medical team can keep an eye on your heart rhythm. The monitor consists of a small box connected by wires to your chest with sticky electrode patches. The box displays your heart rhythm on several monitors in the nursing unit. The nurses will be able to observe your heart rate and rhythm.

A chest X-ray will be done to check your lungs, as well as the position of the pacemaker and leads.

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 Will I be in pain after the procedure? 

You may feel some pain or discomfort during the first 48 hours and will be given pain-relieving medication. There may also be some bruising where the pacemaker was inserted. This usually passes within a few days. Tell the staff if your symptoms are persistent or severe.

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 When can I leave hospital?  

Although it is sometimes possible to go home the same day you have the procedure, you will usually need to stay in hospital for one or two days.

You will need to arrange for someone to pick you up from hospital and take you home.

Before you go home, you will be given a pacemaker registration card, which contains details of the make and model of your pacemaker. Always carry this with you in case of an emergency. 

You may also wish to wear a MedicAlert bracelet or necklace engraved with important information (such as the type of pacemaker you have, a personal identity number and a 24-hour emergency phone number).

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 How soon can I drive? 

If you have an ordinary driving licence, you can start driving again after one week, as long as:


you do not have any symptoms, such as dizziness or fainting, that would affect your driving

you have regular check-ups in the pacemaker clinic

you have not recently had a heart attack or heart surgery


Inform the Driver & Vehicle Licensing Agency (DVLA) and your insurance company that you have a pacemaker.

If you drive a large or passenger-carrying vehicle, you will have to wait six weeks after your pacemaker is fitted before driving again.

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 Will I be able to feel or see the pacemaker? 

You will be able to feel it, but you will soon get used to it. At first, it may seem a bit heavy and may feel uncomfortable when you lie in certain positions.

Modern pacemakers are now so small that they are almost completely hidden by the chest tissue and are barely noticeable.

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 How soon will I be back to normal? 

You should feel back to your usual self, or even better than that, very quickly. It is best to avoid reaching up on the side of your operation for four to six weeks. That means not hanging out washing or lifting anything from a high shelf, for example.

However, it is important to keep your arm mobile by gently moving it to avoid getting a frozen shoulder. The physiotherapist can show you how to do this. You will usually be able to do all the things you want to do after around four weeks.

The time you need off work will depend on your job – your cardiologist will usually be able to advise you about this. Typically, people who have had a pacemaker fitted are advised to take three to seven days off.

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 When can I exercise or play sports again? 

Avoid strenuous activities for around four to six weeks after having your pacemaker fitted. After this, you should be able to do most activities and sports. However, if you play contact sports, such as football or rugby, it is important to avoid collisions. You may want to wear a protective pad. Avoid extremely energetic activities, such as squash.

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 How can I care for my wound? 

Do not get your wound wet until your stitches have been taken out. After that, avoid wearing anything that rubs that area, such as braces. Women may need a new bra with wider straps. Avoid exposing your wound to sunlight in the first year, as this can cause a darker scar.

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 Will I have to have my stitches removed?

 

It d

 

 

 

 

 

epends on the kind of stitches used. Many doctors use soluble stitches that dissolve on their own. Before you go home, you will be told what type of stitches you have. If you need to have stitches removed, this will usually be after about seven to 10 days.

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What check-ups will I need?

You will usually have your pacemaker checked after four to six weeks at the hospital where it was implanted. Provided this check is satisfactory, you will have your pacemaker checked every three to 12 months.

If after having the pacemaker fitted and leaving hospital you feel you're not getting as much benefit as you imagined, your pacemaker may need some small adjustments. The cardiologist or cardiac technician can do this.

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What problems should I look out for?

Signs that your pacemaker is not working as it should, or that you have developed an infection or blood clot, can include:


breathlessness

dizziness

fainting

prolonged weakness

swollen arm on the side of the pacemaker

chest pains

prolonged hiccups

a high temperature of 38°C (100.4°F) or above

pain, swelling and redness at the site of the pacemaker


If you experience any of these problems after having a pacemaker fitted, contact your GP or cardiologist as soon as possible for advice.

If this is not possible, call 111 or your local out-of-hours service.

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Will my pacemaker be affected by electrical equipment?

Most ordinary household electrical equipment is safe to use and will not interfere with your pacemaker. This includes microwaves, as long as they are in good working order.

Specific advice is as follows:


Mobile phones – it is safe to use a mobile phone, but keep it away from your pacemaker. Use the ear on the opposite side or a headset.

Security devices – security at airports or anti-theft devices in shops can interfere with your pacemaker. They are safe, as long as you go through quickly and do not linger. Inform security staff that you have a pacemaker as it can set off the alarm.

MRI scans – you must not have an MRI scan as it uses strong magnets. "MRI-safe" pacemakers do exist, but they are not currently widely used. Other scans are safe.

Lithotripsy – this treatment for kidney stones must be avoided if you have a pacemaker.


If your job brings you into contact with strong electrical fields – such as arc-welding, diathermy or working with high-power radio or TV transmitters – or you have direct contact with car ignition systems, check with your cardiologist or pacemaker technician before returning to work.

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Will I need to have another pacemaker?

Most pacemaker batteries last for six to 10 years. After this, you may need to have the batteries changed. This involves replacing the pacemaker box with a new unit. This is a simple procedure that may or may not require an overnight stay in hospital. The original lead or leads can usually be left in place, although occasionally they will need to be replaced too.

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How often will I need follow-up appointments?

You will need follow-up appointments for the rest of your life. These may be every three to 12 months, depending on the type of pacemaker you have and how well it works.

At the follow-up appointment, the technician or doctor will analyse the discharge rate of your pacemaker, measure the strength of the electrical impulse and record the effects of the impulse on your heart. Most modern pacemakers can store information about the state of the battery and the performance of the pulse generator. Your pacemaker can then be reprogrammed to the best settings for you, if necessary.

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Will my sex life be affected? 

There is no reason you cannot continue to have a good sex life after your pacemaker is implanted and you're feeling better, although you should avoid positions that place pressure on the arms and chest for the first four weeks of your recovery.

Talk to your partner about any worries you may have, such as fear of opening up your scar, and work out ways to get around them. If you do not feel like having full penetrative sex straightaway, there are many other ways to express your desire, so use your imagination.

The risk of sex triggering a heart attack is low (around 1 in 1 million).

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Will the pacemaker improve my quality of life?

Most people who have a pacemaker feel that it has a tremendously positive impact on their life.

Research shows that having a pacemaker can help you be more active. It may also help you stay out of hospital and live longer. Above all, you should feel better, and previous symptoms, such as breathlessness or dizziness, should disappear.

Risks of pacemaker implantation 

As with any medical or surgical procedure, pacemaker implantation has risks as well as benefits. Some of the main risks are described below.

Blood clots

In about one in every 50 cases, a blood clot develops in one of the veins in the arm on the side of the body where the pacemaker was fitted.

This may cause some swelling in the affected arm, but it usually settles in a few days and is rarely a serious problem.

In some cases, you may be given anticoagulant medication, which stops the clot getting bigger.

Pacemaker infection

It is estimated that around one in 100 people with a pacemaker will develop a pacemaker infection. This usually happens within the first 12 months of having a pacemaker fitted.

Symptoms of a pacemaker infection include:


a high temperature of 38°C (100.4°F) or above

pain, swelling and redness at the site of the pacemaker


If you're worried that you have developed an infection, call your GP or cardiologist as soon as possible for advice. If this is not possible, call  111 or your local out-of-hours service.

A pacemaker infection is usually treated using a combination of antibiotics and surgery to remove and then replace the pacemaker.

If an infection is not treated, it could spread into your lungs (pneumonia), the lining of your heart (endocarditis) or your blood (sepsis).

Air leak

As the vein through which the pacemaker wires are sometimes inserted lies very close to one of the lungs, there is a risk of the lung becoming punctured accidentally during pacemaker implantation. This means that air can leak from the affected lung into the chest area.

This problem is known as pneumothorax and it's estimated to occur in about one in every 100 pacemaker implantation procedures.

In most cases, the leak is very small and gets better on its own without treatment. If a lot of air leaks into the chest, this may need to be sucked out using a needle and by placing a special drain into the chest area.

If a drain is required, you may need to stay in hospital for an extra day or two.

Problems with the pacemaker

As with any electronic device, there is a small chance that your pacemaker could stop working properly. This is known as a pacemaker malfunction. 

A pacemaker can go wrong if:


the lead gets pulled out of position

the battery of the pulse generator fails

the circuits that control the pacemaker become damaged by exposure to strong magnetic fields

the pacemaker has not been properly programmed


It's estimated that the pacemaker leads become dislodged in more than one in 100 cases, but a problem with the pacemaker itself is estimated to occur in only one in every 400-500 cases.

Signs that your pacemaker may have failed include:


your heart begins beating more slowly or quickly

dizziness

hiccups

fainting or nearly fainting


As with a pacemaker infection, seek immediate medical advice if you're concerned that your pacemaker has failed.

In some cases, it may be possible to correct a pacemaker remotely using wireless signals or magnets. Otherwise, the pacemaker will need to be removed and replaced.

Twiddler’s syndrome

An often overlooked cause of pacemaker malfunction is known as twiddler’s syndrome.

This is when the pacemaker generator is pulled out of its normal position because a person is – often without realising – moving the generator under the skin back and forth or round and round (twiddling with it).

One treatment option is to stitch the generator more firmly to the surrounding tissue so it cannot be moved.