Pacemaker Implantation

Permanent Pacemaker Implantation :

A pacemaker is implanted to treat bradycardia (an abnormally slow heart rate). Pacemakers can also adjust the heart rate to meet the body's needs, whether during exercise or rest. Implantation of a pacemaker involves positioning leads (thin, insulated wires) in the heart and placing the device in a pocket of skin, usually in the shoulder area. Typically the implant procedure involves only local anesthetics and a sedative, rather than general anesthesia. Most people have a fairly quick recovery after a pacemaker implant.

What Is a Pacemaker?

A pacemaker is a small implantable device that treats abnormal heart rhythms called arrhythmias. Specifically, a pacemaker treats slow arrhythmias called bradycardia.
Arrhythmias result from a problem in the heart's electrical system. Electrical signals follow a certain pathway through the heart. It is the movement of these signals that causes your heart to contract.
A pacemaker system has two parts, and each plays a role in treatment. The pacemaker leads are thin, insulated wires that carry electrical signals back and forth between the device and the heart. The leads can sense when the heart is beating too slowly and needs treatment.
The pacemaker device, or pulse generator, is quite small, easily fitting in the palm of your hand. It contains computerized parts that run on a battery. The device treats your heart by sending very small amounts of electrical energy to the heart through the leads. Patients usually can't feel the treatment. The pacing system delivers treatment based on what it senses in your heart, even if you don't feel any symptoms.

How Should I Prepare for the Implant?

Your doctor or nurse will give you specific instructions. Common guidelines include:

  •  Whether to continue or stop certain medications
  •  What to avoid eating or drinking before surgery
  •  What your hospital's check-in procedures are
  •  Where Is the Device Implanted?

The pacemaker can be implanted below the collarbone on either the right or left side of the body. In some cases the device is implanted in the abdomen. Before confirming where to place the device, you and your doctor will talk about:

  •  Your age and overall health

  •  Whether you have had chest surgery

  •  Your activities and lifestyle

  •  How Is a Pacemaker Implanted?

Implanting the Leads: You lie on an exam table and an intravenous (IV) line is put into your arm. The IV delivers fluids and medications during the procedure. The medication makes you relaxed and groggy, but not unconscious. (General anesthesia is usually not needed.) During the procedure, you will be attached to several monitors.
Your doctor numbs a small area of skin and inserts the leads through a small incision, usually near the collarbone. The doctor gently steers the leads through the blood vessels and into the heart. The doctor can see where the leads are going by watching a video screen with real-time, moving x-rays (fluoroscopy).
Depending on the treatment your heart needs, either one or two leads are implanted in your heart. A pacemaker that uses one lead is called a single-chamber pacemaker. A pacemaker that uses two leads is called a dual-chamber pacemaker. With a dual-chamber pacing system, one lead goes in your top right chamber (the atrium) and the other lead goes in your bottom right chamber (the ventricle).
Testing the Leads and Device: Your doctor connects the implanted leads to the device and tests the system. In this way the doctor makes sure that both parts of the pacemaker system—the leads and the device—work properly. During the testing you may feel your heart beating faster.
Implanting the Device: Your doctor places the device just under the skin—usually near your collarbone—and then stitches the incision closed.

A pacemaker is a small device about the size of a matchbox that weighs 20-50g. It consists of a pulse generator – which has a battery and a tiny computer circuit – and one or more wires, known as pacing leads, which attach to your heart.
The pulse generator emits electrical impulses through the wires to your heart. The rate at which the electrical impulses are sent out is called the pacing rate.
Almost all modern pacemakers work on demand. This means 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 doesn't 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're active. Doctors describe this as rate responsive.

  •  an abnormally slow heartbeat (bradycardia) or an abnormally fast heartbeat (tachycardia)

  •  heart block – where your heart beats irregularly because the electrical signals that control your heartbeat aren't transmitted properly

  •  cardiac arrest – when a problem with the heart's electrical signals cause the heart to stop beating altogether

Having a pacemaker implanted is a relatively straightforward process. It's usually carried out under local anaesthetic, which means you'll be awake during the procedure.
The generator is usually placed under the skin near the collarbone on the left side of the chest. The generator is attached to a wire that's 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.

You should be able to return to normal physical activities soon after surgery. As a precaution, it's usually recommended that strenuous activities are avoided for around four to six weeks after having a pacemaker fitted. After this, you should be able to do most activities and sports.
You'll be able to feel the pacemaker, but you'll soon get used to it. It may seem a bit heavy at first, and may feel uncomfortable when you lie in certain positions.
You'll 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, your doctor can retrieve this information and use it to check how well your heart and the pacemaker are working.
Most ordinary household electrical equipment is safe to use and won't interfere with your pacemaker. This includes microwaves, as long as they're in good working order.

Having a pacemaker implanted is usually a very safe procedure with a low risk of complications. The biggest concern is the pacemaker losing its ability to control the heartbeat, either because it malfunctions or the wire moves out of the correct position.
It's sometimes possible to reprogramme the pacemaker to fix a malfunction using wireless signals. However, further surgery may be needed if the pacemaker moves out of position.

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 medication 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.
If your cardiologist recommends having a pacemaker fitted, ask them why they think it's the best option and discuss any possible alternative treatments you could have.

The pacemaker implant experience can vary from one person to another. Some people stay in the hospital overnight, while others go home the same day as the procedure. There is usually tenderness at the incision site, just as there is any time you have stitches. However, most people have a fairly quick recovery.

You may have an appointment a few weeks after the procedure so that your doctor or nurse can make sure your incision site is healing well. Many people with a pacemaker have an improved quality of life, since the device helps relieve symptoms of a slow heart rate.