Pacemaker implantation

Pacemaker implantation is a procedure to put a small battery-operated device called a pacemaker into your chest.

Introduction

Pacemaker implantation is a procedure to put a small battery-operated device called a pacemaker into your chest. The pacemaker sends regular electrical pulses which help keep your heart beating regularly.

Having a pacemaker fitted is one of the most common types of heart surgery.

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, that run to your heart.

The pacemaker contains:

  • a battery, which usually lasts from 8 to 10 years depending on how advanced the device is (pacemakers that are more advanced 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:

  • damage to part of the heart called the sinus node – which can cause an abnormally slow heartbeat (bradycardia), an abnormally fast heartbeat (supraventricular tachycardia), or sometimes a combination of both
  • heart block – where your heart beats irregularly because the electrical signals that control your heartbeat are not transmitted properly
  • cardiac arrest – when the heart stops 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 modern devices contain both a pacemaker and an ICD.

ICDs are often used a preventative treatment for people who are 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.

Read more about why you might need a pacemaker.

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. The generator is attached to a wire that is guided through a blood vessel to the heart.

The procedure takes around 30–60 minutes and most people are well enough to leave hospital the day after surgery.

Read more about how a pacemaker is fitted.

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 three to four 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're in good working order.

Read more about recovering from pacemaker surgery.

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.

Read more about the risks of having a pacemaker.

Afterwards

  • 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 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?
  • 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?

You will usually be able to go home after one or two days.

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 driving licence issuer 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 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.

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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 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.

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When can I exercise or play sports again?

Avoid strenuous activities for around three or four 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, although skiing should be fine.

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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 depends 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 10 days.

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What check-ups will I need?

You will usually have your pacemaker checked after four weeks at the hospital where it was implanted. Provided this check is satisfactory, you will have your pacemaker checked every 3 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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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.
  • Electronic surveillance – 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 scan – you must not have an MRI scan (body imaging scan) as it uses strong magnets. 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 8 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 3 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?

Some heart medications can affect a man's ability to get an erection. Try to relax and not anticipate problems (anxiety about performance may be the cause rather than your medication). If you suspect that a drug you're taking is causing erection problems, talk to your doctor.

There is no reason you cannot continue to have a good sex life after your pacemaker is implanted. 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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Risks

As with any medical or surgical procedure, pacemaker implantation has risks as well as benefits. The risks are described below.

Pacemaker infection

There is a small risk that the site of the pacemaker, implantable caridoverter defibrillator (ICD) or their leads can become infected.

It is estimated that around 1 in 100 people with a pacemaker will have 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 38C (100.4F) or above
  • pain, swelling and redness at the site of the pacemaker

If you're worried that you have developed an infection, call your doctor or cardiologist as soon as possible for advice.

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

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

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

Pacemaker malfunction

As with any electronic device, there is a small chance that your pacemaker could stop working properly. This is known as a pacemaker malfunction. It's estimated to affect around 1 in every 250 people with a pacemaker.

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

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.

What happens

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 quitting smoking if you smoke and eating a healthy diet, should help speed up your recovery time and reduce the risk of complications.

Read more about preparing for surgery.

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

In transvenous implantation, the wires of the pacemaker (pacing leads) are inserted into your heart through a vein. This is the most common method of fitting a pacemaker and is done under local anaesthetic, where the area is numbed.

Medication is given through your IV line to relax you and make you feel drowsy, but you will be awake during the procedure.

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

During the procedure:

  • The cardiologist makes a 5–6cm cut below the collarbone and inserts the pacing lead into a vein.
  • The pacing lead is guided into the correct chamber of your heart using X-rays, and becomes lodged in the tissue of your heart.
  • The other end of the lead is connected to the pacemaker, which is fitted into a small pocket created under the skin of your upper chest.

The procedure usually takes 30–60 minutes. 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, which is called the epicardium. Epicardial implantation is often used in children and people who have heart surgery at the same time as the pacemaker implantation.

The procedure is done under general anaesthetic so you will be asleep during it.

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

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

Recovery usually takes longer than when using the transvenous approach.

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 rate increase or 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.

Why it is neccesary

To understand why you might need to have a pacemaker fitted, it is useful to know about how the heart beats.

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 caridoverter 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 discussed 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, in some cases, a combination of both.

Symptoms of sick sinus syndrome include:

  • [feeling tired all the time]
  • fainting or nearly 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 is angina)

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

An implantable cardioverter defibrillator (ICD) is mainly used to prevent you from having a 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 within minutes, 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 (a bit like fixing a faulty computer by turning it off and on again). 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:

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