Why do I need a pacemaker?

Your doctor may have decided that you have a heart condition that requires a pacemaker. There are many conditions where pacemakers can be of benefit, but mostly they help when the heart beats slowly either intermittently or persistently. Some patients are symptomatic with this – shortness of breath, dizziness or even collapsing episodes may occur. Other patients may be free of symptoms, but still require a pacemaker to reduce the risks of future problems. 

What is a pacemaker?

The pacemaker system consists of a small box made of titanium (the generator), and one or two leads connected to the generator. The generator typically weighs 30-50g (about 1-2 ounces) and is about the size of a book of matches. It contains the electronic circuitry as well as the battery to power the system. The leads are thin wires coated in silicon or a similar compound. One end connects to the generator, and the other end of the lead is positioned within the inside wall of the relevant heart chamber. This creates an electrical circuit that involves the heart muscle. The generator can then monitor when the heart is beating appropriately, and also trigger a heartbeat when it is not, by sending a tiny current down the lead. In this way, the system can artificially increase a slow heart rate to a more appropriate speed. You cannot feel the pacemaker working.

What kinds of pacemaker are there?

There are many different manufacturers of pacemaker systems. Some device manufacturers offer slightly different setup options, which can be tailored to each patient as needed.

Generally speaking, regardless of manufacturer, there are two main types of pacemaker used - single chamber and dual chamber. As the name suggests, single chamber devices use one lead and control pacing in one heart chamber (either the right ventricle, or the right atrium as appropriate). Dual chamber devices use two leads and control activity in two chambers (right atrium and right ventricle). Additionally, “rate responsive pacing” is often used to mimic heart rate increase with exercise in patients whose hearts cannot do this on their own.

Your doctor will choose a specific device to address your particular needs.

What does a pacemaker implant involve?

The procedure itself usually takes around an hour to do and you can expect go home the day after the implant.

You will be awake as the procedure is done under a local anaesthetic, but sedation can be given if required. Very rarely would a general anaesthetic be needed.

Once the skin has been numbed with an injection of local anaesthetic, a small cut, approx. 5cm (2”) long, is made to the skin below the collar bone. Through this small cut, a lead is passed into the large vein that runs just below the collar bone (or via a small branch that flows into it). The lead is then passed down to the inside of the heart where it is sited to make contact with the heart wall. As there are no nerve endings on the inside of the heart and circulation, once inside the vein, the lead cannot be felt by the patient. The process is repeated if a second lead is needed.  Once the leads are secured, a small space (pocket) is opened up to place the generator on top of the muscle, below a layer of fat that acts as padding. The wound is then stitched closed and the skin sealed in most cases with surgical glue.

Apart from a small scar, you may be able to see (and feel) a small lump where the device is sited. This is generally unobtrusive but may be more prominent in thin patients. There may be some bruising, but this will be transient.

Who implants the pacemaker?

A doctor (Cardiologist) implants the pacemaker, but he/she is only one part of a team that also includes experienced cardiorespiratory physiologists, nurses and radiographers. They all work closely together to ensure that the procedure is performed as quickly and safely as possible.

Should I take any precautions before the pacemaker implant?

You will have been given a sheet with instructions about precautions before the pacemaker. These include some tablets that may need to be stopped (such as warfarin and clopidogrel (PlavixTM).

If there is a chance that could have an infection (such as a chest, skin or water infection) at the time of the implant, you must tell the cardiologist. It may be safer to delay the procedure to avoid the device becoming infected. This is a rare but serious complication (see below).

What are the risks of a pacemaker implant?

Implanting a pacemaker system is considered a very safe procedure. There are recognised risks of doing this, but they are small. The most important risks are as follows:

pneumothorax (punctured lung) – less than 1%

accidental puncture of artery instead of vein – less than 1%

wound haematoma (bleeding into the wound around the time of implant) – less than 1%

lead displacement (requiring a second procedure to resite or replace the lead) – less than 1%

wound infection – less than 1%

What will happen after I leave hospital?

On the morning after the implant you will have a pacemaker check and a chest xray.

You will be supplied with an ID card that gives the details of the pacemaker device as well as the lead(s) used Assuming all is well, you will be discharged home with an appointment for a further pacemaker check in a further 8 weeks time.

A “pacemaker check” in clinic takes about 20 mins. The device is “interrogated” using a magnetic wand that communicates with the device through the skin. This is completely painless.

Follow up clinics are scheduled for 8 weeks after implant, 6 months, and then annually. At each check, an assessment of the battery status is made. When there is evidence that the battery is starting to run down, frequency of the follow ups is increased to every 3 to 6 months again.

Before the battery becomes depleted, a “box change” is arranged. This is a repeat procedure where the skin is reopened, again under a local anaesthetic, and a new generator swapped for the old one. This is usually a much shorter procedure and is done as a daycase.

There is plenty of warning regarding battery status. Devices tend to last 7 to 8 years before a box change is required.

What care do I need to take afterwards?

The wound may be sore for a few days, but generally paracetomol is adequate for relief.

There may be a small amount of bruising. This is normal and generally resolves within a week or two.

Patients are advised to avoid as much as possible, using the arm on the side of the device for the first 48 hours. This reduces the chance of the leads being displaced. Please bear this in mind when planning convalescence after the procedure. You will not be able to drive yourself home after the procedure (because of the wound).

There may be separate issues regarding your fitness to drive after the implant has been done. Please discuss these with your doctor.

Any other considerations?

Pacemakers can be damaged by blunt force. Contact sports such as martial arts and rugby are therefore prohibited.
If your doctor feels that you need Magnetic Resonance Imaging (MRI), they must be made aware that you have a pacemaker. These scanners use very powerful magnets to generate images. Many modern pacemakers are shielded and may be safe with these scanners, but many devices are not and could be reset or even damaged by the magnetic field.

Normal xrays, CT and ultrasound scans do not affect pacemakers.
Electronic security systems, such as those common in airports and shop doorways can pose problems if exposure is prolonged. Passing through such systems as normal, even several times, does not pose a threat. However, patients with pacemakers should avoid the “wand” used in some security checks as this too is magnetic. The pacemaker may trigger an alarm at airport security as it is made of metal. It's advisable to declare your pacemaker ID card to the security staff, to undergo a manual search rather than a wand search.

Microwave ovens and electric blankets do not, as myth might have it, affect pacemaker functioning.

Modern devices are also shielded from the effect of mobile phones. However it is still advisable to use the phone on the side away from the device, and if a phone is carried in a jacket pocket, this too should be on the other side, at least 15cm (6”) away.

Pacemaker infection is rare but serious. Please be alert for any new swelling, redness or discomfort around the implant site. Pacemaker infection is considered an emergency and must be reviewed that day. You should consult your GP as soon as possible, and if they have any concerns, it is likely that they will send you in to hospital to be further assessed.

Written in conjunction with Jason Causer

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