Page last reviewed: 13/07/2011
Pacemaker implantation is a procedure to put a small, battery-operated device called a pacemaker into your chest, to help your heart beat regularly.
This is a minor surgical procedure that is usually performed under a local anaesthetic (the area is numbed but you are awake during the operation).
Why is it necessary?
The heart has its own natural pacemaker, called the sinoatrial (SA) node (see box, below left). The SA node is a small clump of cells in your heart that generates electrical impulses that spread throughout your heart, causing it to beat. If this process stops working properly, you may need an artificial pacemaker.
The main reasons for needing an artificial pacemaker are:
- Heart block: a condition where your heart beats irregularly or more slowly than normal because the electrical signals that control your heartbeat are not being transmitted properly.
- Bradycardia: a heart condition featuring episodes of an abnormally slow heart rate (less than 60 beats a minute). This is sometimes caused by sinus node disease, where your natural pacemaker does not function properly, which can happen as a result of age, heart disease or medication.
- Heart failure: when your heart is not pumping blood around your body very efficiently.
Having a pacemaker fitted is very straightforward and the risk of complications is low. After the procedure, you should feel back to normal, or even better, very quickly.
How the heart works
The heart has two upper chambers (left and right atria) and two lower chambers (left and right ventricles).
The atria and ventricles have walls of muscle. A heartbeat happens when this muscle suddenly contracts (tightens). The chambers become smaller and the blood inside them is squeezed out.
The sinoatrial node is a small clump of cells in the right atrium which is involved in controlling the heartbeat. It acts as the heart's natural pacemaker by sending out electrical impulses through the heart to another clump of cells called the atrioventricular node, found between the atria and ventricles.
The atrioventricular node determines the rate at which these electrical impulses are transmitted and, therefore, the rate at which the ventricles contract. It is the contraction of the left ventricle that produces the pulse rate.
Page last reviewed: 13/07/2011
The pacemaker is a small metal box weighing 20-50g, which is attached to one or more pacing leads (wires) that run to your heart. The pacemaker contains:
- a battery (which usually lasts 6 to 10 years),
- a pulse generator, and
- 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.
Setting the pace
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, and
- if it senses that your heart is beating normally by itself, it does not send out any signals.
Most pacemakers have a special sensor, which recognises body movement or breathing rate, enabling them to speed up the discharge rate when you are active. Doctors describe this as rate responsive.
Most pacemakers can analyse and store information about your natural heart rhythms. When you have follow-up appointments at the pacemaker clinic, the technicians and doctors can retrieve this information and use it to check how well the pacemaker and your heart are working.
The type of pacemaker you need depends on your heart problem.
This has one wire and is used when:
- the upper chambers of your heart always beat irregularly, or
- your natural pacemaker does not work properly but you do not have heart block.
This has two wires and is used when:
- your heart sometimes beats irregularly,
- you have heart block but your natural pacemaker is working properly, or
- you have heart block and your natural pacemaker is not working properly.
This has three wires and is used when you have advanced heart failure. It is also known as cardiac resynchronisation therapy.
Page last reviewed: 13/07/2011
Alternative treatments to having a pacemaker fitted include:
- cardiac catheter ablation, and
- an implantable cardioverter-defibrillator (ICD).
Medicines called anti-arrhythmics can control heart rhythm disorders by:
- restoring a normal heart rhythm, and/or
- controlling the rate at which the heart beats.
Examples are calcium channel blockers (such as verapamil), which slow your heart rate, and beta-blockers (such as sotalol), which restore a normal heart rhythm.
The most common side effects of beta-blockers are coldness of hands and feet, low blood pressure and impotence. Possible side effects of calcium channel blockers are low blood pressure, ankle swelling and heart failure.
Cardiac catheter ablation
Catheter ablation is a procedure that very carefully destroys the diseased area of your heart and interrupts abnormal electrical circuits. It is an option if medication has not been effective or tolerated.
Catheters (thin, soft wires) are guided through one of your veins into your heart, where they record electrical activity. When the source of the abnormality is found, an energy source (such as high-frequency radio waves that generate heat) is transmitted through one of the catheters to destroy the tissue.
This can be quite a long procedure and commonly takes two to three hours, so it may be done under general anaesthetic (where you are put to sleep).
Implantable cardioverter-defibrillator (ICD)
An ICD is a device slightly bigger than a matchbox that is implanted under your collarbone, with wires leading to your heart. Like a pacemaker, it can be used to pace your heart.
An ICD is often inserted under local anaesthetic (which numbs the area), but a general anaesthetic (which puts you to sleep) may be used if you are at high risk of having a cardiac arrest (when your heart stops).
You may need an ICD if:
- you have had a previous cardiac arrest and are at risk of another one, or
- you have never had a cardiac arrest but tests show you have high risk of having one at some point in the future because of abnormal heart rhythms.
How is an ICD different from a pacemaker?
If the ICD detects an abnormal heart rhythm, it tries to correct this by pacing your heart and, if this fails, delivering a small, controlled electric shock. If this fails, it delivers a larger shock, known as defibrillation. A pacemaker does not give you any electric shocks.
Treating severe heart failure
A combination of a biventricular pacemaker and an implantable cardiac defibrillator (ICD) may be used for severe heart failure. This works to:
- resynchronise your heartbeat (make it regular again),
- slow down an abnormally fast heart rate,
- prevent an abnormally slow heart rate,
- record a history of your heart rate and rhythm, and
- give the heart an electric shock, if necessary.
For more information, see Treating heart failure.
Page last reviewed: 13/07/2011
Your pacemaker will be fitted in the radiology department of the hospital, in a room called a catheter laboratory.
Before the procedure, an intravenous (IV) line will be put into your arm or hand to allow medications and fluids to be given to you during the procedure.
The area of your chest where the pacemaker will be implanted is kept sterile (clean of germs) to prevent infection.
Fitting the pacemaker
The pacemaker can be fitted in two ways:
- transvenous (endocardial) implantation, or
- epicardial implantation.
Transvenous (endocardial) implantation
Transvenous implantation means that the pacing leads (wires of the pacemaker) are inserted into your heart through a vein. This is the most common method of fitting a pacemaker and is done under local anaesthetic (the area is numbed).
A medication will be 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. You will soon become numb, but you may feel a pulling sensation as the cardiologist (heart specialist) makes the pocket in the tissue under your skin for the pacemaker.
A summary of the procedure is as follows:
- 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 and the pacemaker is fitted into a small pocket created under the skin of your upper chest.
This usually takes 30-60 minutes or longer if you are having a bi-ventricular pacemaker fitted (with two leads) 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.
In this method, the pacing lead or leads are attached to the outer surface of your heart, 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 (you are put to sleep).
The surgeon attaches the tip of the lead to your heart and the other end of the lead to the pacemaker box, which 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 is usually longer than that from 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 are working 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.
Page last reviewed: 13/07/2011
As with any medical or surgical procedure, there are risks as well as benefits. Risks associated with pacemaker implantation include:
- Infection. There is a small risk of infection at the site of the implant. If it spreads, there is a risk that the pacemaker and/or the leads may need to be replaced.
- Problems with the pacing leads. There is a small risk that one of the leads may move out of position, which is why you are advised to avoid vigorous exercise for a few weeks after the procedure. Also, there is a small chance that the leads may stop functioning or cause heart rhythm problems, in which case they would need to be removed .
- Air leak around the lungs (pneumothorax). There is a small risk of the surgeon accidentally nicking the lungs during the procedure, causing air to leak from the lungs and into the chest. The doctor will check your lungs for damage using X-rays before you leave hospital.
- Perforation (hole) in the muscle layer of the heart. This is rare but serious as it may lead to a build-up of fluid around the heart. This may require an additional procedure to relieve the pressure on the heart.
For about 1 in 20 people, the operation to implant a pacemaker has to be abandoned because it is too difficult.
Removing pacing leads
Pacemaker leads may need to be removed or changed if they stop working, cause heart rhythm problems or become infected.
If the leads have been in place for more than a few months they can become tightly attached by scar tissue to the heart and veins, making removal difficult and risky.
Contact your doctor if you:
- feel dizzy or breathless, or have new symptoms that you did not experience before you had the pacemaker, or
- have pain, tenderness, swelling, redness or discharge around the pacemaker wound site at any time.
Page last reviewed: 13/07/2011
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 lead(s).
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 at the site of the pacemaker. This usually passes within a few days. Tell the staff if your symptoms are persistent or severe.
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 like 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.
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, and
- you have not recently had a heart attack or heart surgery.
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.
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 avoiding hanging out washing or lifting anything from a high shelf. It is important, however, to keep your arm mobile by gently moving it to avoid getting a frozen shoulder. The physiotherapist can show you how. You will usually be able to do all the things you want to do after around four weeks.
When can I do 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.
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. You may need a new bra with wider straps. Also avoid exposing your wound to sunlight in the first year, as this can cause a darker scar.
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.
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 that you are not getting as much benefit as you imagined, your pacemaker may need some small adjustments, which the cardiologist or cardiac technician can do.
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 microwave ovens, 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 and 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, provided 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.
Will I need to have another pacemaker?
Most pacemaker batteries last for 6 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 can be done as a day case or with 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.
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 is working.
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.
Will my sex life be affected?
Some heart medications can affect your ability to get an erection. Try to relax and not anticipate problems (performance anxiety may be the cause rather than your medication). If you suspect that a drug you are taking is causing erection problems, talk to your GP.
There is no reason why you cannot continue to have a good sex life after your pacemaker implantation. 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 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 one in a million).
Will the pacemaker improve my quality of life?
Most people who have a pacemaker feel it has a tremendously positive impact on their life. Research shows that having a pacemaker can help you to be more active. It may also help you to stay out of hospital and live longer. Above all, you should feel better and previous symptoms, such as breathlessness or dizziness, should disappear.