Pacemaker placement

A pacemaker can be used to replace the function of the natural pacemaker of the heart when the heart is beating too slowly.

A pacemaker is a small, battery-powered device that sends out weak electrical impulses that cause the heart muscle to contract. The pacemaker itself is a waterproof object about the size of a silver dollar. A pacemaker consists of wires (leads), which transmit electricity to the heart, and the pulse generator and battery, which generate the electrical impulses.

See an illustration of a pacemaker.

Pacemakers can be surgically placed into the chest (a permanent pacemaker) through a small incision, or they can be worn outside the body (a temporary pacemaker) and attached to the heart through a wire that is threaded through a neck vein. Temporary pacemakers are used only while a person is in the hospital.

There are several types of permanent pacemakers.

• A fixed-rate pacemaker gives off electrical impulses at a steady, regular rate, regardless of your level of activity.
• A rate-responsive pacemaker changes the rate of electrical impulses as your activity level changes.
• A single-chamber pacemaker controls only the lower chamber of the heart (ventricle).
• A dual-chamber pacemaker controls both the top (atrium) and bottom (ventricle) chambers of the heart.

Many times the pacemaker is set to work only when the heart rate falls below a certain predetermined rate (demand mode).

The battery in a permanent pacemaker usually lasts 5 to 15 years. Your doctor will monitor your pacemaker regularly to decide when the battery should be changed.

The surgery needed to implant a permanent pacemaker is considered a minor surgical procedure. It can usually be done using local anesthesia, which means part of your body is numbed, but you stay awake.

A small incision is made in the chest wall. The pacemaker leads are usually threaded through the incision into a large blood vessel in the upper chest and into the heart. Using the same incision, a small pocket is created under the skin to hold the pulse generator. The leads are then hooked up to the pulse generator. The entire procedure usually takes about 1 hour.

It is normal for the surgical wound to be somewhat painful and swollen for a few days after the procedure. This can usually be controlled with medications. The wound may also appear mildly red for a few days; however, if the area of redness enlarges, you should notify your doctor. You should also call your doctor if the wound starts to bleed, fluid starts to drain from the wound, fever develops, or the pain at the surgical site gets worse.

If there are no other problems, most people who have a permanent pacemaker surgically implanted can go home the next day. You can usually return to normal activities within 6 weeks. For several weeks after having a pacemaker implanted, you may be asked not to lift more than 5 lb (2.3 kg) or raise the affected arm over your shoulder.

Suggested guidelines for permanent pacemaker follow-up include the following:¹

• Before you leave the hospital, you usually will have a full evaluation, including a chest X-ray, electrocardiography (EKG, ECG), and a pacemaker check. One week to 10 days after discharge, your incision will be checked.
• 6 to 8 weeks after placement of the pacemaker, you generally will have a full evaluation, including an EKG, and have your pacemaker checked.
• 3 to 6 months after placement, you generally will either visit your doctor or clinic in person or have your pacemaker checked over the phone. Information can be sent directly over the phone to a computer on the other end of the line. This computer prints the information, and it can be reviewed by your doctor.
• About every 1 to 3 months, you generally will be asked to have your pacemaker checked over the phone.
• Once or twice per year, you will be asked to visit your doctor to have a full evaluation of your pacemaker.
  • If the battery life is low, the battery will need to be replaced. (Although people refer to this procedure as a battery change, the entire pacemaker is actually replaced so that you can benefit from new circuitry and any new features that have recently been added to pacemakers.) This involves a surgical procedure similar to the initial implantation, except that the battery change is often a more simple procedure since the leads are already in place. The batteries may last 5 to 15 years, depending on the type of device and the frequency with which the device is used.
  • The leads are routinely tested when the battery is replaced. If they are functioning adequately, the new pacemaker may simply be connected to the existing leads. However, if there is a problem with the old lead system, it may be wise to replace the lead system while inserting the new pacemaker.

Pacemakers are inserted to treat bradycardia when the heart beats so slowly that it does not pump enough blood to meet the body's needs, resulting in symptoms such as fainting (syncope). At other times, pacemakers are implanted when bradycardia is expected to get worse and cause complications. If a person with a slow heart rate does not have symptoms, pacemakers are used only when a doctor finds some very specific indications.

Pacemakers effectively treat a slow heart rate, especially when an abnormally slow heart rate is permanent or expected to occur again.²

After having a permanent pacemaker implanted, you may need to avoid certain activities or conditions that might interrupt the signals sent by the pacemaker to the heart. Follow your doctor's specific instructions about what precautions to take. Make it known to health professionals that you have a pacemaker before you have any diagnostic testing, such as an MRI scan or surgery.

The risks of putting in a pacemaker include:

• Puncture of the heart.
• Infection.
• Blood clot.
• Bleeding.
• Breathing problems.
• Irregular heart rhythms.
• Pacemaker malfunction (wire breakage, sensing problems).

In rare cases, people feel throbbing in the neck, chest fullness, or lightheadedness when the pacemaker sends out impulses. Talk to your doctor about what types of side effects you may expect from your pacemaker.

Rate-responsive pacemakers are often the ideal choice for active people. These pacemakers closely reproduce natural heart rhythms and are able to raise heart rate in response to physical activity. Your doctor can decide how fast the pacemaker should respond and how quickly your heart rate should return to a resting rate.

Strong electric or magnetic fields can interfere with your pacemaker. You can safely use most household and office equipment. And you can usually avoid electrical interference from magnetic or electrical sources by keeping certain things a few inches away from your pacemaker. You should completely avoid things like heavy electrical or industrial equipment.

You may walk through metal detectors (in airports or other security checkpoints) at a normal speed, but avoid standing near or leaning on these systems. Your pacemaker may set off a metal detector, but the security archways will not damage the device. Your doctor will give you a pacemaker identification card to carry at all times. Before you pass through a metal detector, tell the security guards that you have a pacemaker, and show them your device identification card.

If you have a pacemaker, you will not be able to have an MRI (magnetic resonance imaging) test. Before you have any tests or surgery, tell all of the health professionals involved in your care that you have a pacemaker. You may choose to wear a medical alert bracelet that says you have a pacemaker. Experts are trying to make pacemakers that can work safely during an MRI test.

Complete the surgery information form (PDF)(What is a PDF document?) to help you prepare for this surgery.

Citations

1. Bernstein AD, et al. (1994). Policy conference report. Antibradycardia-Pacemaker Follow-up: Effectiveness, Needs, and Resources. Available online: http://www.hrsonline.org/swPositionStatementFiles/ps99313915.asp.

2. Mangrum JM, DiMarco JP (2000). The evaluation and management of bradycardia. New England Journal of Medicine, 342(10): 703–708.