Pacemaker implantationSee all parts of this guide Hide guide parts
Pacemaker implantation is a procedure to put a small battery-operated device called a pacemaker into your chest. The pacemaker sends regular electrical impulses, which help keep your heart beating regularly.
Having a pacemaker fitted is one of the most common types of heart procedures.
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)
- an impulse 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 pulses 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 electrical circuit 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 – when your heart beats irregularly because the electrical signals that control your heartbeat are not transmitted properly
- cardiac arrest – when the heart stops pumping blood around your body
Implantable Cardioverter Defibrillator (ICD)
An implantable cardioverter defibrillator (ICD) is a device similar to a pacemaker. An ICD delivers an electrical shock to the heart during a life threatening heart rhythm. The aim is to ‘reboot’ the heart to get it back into a normal rhythm 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 on ICDs by British Heart Foundation.
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 into the muscle 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 the procedure.
Read more about how a pacemaker is fitted from British Heart Foundation.
After a pacemaker implant
You should be able to get back to normal physical activities very soon afterwards. As a precaution, it is normally recommended that you avoid strenuous activities for around 3 to 4 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.
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 're-programme' the pacemaker to fix a malfunction by using wireless signals. However, further procedures may be required if the pacemaker moves out of position.
How a pacemaker is fitted
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 the procedure. 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 may 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.
A heart specialist, known as a cardiologist, who will probably have a special interest in pacemakers, will carry out the procedure. If you are being treated in a large heart hospital, an electrophysiologist will most likely carry out the operation. An electrophysiologist is a cardiologist who specialises in heart rhythm disorders.
Fitting the pacemaker
The most widely used method to fit a pacemaker or an implantable cardioverter defibrillator (ICD) is known as 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 - it is done when you are awake but the area of your body affected is numb.
First medication is given through a needle into a vein (called a venflon) to relax you and make you feel drowsy.
You will feel an initial burning or pricking sensation when the cardiologist injects the local anaesthetic under your skin where the pacemaker is to be inserted. You will soon feel the area of skin 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 it 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 3 leads) fitted or other heart surgery at the same time. Most people are treated as a day case, which means you will get home that day unless you have complications.
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 1 to 2 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.
Recovering from pacemaker implantation
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.
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.
Getting home from hospital?
Most pacemaker and ICD procedures are done as day cases, so you will get home the same day unless you have complications.
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).
How soon can I drive?
If you have an ordinary driving licence and have had a pacemaker fitted, 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 the Driver and Vehicle Licensing Agency (DVLA) and your insurance company that you have a pacemaker.
If you drive a large or passenger-carrying vehicle, you will have to wait 6 weeks after your pacemaker is fitted before driving again. However, if you have had an ICD fitted you must be shock free for 6 months.
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 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.
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.
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.
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 4 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.
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. However, MRI-safe pacemakers are becoming more common now so check which one you have with your pacemaker clinic or doctor if this situation arises
- 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 8 to 10 years. After this, you will 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.
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 impulse 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 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 GP.
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 the 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 intimacy, so use your imagination.
The risk of sex triggering a heart attack is low - around 1 in 1 million.
Risks of pacemaker implantation
As with any medical or surgical procedure, pacemaker implantation has risks as well as benefits. The risks are described below.
There is a small risk that the site of the pacemaker, implantable cardioverter 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
- the site may become hot to touch and have some discharge
If you're worried that you have developed an infection, call your GP or pacemaker clinic as soon as possible for advice.
If this is not possible, call the NHS 24 111 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 a procedure to remove and then replace the pacemaker.
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 impulse 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
- 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.
An often overlooked cause of pacemaker malfunction is known as twiddler’s syndrome.
This is when the pacemaker generator is pulled out of its normal position because a person is – often without realising – moving the generator under the skin back and forth or round and round (twiddling with it).
One treatment option is to stitch the generator more firmly to the surrounding tissue so it cannot be moved.
01 November 2021
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