Pacemaker Implantation

You need to have a pacemaker typically because your heart is beating too slowly or your heart has a condition called atrial fibrillation and is beating very rapidly and it is not possible to effectively control it with medicines alone.

Below are examples of a standard dual chamber pacemaker on the left hand side of the image plus a biventricular pacemaker (CRT-P) on the right.

Note the pacemaker lead with the very small screw on the end to allow attachment of the pacemaker within the heart.

If your heart is beating too slowly often this can result in dizzy spells or even blackouts. The pacemaker can often stop these symptoms.  The pacemaker doesn’t work all of the time but generally will make the heart beat if the heart drops below a certain heart rate such that the pacemaker “moves into action” by delivering a small electrical pulse to the heart muscle making it beat. 

Around 3% of people who have a pacemaker will have some adverse event.  Pain and discomfort – it is normal to feel some discomfort of pain around the wound site but this will typically settle within 2-3 days using basic painkillers such as paracetamol or ibuprofen.

• Infection – this occurs in around 1-2% of patients.  It may be a simple wound infection that can be treated with antibiotics however if it is an infection within the pocket itself the whole pacemaker system can sometimes have to be removed. 

• Bruising/bleeding – this is relatively frequent occurrence after a pacemaker implant particularly if patients are taking blood thinning medication.  Providing it is superficial (ie; there is not a large hard lump/swelling) then it will usually settle over 3-6 weeks.

• Pneumothorax – this is a small air leak around the lungs.  In some cases this will involve a small tube called a chest drain having to be implanted in the chest to allow the lung to re-inflate.  This will typically occur in around 1% of cases.  It rarely causes a long term problem but can result in a more prolonged stay in hospital of 2-3 days if the lung tube (chest drain) has to be implanted. 

• Pericardial effusion – this is a collection of blood around the heart itself.  This is unusual and a rare occurrence and occurs in less than 1% of cases. 

• Lead displacement – this is when the lead falls out of the place that it was initially put in at the time of the implant.  This can mean that the wound has to be reopened and the lead re-positioned.  This occurs in less than 1% of cases.

You will receive an invitation for a pre-op assessment.  This is a standard clinic where routine blood tests and MRSA skin swabs are taken.  Any questions about the admission process can be answered at that stage.  On the day of the admission please take your medicines as normal unless you are advised otherwise. If you are on anticoagulants such as warfarin or Rivaroxaban/Apixaban/Dabigatran please check with your cardiologist if they wish to discontinue them a few days before the pacemaker implant.

This is performed in the cardiac catheter laboratory (cath lab).  A small drip is placed in the arm and intravenous sedation is given to make you relaxed.  

The chest wall is then shaved (if appropriate) and then cleaned with an antiseptic preparation which cleanses the skin of bacteria then whilst you are being sedated local anaesthetic is then injected under the collar bone (usually on the left) and a small incision around 4-5cm in length is made to allow the pacemaker to be tunnelled under the skin. 

At the same time access is obtained into the large vein under the collar bone which allows us to position the leads through this vein into the heart (there can be between one and three leads).  An X-ray tube will be positioned above you and will move around to allow the doctor to see where the leads are being positioned inside the heart.  

Once the leads are in good positions the thresholds of the leads are checked electrically and then the leads are stitched onto the muscle of the chest wall and attached to the pacemaker generator.  The wound is then closed with two layers of stitches and glue to the surface of the skin.

You will then be sent for a chest X-ray to ensure the leads are in good positions and there is no air leak (pneumothorax) that has occurred and will be returned to the ward where you can eat and drink as normal.  We generally encourage patients not to do too much with their left arm for the first 24-48 hours to avoid putting any strain on the pacemaker wound.  We typically discharge patients home the following day with a follow-up out patient appointment in 2-3 weeks to check the pacemaker wound and leads.

We generally tell patients to take things easy for the first 2-3 days.  We would recommend for the first 4-6 weeks to avoid carrying anything heavy with the arm on the side of your pacemaker and to try and avoid stretching above shoulder height. If you were on blood thinning medication (anticoagulants) these are normally restarted shortly after the pacemaker implant is finished. Please check with your cardiologist when he/she wants the anticoagulants to restart. If you have a normal driving licence you can resume driving after one week.