A pacemaker is a device that sends small electrical impulses to the heart muscle to maintain a suitable heart rate or to stimulate the lower chambers of the heart (ventricles).
The primary purpose of a pacemaker is to maintain an adequate heart rate, either because the heart's natural pacemaker is not fast enough, or because there is a block in the heart's electrical conduction system.
The atria (top chamber of the heart) and ventricles (bottom chamber of the heart) work together, alternating contracting and relaxing to pump blood through the heart. The electrical system around the heart makes this possible.
The normal conduction of the heart begins at the sinoatrial (SA) node, located in the right atrium. The electrical activity spreads through the walls of the atria, causing them to contract.
Next, the electrical impulse travels through the AV node, located between the atria and ventricles. The AV node acts like a gate that slows the electrical signal before it enters the ventricles. This delay gives the atria time to contract before the ventricles do.
From the AV node, the electrical impulse travels through the His-Purkinje network, a pathway of specialized electricity-conducting fibers. Then the impulse travels into the muscular walls of the ventricles, causing them to contract. This sequence occurs with every heartbeat (usually 60-100 times per minute).
Most cases will take around 60 to 90 minutes.
You will be taken to a special area called the Electrophysiology Laboratory to have the pacemaker implanted:
You will lie on a bed and the Electrophysiology Lab staff will connect monitoring equipment to your chest. They will also start an IV (intravenous) drop in a vein in your arm or hand. The IV is used to deliver antibiotic medication and fluids during the procedure.
The doctor will then clean the chest using a special soap, and cover you using sterile drapes from your neck to your feet. He or she will then inject local anaesthetic to the skin and give you sedation before implanting the pacemaker.
The pacemaker is implanted through a small (approximately 5 cm) incision in the upper chest, usually on the left side. After the incision is made, the pacemaker “lead” is placed under X ray guidance into the heart; the pacemaker box is then connected to the other end of the lead and secured under the skin incision, in a little “pocket”.
At this point, the doctor would test the device to make sure it is working properly. Once he or she is satisfied with the device, the skin will be sutured up and you will be woken up and returned to the ward.
The pacemaker is usually implanted using the endocardial (transvenous) approach. During the procedure, a local anesthetic (pain-relieving medication) is injected to numb the area, and you will be awake during the procedure.
Small incisions are made in the chest where the lead (or leads) and device are inserted. The lead is inserted through the incision and into a vein, then guided to the heart with the aid of the fluoroscopy machine. The lead tip is attached to the heart muscle, while the other end of the lead is attached to the pulse generator. The generator is placed in a pocket created under the skin in the upper chest.
Your doctor will arrange a date for you to be admitted to the hospital. Usually you are admitted on the day of the procedure; occasionally, you will be admitted the day before. Most patients can expect to be discharged the following day; occasionally, your hospital stay may be longer if the procedure is difficult or complicated.
Your doctor should already have instructed you on what to do before the procedure.
Please check with your doctor before discontinuing any medications. The following information is a general guide only.
If you are on warfarin, this will normally need to be discontinued around 5 days prior to the procedure, and a blood test (“INR”) taken to confirm that your blood clotting is normal prior to implantation. Please check with your doctor before discontinuing your medications.
If you are taking aspirin or clopidogrel (Plavix), you may be asked to discontinue one or both of these prior to implantation; however, please confirm this with your doctor.
You can normally continue taking your other medications as usual.
If you have diabetes, liase with the nurse to adjust your diabetic medications or insulin accordingly.
In most cases, you will be told to eat a normal meal the evening before your procedure. However, do not eat, drink or chew anything after 12 midnight before your procedure. This includes gum, mints, water, etc. If you must take medications, only take them with small sips of water. When brushing your teeth, do not swallow any water.
When getting ready, please do not wear makeup and remove nail polish. Wear comfortable clothes when you come to the hospital. You will change into a hospital gown for the procedure. Please leave all jewelry (including wedding rings), watches and valuables at home.
Before the procedure begins, a nurse will help you get ready. You will be given a hospital gown to change into. You may keep your clothes in a locker or you may give them to a family member.
You will lie on a bed and the nurse will start an IV (intravenous) line in a vein in your arm or hand. The IV is used to deliver medications and fluids during the procedure.
To prevent infection and to keep the device insertion site sterile:
In rare cases, when the endocardial approach cannot be used, the epicardial (surgical) approach is used (more common in children). With this approach, general anesthesia is given to put you to sleep during the procedure and the generator is placed in a pocket created under the skin in the lower abdomen.
The hospital recovery time is generally 3 to 5 days with the epicardial approach, although minimally invasive techniques may be used to allow a shorter hospital stay and quicker recovery time.
The doctor will determine which pacemaker implant method is best for you.
You will return from the Electrophysiology Laboratory with pressure dressing over the site of the pacemaker implant. If you have any pain, please inform your nurse so you can be given enough painkillers.
You will stay overnight in the hospital and usually will be able to go home the day after the device is implanted. Wound care will be taught and outpatient appointment will be given to ensure proper wound healing.
A chest x-ray will be done after the device implant to check your lungs as well as the position of the device and lead(s).
The following day, an Electrophysiology Technician will confirm your pacemaker is working properly; this is done on the ward, from outside the body.
If there are no problems, you can expect to be discharged the following day with a return appointment in 1 week. You may also be given a short course of antibiotics to prevent infection.
You will need long term follow up. Initially you will be seen at 4 to 6 week intervals to check the pacemaker is functioning as intended. If there are no problems, the follow up interval may be lengthened to every 3 months or more.
After the pacemaker is implanted, you will need to keep the implant site clean and dry while the overlying skin heals. On discharge from the ward, the nurses will arrange regular dressing changes.
For 2-3 weeks after implantation, you should also avoid raising your arm on the side of the implant above shoulder level to avoid dislodging the lead or device. After two to three weeks have elapsed, the lead and device should be secure so that this is no longer an issue and you can move your arm normally.
There are few restrictions from having a pacemaker. Most sports are permitted except contact sports such as rugby where vigorous impact could damage the pacemaker.
Swimming is permitted but we do advise common sense precautions such as not swimming in deep water alone.
No. For your safety, a responsible adult should drive you home. Ask your doctor when you could resume driving.
The pacemaker is battery-powered. How often does the battery need changing and how is it changed?
Most pacemakers will last around 5 to 10 years depending on the type and model of your pacemaker. We will check on the battery status during your regular clinic follow ups. The battery life of your pacemaker depends on how often it is used and the power output. Changing the battery is similar to implanting a new device except the pacemaker leads (the wires which connect the device to the heart which can last typically up to 20 years) do not need to be changed.
Your doctor will discuss the results of the procedure and answer any questions you have. Be sure to ask the doctor if you can continue taking your previous medications.
You will receive specific instructions about how to care for yourself after the procedure including medication guidelines, wound care, activity guidelines, device care and maintenance, and a follow-up schedule.
Should I carry my identification card (ID) with me all the time?
Yes. Your ID card contains pertinent information about yourself, type of pacemaker and your physician.
This is made available quickly in the event of an emergency. If you lose your card, please ask for a replacement.
Things that use electricity and magnets have electromagnetic fields around them and may cause Electromagnetic Interference (EMI). These fields are usually weak and will not affect your pacemaker.
However, strong electromagnetic fields have the potential to alter the function of your pacemaker. A strong magnetic field can “blind” the pacemaker to send pacing beats when your heart does not need it. If you move away from the source of EMI, your pacemaker will return to normal. Most office and shop equipment are unlikely to interfere with your pace maker.
If you are uncertain, please do consult with your doctor.
Airport screening devices are unlikely to affect your pacemaker but they may detect the metal housing of your device and set off the security alarm. If it does, inform the security personnel that you have a pacemaker implanted and show them your identification card.
Passing through the metal detector portal will not harm your device; however do not linger near it as the magnetic field may temporarily interrupt the normal function of the device.
Properly maintained electrical household items are unlikely to interfere with your pacemaker.
Always mention to the medical personnel about your pacemaker implantation and show them your identification card. With proper precautionary measures prior procedures, most medical procedures and dental procedures are unlikely to interfere with your pacemaker except Magnetic Resonance Imaging (MRI), which is not recommended.
Alert your doctor if you are scheduled for medical procedures, including dental procedures as your pacemaker may need to be reprogrammed before the procedure to lower the chance of interference or damage to the pacemaker’s function.
Ultrasound scans (including echocardiograms), as well as X ray scans (including CT scans) do not affect the function of your pacemaker; you may proceed with these normally.
However, you should not have MRI (magnetic resonance imaging) scans if your pacemaker is not MRI compaitable. Please inform the doctor or radiologist prior the scan.
Most people with pacemakers can travel freely unless they are restricted by their underlying medical condition or other unrelated conditions.
