Pacemaker

A pacemaker is a small, sealed metal and plastic device (pacemaker box), which contains a battery and electronic circuits. The device is connected to your heart by one or more wires (called leads). These leads are passed along a blood vessel to your heart and the pacemaker box is usually implanted under the skin in your upper chest, near your collarbone. The pacemaker can monitor your heart and produce electrical impulses to treat abnormal heart rhythms. Pacemakers are largely used to treat slow heart rhythms (bradycardia), but are also used to treat some fast heart rhythms that come from the top chambers of the heart (the atria). A new type of pacemaker, the biventricular pacemaker or cardiac resynchronisation therapy, is increasingly being used to treat patients with heart failure; this is not suitable for all but can be discussed with your doctor. Pacemakers may be single (one lead), dual (two leads) or triple (three leads) chamber and you will have the one appropriate for your underlying problem.  

If your doctor has suggested that you have a pacemaker fitted it is because you have an abnormality in the electrical conduction system of your heart. To help you understand this, it may be useful for you to know how the electrical conduction system in your heart works normally. The heart is a muscle; its function is to pump blood and oxygen around your body to all of your vital organs. A normal healthy heart usually beats in a regular fashion between 50 to 100 times a minute.

The Heart and Normal Conduction (click here)

The heart has four chambers, two at the top (the right and left atria) and two at the bottom (the right and left ventricles). The heart also has an electrical system (rather like the wiring system in your house or car), which sends impulses (beats), through the heart causing it to contract and pump blood around the body. Each normal heartbeat begins in the natural pacemaker of the heart (the sino-atrial or SA node), which lies at the top of the right atrium. It then travels across the two top chambers and down through a small junction box (the atria-ventricular or AV node), which lies between the upper and lower chambers. It then spreads rapidly through a special conducting system through the ventricles and then across the bottom chambers causing the heart to contract and pump. Sometimes the electrical system in your heart does not work as well as it should. This can cause the heart to beat too slowly, too quickly or irregularly. A pacemaker can treat some of these abnormal heart rhythms.  

There are several different common conditions, which cause the heart to beat abnormally. These are:

Complete heart block

This accounts for about 60% of patients who have pacemakers implanted. This is a condition where the AV node or junction box breaks down and does not transmit the electrical pulse from the top to the bottom of the heart. This is called heart-block. When this happens the heart usually goes very slowly and you may have symptoms of dizziness or blackouts. A pacemaker is required to restore a normal heart rate and bypass the “block.” This is most commonly due to the conduction system “wearing out with age” but can also occur as a congenital (in-born) problem.  

Sick sinus syndrome

This is a condition where the natural pacemaker does not function properly and results in your heart going either too slowly or too fast or a combination of both. An implanted pacemaker is used to support the slow heart rate and medicine is usually given to control the fast heart rhythms.

On the day of your procedure, you will be taken to the cardiac pacing theatre. You will be given sedation; which will make you relaxed and sleepy. Before the procedure starts your skin will be cleaned with antiseptic solution. Then some local anaesthetic will be placed under the skin just below your collarbone (on the left side most commonly). This will numb the area and allow a small wire (lead) to be placed through a vein into your heart. You may have one, two or three leads inserted depending on what type of pacemaker you need. The lead(s) are then connected to the pacemaker box. This will be placed under the skin on your chest wall. The area will then be stitched with dissolvable sutures (stitches) and a dressing will be placed over the top.

There are risks associated with any heart operation. The most common risks are;

• A small risk of infection, bleeding and bruising to the pacemaker site
• A small risk of perforation of the lung during the procedure (a pneumothorax) – this can be detected on a chest X ray that is performed following the pacemaker implant. A pneumothorax can sometimes rectify itself without treatment. Occasionally a small drain may need to be inserted through your side into your lung (in the space between your ribs). This is a simple procedure and the drain will be removed prior to your discharge home.
• A small risk of lead displacement – the pacemaker lead can move and would then need to be repositioned
• A small risk of perforation of the heart which can cause bleeding around the heart

After the procedure, you will be taken back to the ward. You will be asked to lie in bed for a couple of hours then you can get up and eat and drink. You will have a chest X Ray to check the lungs and the position of the pacemaker leads. As the wound can feel quite bruised and sore, especially for the first day or two, it is recommended that you have regular painkillers.   Your pacemaker will be checked before you go home by a cardiac technician. This check will involve the use of a special programmer that can look at the device settings and make sure the pacemaker is working properly. You will be allowed to go home the next day in most cases. You will be given a pacemaker identity card, which has details of the make and model of your pacemaker. You should always carry this card with you. If you require treatment in the future it is important that you show this card to the health care professionals treating you.

Arm movements

Try to avoid lifting the arm on the same side as the pacemaker above shoulder level for the first 6 weeks. Extra tissue will grow around the lead(s) in your heart after period, which will prevent the leads moving out of place. After this time you will be able to return to normal activity.    

Wound site

You should avoid showering or bathing for the first 24 hours after the procedure. Showering after this is OK, but direct water contact on the dressing is best avoided. Your doctor will advise when the dressing should be removed. The skin sutures (stitches) will dissolve and do not require removal. Bruising at the site of the operation is not uncommon and usually settles on its own. Your wound site should take about six weeks to fully heal. Try to avoid wearing tight clothing over the wound until it has healed completely to avoid excess rubbing over the area. If you notice any redness, soreness or swelling of the area, or any signs of bleeding or oozing from the wound, report this immediately to your doctor as these may be a sign of wound infection. You will probably be able to feel the pacemaker box under your skin as well as other lumps close by. These are the leads that are attached to the box or curled up beside the box under the skin. It is extremely important that you don’t try to move the box or leads, but please let your doctor know if they continue to bother you.

You should not be aware of the pacemaker working but occasionally people are conscious of their heart beating faster, particularly if you had a very slow heart rhythm before the pacemaker was implanted. The device will be programmed to the best settings for you. This will be done before you leave hospital, but the settings can be modified during your follow up appointments in the clinic as and when necessary. The pacemaker will not usually stop the heart from speeding up so if you had fast palpitations before then they may continue. If this occurs the palpitations are usually treated by medicine. The pacemaker will be set to enable your own heart to work as much as possible on its own and will only come in if your heart rhythm slows down to a certain level. It works on “demand”.  

Driving restriction do apply following implantation and these will be discussed with you.  

A certain level of exercise is needed to keep your heart healthy. You can take part in most sports but it is advisable to avoid contact sports to minimise the risk of damaging your pacemaker.

Electromagnetic interference will not damage your pacemaker but may temporarily interfere with its settings whilst you are in contact with it. Most mechanical and electrical devices that you use in your normal daily activities will not affect your pacemaker. Household equipment such as ordinary radios, fridges, cookers, remote controls, televisions, electric razors, computers and microwaves etc. will not affect your pacemaker as long as they are in good working order.

Magnets: Do not carry magnets or place a magnet over your chest. Avoid carrying stereo or hi-fi speakers as they contain strong magnets that can interfere with your pacemaker.  

Shop doorway security systems: It is advised that you walk through shop doorway security systems at a normal pace and not to wait around in this area.

Medical equipment / other hospital treatments: Most equipment used by your hospital or GP surgery will not cause any problems to your pacemaker. However it is advised that you let medical and dental staff know that you have a pacemaker. Please take your ID card with you whenever you go to hospital.

It is safe for you to have X-rays, CT scans and mammograms.

You should however avoid magnetic resonance imaging (MRI) machines unless you are told you device is MRI compatible. Some electrical nerve and muscle stimulators (TENS units) may cause interference with pacemakers but this depends on where they are being applied, and, if any of these treatments are suggested to you then your pacemaker clinic should be contacted for advice.  

Travel: You can safely travel abroad with your pacemaker, but you are advised to show the security staff your identification card. Walk through the metal detector archway if asked to do so, but the metal casing of the device may set off the airport security alarm. The detector will not cause any harm to your pacemaker provided you walk briskly through the arch.  

Arc welding: Generally, this should be avoided.

Mobile phones: Some studies have shown that some mobile phones can affect the pacemaker if held within 10 centimetres of the device. It is therefore recommended that you do not keep a mobile phone in a coat or shirt pocket over the pacemaker. Keep the handset more than 10 centimetres away from the pacemaker; ideally hold the phone over the ear on the opposite side to the device.  

Pacemaker clinic visits

Your pacemaker should be checked regularly. You will be seen at least once a year and may be asked to attend more often if necessary. During each clinic visit, the pacemaker technician will examine your pacemaker using a special programmer. This machine allows examination of the settings and the battery life of your device. Special measurements are also done to assess the state of the leads that connect the pacemaker to your heart. If your condition has altered, changes may be made to the pacemaker settings using the special programmer. All the information is stored in your records. Your wound will also be checked and you may have other tests done. Please also take this opportunity to ask any questions or communicate any problems or concerns.

Changing the pacemaker

 Normally a pacemaker battery lasts between six and ten years. Your battery will be checked at every visit to the pacemaker clinic and staff at the clinic will be able to predict when you need a new pacemaker box and arrange for this to be performed. Don’t worry! It will not be allowed to completely run down. In order to have the box changed, you will need to be admitted to hospital. The procedure will usually be a much shorter operation than the initial pacemaker procedure as there is no need to implant the pacemaker wires (leads) in most cases. Pacemaker leads are designed to stay in place and last for a very long time thus the existing lead are kept in place and simply attached to the new pacemaker box.