Having a permanent pacemaker implanted to regulate your heart rhythm
The aim of this leaflet is to answer any questions you may have about having a permanent pacemaker. It will explain what a pacemaker is and how it works, as well as the benefits and risks of having it implanted.
There are a number of possible reasons for why you need a pacemaker:
- Your heart goes too slowly which may cause you to feel breathless, dizzy or even have blackouts
- You need to take medicine, which may make your heart go too slowly.
Your cardiologist (heart specialist) believes that the best way to manage your condition is for you to have a pacemaker. You should have already spoken with your cardiologist, electrophysiologist about having a pacemaker. This booklet is not meant to replace these discussions, but we hope it will make you feel more comfortable with your decision to have this procedure.
Your cardiologist will answer any questions you may have after reading this booklet. We encourage you and your family to ask questions, and are more than happy to talk through any concerns you may have.
The healthy heart Abnormal heart rhythms - arrhythmias,benefits, risks and alternatives Having my pacemaker implanted
Recovering from my operation When can I go back to normal activities?
The healthy heart What does the heart do?
The heart’s job is to move blood around the body. Blood contains oxygen and other nutrients that the body needs to do its work. Blood cells pick up oxygen in the lungs and the pumping action of the heart moves this oxygen-rich blood to the rest of the body.
What does the heart look like?
The heart has four chambers – the top chambers are the left and right atrium, and the larger, bottom chambers are called the left and right ventricles. The heart has large blood vessels called veins that bring blood to the heart, and large blood vessels called arteries that take blood away from the heart.
How does the heart normally beat?
Your heart muscle needs an electrical signal to contract and pump blood around your body. In a normal heart, the electrical signal that tells the heart to pump comes from a special area called the sino-atrial node or SA node. This is sometimes called the heart’s natural ‘pacemaker’ and can be found at the top of the heart in the right atrium. The electrical signals from your SA node travel through the top two chambers (atria) causing the heart muscle to contract (pump). They then pass through a second node called the atrio-ventricular node or AV node, and down to the lower two chambers (ventricles), making them contract. The contraction (heartbeat) pumps the blood out of the atria and ventricles and around the body. Between each heartbeat, when the heart is at rest, blood flows into the atria and ventricles, ready for the next heartbeat.
Normally, a heart beats 60 to 100 times each minute. When a heart’s rhythm is normal, this is called sinus rhythm. When you exercise, become excited or experience stress, your body needs more oxygen and your heart beats faster to keep up with this demand.
Abnormal heart rhythms (arrhythmias) What is an arrhythmia?
Sometimes people develop an abnormal heartbeat, also called an arrhythmia. The heart may beat too slowly or it may beat in response to an electrical signal that does not come from the SA node. An abnormal heartbeat can interrupt the usual pumping action of the heart. It may be as short as one or two beats, or it may continue for several minutes or even hours. In a very small number of cases this can cause cardiac arrest. This happens when the heart is beating so fast that there is no time for the ventricles to fill and pump blood around the body.
What causes arrhythmias?
Arrhythmias can be caused by many things, including:
- coronary heart disease and previous heart attacks
- abnormal heart muscle function, including cardiomyopathies or heart failure
- congenital (inherited/present at birth) heart problems such as Brugada Syndrome and long QT Syndrome.
Having any one of the problems listed above does not mean that you will have an arrhythmia, but your doctor will assess the risks specific to you.
How are arrhythmias diagnosed?
To assess your heart rhythm we will need to do an electrocardiogram (ECG). This involves putting small sticky pads on your arms, legs and chest, which are connected to an ECG machine. It is not painful. The machine then measures and records the electrical activity of the heart and gives us a printed record. Sometimes we need to leave this on for 24 hours or more, to record the electrical activity in your heart over a longer period of time. In these cases, the sticky pads are connected to a small portable recorder that you can carry around with you.
Unusually slow heartbeats (bradycardia)
Sometimes, due to disease or ageing, the electrical signals in the heart slow down or fail to work properly and your heart rate slows. This is called bradycardia.
A person with bradycardia may feel very tired, because the body is not getting enough oxygen. They may also feel short of breath, light-headed or dizzy, or may have had blackouts. Sometimes a pacemaker is implanted (inserted during surgery) to speed up their heartbeat. A pacemaker is a small device that monitors the heart and can increase the heart rate by sending electrical signals to the heart, making it contract. These signals are very small and cannot be felt.
Benefits, risks and alternatives What are the benefits of having a pacemaker?
A pacemaker regulates your heart beat. If it gets too slow, it speeds your heart beat up.
Many patients feel that their pacemaker gives them peace of mind. They feel safer because it automatically treats their heart condition.
What are the risks of having a pacemaker?
As with any operation, there are risks in having a pacemaker implanted. A very small number of people develop a complication because of the surgery. The risk of you developing any kind of complication is about one in 100.
The potential risks are:
- Infection. We will give you antibiotics before the procedure to reduce this risk. If you develop an infection after you have left the hospital, you must return for evaluation. About two in every 100 patients develop an infection. Signs of infection to look out for include:
high temperature your wound becoming red and inflamed, or warm and painful o your wound starting to ooze.
- Reaction to medicines. We try to reduce the risk of this by carefully recording any known allergies that you might have. It is not always possible to know if you will react to a medicine that you have not used before.
Reactions to medicines can vary from developing a rash or feeling sick or unwell, to a drop in your heart rate or blood pressure that needs treatment, problems with breathing, or even death. Our staff are trained to act on any emergency if you have a reaction to the medicines we give you.
- Haematoma (collection of blood in the tissues causing swelling and bruising). There is a risk of severe bruising or swelling around the site where the pacemaker is implanted. This is more common in people who are taking anticoagulants (such as warfarin) before their procedure. If this does happen, we may need to take you back to the operating theatre to re-open your wound and drain it. About three to four in every 100 patients have severe bruising.
- Pneumothorax (air in the spaces around the lungs also known as a collapsed lung). The pacemaker wires are inserted into the heart through a vein in the upper chest area. When this happens, there is a risk that a small puncture may be made in the top of the lung. This can cause air to leak into the spaces around the lungs and partially collapse your lung. If the leak is small, it may be left to heal by itself. Sometimes we have to insert a chest drain to remove the air and allow your lung to fully inflate again. This happens in about one in every 100 patients.
- Pericardial effusion (blood leak around the heart). When the leads are positioned in the heart, they can damage the heart wall and the sac surrounding the heart (pericardium) may fill with blood. This may heal by itself, or you may need a small drain put in to remove the blood. This happens to about one in every 500 patients.
- Lead displacement. There is a risk that the leads we put in will move after the procedure. If this happens, your pacemaker will not work properly and you will probably need another procedure to have the leads repositioned. You can help to lower the risk of this, by following the instructions on limiting your arm movements after the procedure . This happens in about four to five in every 100 patients.
- Blockage in the veins. Sometimes when we put more than one lead through a vein into your heart, there can be problems with the flow of blood through that vein. If this causes a problem for you, the doctors might consider giving you an anticoagulant medicine (such as warfarin), or removing one or more of the leads. You would need to come back in for another operation for this, and the leads would be replaced using a different vein.
- X-rays. Your examination and/or treatment will involve a period of x-ray scanning that will give you a relatively small x-ray dose. If we need to do more extensive investigation and treatment, there is a small chance that you will get a skin reddening reaction like sunburn which will fade after a few days.
The vast majority of patients undergoing permanent pacemaker implantation will survive – the approximate risk of death is very small (one in every 1,000). Some people are more at risk than others, depending on their general health and well-being.
The cardiologist will discuss the risks with you in more detail before asking you to sign a consent form. Please feel free to discuss all your questions and concerns with him/her.
What are the alternatives?
An alternative to having a pacemaker could be managing your bradycardia with medicines.
Usually your cardiologist has considered this before recommending that you have a pacemaker, but has decided that the safest treatment for you is to have a pacemaker fitted. If you would like more information on this option, please feel free to talk with your cardiologist.
Giving my consent (permission)
We want to involve you in decisions about your care and treatment. If you decide to go ahead, you will be asked to sign a consent form. This states that you agree to have the treatment and you understand what it involves.
Having my pacemaker implanted Will I have a local or general anaesthetic?
Inserting your pacemaker can be carried out under local or general anaesthetic. Your doctor will talk to you about which one would be best for you.
What will happen before the procedure?
You may need to remain in hospital while you are waiting to have your pacemaker inserted.
You will need to fast, which means that you cannot eat or drink anything (except water) for six hours before your operation. You may drink water (not fizzy) up until two hours before the procedure. We will give you clear instructions on when to start fasting. If you take insulin for diabetes, please half your morning dose and bring your insulin with you into hospital.
A nurse will give you a single dose of an antibiotic before the procedure to help prevent infection.
If you are having the surgery under general anaesthetic, the anaesthetist (doctor specialising in anaesthesia) will come to see you on the ward before your operation. He/she will ask you questions about your general health and about any previous operations that you have had under general anaesthetic.
What will happen during the procedure?
Our staff are fully trained for these procedures and will be monitoring you closely at all times. In the operating theatre, the nursing staff will check your details, such as any allergies and when you last ate. They will then help you onto the operating table. A number of staff will be present, including nurses, doctors, radiographers and cardiac physiologists.
A technician will connect you to an electrocardiogram (ECG) machine, which will monitor your heart rhythm during surgery. A nurse will put a cuff around your arm to monitor your blood pressure and a clip on your finger to measure your oxygen levels. These are not painful.
If you are having the procedure under local anaesthetic and have not yet had a needle inserted into your hand or arm, one will be put in now. All medicines will be given through this needle. We will then assess you, and give you a painkiller (morphine) and sedation to help you relax and become drowsy. Sedation will be ‘topped-up’ throughout the procedure.
The pacemaker is usually put in on the opposite side to your dominant arm. For example, if you are right handed, it will be put in on the left side. This is usually because the leads will be under less strain on this side. The doctor will then clean the relevant side of your chest with an antiseptic liquid. After this, you will be covered with drapes to make sure the whole area is kept sterile throughout the operation.
The doctor will warn you before they inject the local anaesthetic. At first, the local anaesthetic will sting, but shortly after that the whole area will go numb. You should not feel any pain during the procedure, but you may be aware of pressure in the area where the doctor is working. Please let us know if you feel uncomfortable.
Depending upon the type of pacemaker you are being given, the doctor will put in one or two wires into your heart through a vein. In some cases, up to four wires may be put in. The wires will be put in under x-ray guidance. Once in place a cardiac physiologist will test these wires to make sure they have good contact with your heart muscle.
The wires either have small prongs or a tiny screw to hold them in position against your heart wall. Once the wires are in position, the doctor will make a small pocket under the skin to fit the battery (generator), and will then connect the wires to this.
After this has been done, your pacemaker will be tested.
When this test has been completed, the doctor will close your wound with dissolvable stitches. It will then be sprayed with an antiseptic solution to help protect it from infection, and will be left uncovered. The cardiac physiologists will make sure that your pacemaker is programmed correctly and switched on. You will then be ready to return to the ward.
What if I am having a general anaesthetic?
If you are having a general anaesthetic, you will have the same procedure as above but you will be asleep throughout the surgery. Once you are connected to the monitoring equipment, you will be put to sleep by your anaesthetist. A tube will be passed into your windpipe and connected to a machine called a ventilator. This will control your breathing during the operation. You will also have extra monitoring of your blood pressure through a special needle in your wrist, which will be put in once you are asleep.
You will wake up in the operating theatre once the procedure is over and the tube will be removed from your windpipe. When the anaesthetist is happy that you are fully awake, you will be taken back to your ward.
What happens after my surgery?
You may need to be attached to a heart monitor to keep an eye on your heart rhythm for a few hours. Because of the anaesthetic (local or general) and sedation, you may need an oxygen mask for a few hours to help with your breathing. Your nurse will also check your blood pressure and wound regularly..
You can expect to feel drowsy for a few hours following the procedure. As you will have had nothing to drink before your surgery, you may need a drip of intravenous fluid. You will need to stay in bed for a few hours while the sedation wears off. Your nurse will let you know when it is safe to eat and drink.
You will have a chest x-ray to check the positioning of the pacemaker leads in your heart. This is usually done the following morning.
Will my pacemaker be checked before I go home?
Yes. You will be taken down to the Cardiac Outpatient Department to have your pacemaker checked by the cardiac physiologists. This is to make sure that your pacemaker is working as it should be and that it has been programmed correctly before you go home. The cardiac physiologists will give you your ID card with all the technical details for your pacemaker. This gives useful information for anyone needing to treat you or your pacemaker, wherever you are.
You will also receive information on how often your pacemaker will need to be rechecked (usually every three to six months), and how to contact the hospital if you have any problems or concerns. Your cardiac physiologist will let you know if your future pacemaker checks can be done at a hospital closer to where you live. Be sure to ask questions if anything is unclear or confusing.
Recovering from my operation
Your wound and the shoulder where the pacemaker has been implanted will be uncomfortable for the first few days. You will be given painkillers by the nursing staff to help with this.
When can I go back to my normal activities?
You should be able return to your normal activities as soon as you feel up to it. On the side of your body where the pacemaker has been inserted, you must not lift your arm above shoulder height for at least four weeks. You will also have to avoid lifting, pushing or pulling heavy objects for the first four weeks. Do not be afraid to move your arm normally, as this will prevent your shoulder from becoming stiff. You may feel a little tired or sore at first, so build up slowly to your normal routine.
There are rules that regulate whether you can drive with your implant, and you will also need to take some precautions before you travel.