A pacemaker is a small electronic device that helps regulate slow electrical problems in the heart. The pacemaker is usually implanted in the chest, just below the collarbone. Your doctor may recommend this device to keep your heartbeat from slowing down to a dangerously low rate.
The heart is a pump made up of muscle tissue that is stimulated by electrical currents, which normally follow a specific circuit within the heart. These natural electrical impulses coordinate contractions of the different parts of the heart to keep blood flowing the way it should. A pacemaker may be needed when there are problems with the natural electrical conduction system of the heart.
A pacemaker is made of 3 parts: a pulse generator, 1 or more leads, and an electrode on each lead. A pacemaker signals the heart to beat when the natural heartbeat is too slow or irregular.
Your doctor may recommend a pacemaker to stimulate a faster heart rate when your heart beats too slow and the problem can't be fixed with other treatments.
Problems with the heart rhythm may mean your heart is not pumping enough blood to the body. If your heart rate is too slow, the blood is pumped too slowly. If the heart rate is too fast or too irregular, the heart chambers are unable to fill up with enough blood to pump out with each beat. When the body does not get enough blood, symptoms such as tiredness, dizziness, fainting, or chest pain may occur.
Some examples of heart rate and rhythm problems for which a pacemaker might be inserted include:
- Bradycardia. This is when the heart beats too slowly.
- Tachy-brady syndrome. This is characterized by alternating fast and slow heartbeats.
- Heart block. This occurs when the electrical signal is delayed or blocked as it travels through the heart muscle. There are several types of heart blocks.
There may be other reasons for your healthcare provider to recommend pacemaker insertion.
Possible risks of pacemaker insertion include:
- Bleeding from the incision (cut) or catheter insertion site
- Damage to the vessel where the catheter is put into the heart
- Infection of the incision or catheter site
- Collapsed lung
- Pericardial effusion (bleeding that can occur from the heart with blood accumulating in the sac (pericardium) surrounding the heart)
- Lead displacement (when the wires of leads of the pacemaker become disconnected or displaced you may need another procedure to reposition them)
For some people, having to lie still on the procedure table for the length of the procedure may cause some discomfort or pain.
There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your healthcare provider before the procedure.
- Your healthcare provider will explain the procedure to you and ask if you have any questions.
- You will be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if anything is not clear.
- Tell your healthcare provider if you are sensitive to or are allergic to any medicines, iodine, latex, tape, or anesthetic agents (local and general).
- You will need to fast (not eat or drink) for a certain period before the procedure. Your healthcare provider will tell you how long to fast, usually overnight or at least 8 hours before the procedure.
- If you are pregnant or think you might be, or if you are breastfeeding, tell your healthcare provider.
- Be sure your healthcare provider knows about all medicines (prescription and over-the-counter), vitamins, herbs, and supplements that you are taking.
- Tell your healthcare provider if you have heart valve disease, as you may need to take antibiotics before the procedure.
- Tell your healthcare provider if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medicines, aspirin, or other medicines that affect blood clotting. You may need to stop some of these medicines before the procedure.
- Your healthcare provider may do a blood test before to the procedure to see how long it takes your blood to clot. Other blood tests and a chest X-ray may be done as well.
- You may get a sedative before the procedure to help you relax. If a sedative is given and there is a possibility that you may be able to go home afterward, you will need someone to drive you home. You will likely spend at least one night in the hospital after the procedure for observation and to be sure that the pacemaker is working the way it should.
- Based on your medical condition, your healthcare provider may request other specific preparation.
A pacemaker insertion may be done on an outpatient basis or as part of your hospital stay. Procedures may vary depending on your condition and your healthcare providers practice.
Generally, a pacemaker insertion follows this process:
- You will be asked to remove any jewelry or other objects that may interfere with the procedure.
- You will be asked to remove your clothing and will be given a gown to wear.
- You will be asked to empty your bladder before the procedure.
- If there is a lot hair at the incision site, it may be shaved off.
- An intravenous (IV) line will be started in your hand or arm before the procedure to give medicine and fluids.
- You will lie on your back on the procedure table.
- You will be connected to an electrocardiogram (ECG) monitor that records the electrical activity of your heart and monitors the heart during the procedure using small, plastic electrodes that stick to your skin. Your vital signs (heart rate, blood pressure, breathing rate, and oxygen level) will also be monitored during the procedure.
- You will get a sedative in your IV before the procedure to help you relax. However, you will likely stay somewhat awake during the procedure.
- The skin at the pacemaker insertion site will be cleaned with antiseptic soap.
- Sterile towels and a sheet will be placed around this area.
- A local anesthetic will be injected into the skin of the chest at the insertion site.
- Once the area is numb, the healthcare provider will make a small incision (cut) at the insertion site.
- A sheath, or introducer, is put into a large blood vessel, usually under the collarbone. The sheath is a plastic tube through which the pacer lead wire(s) will be threaded into the blood vessel and advanced into the heart.
- It will be very important for you to stay still during the procedure so that the catheter does not move and to prevent damage at the insertion site.
- The lead wire will be threaded through the introducer into the blood vessel. The healthcare provider will advance the lead wire through the blood vessel into the heart. Fluoroscopy, (a special type of X-ray “movie” that is displayed on a TV monitor), may be used to help check the location of the leads.
- Once the lead wire is inside the heart, it will be tested to be sure it’s in the right location and it works. There may be 1, 2, or 3 lead wires inserted, depending on the type of device your healthcare provider has chosen for your condition.
- The pacemaker generator will be slipped under your skin through the incision (just below the collarbone) after the lead wire is attached to it. Generally, the generator will be placed on the nondominant side. (If you are right-handed, the device will be placed in your upper left chest. If you are left-handed, the device will be placed in your upper right chest).
- The ECG will be checked to be sure that the pacer is working correctly.
- The skin incision will be closed with sutures, adhesive strips, or a special glue.
- A sterile bandage or dressing will be applied.
In the hospital
After the procedure, you may be taken to the recovery room for observation or returned to your hospital room. A nurse will monitor your vital signs.
Let your nurse know right away if you feel any chest pain or tightness, or any other pain at the insertion site.
After the period of bed rest has been completed, you may get out of bed with help. The nurse will be with you the first time you get up, and will check your blood pressure while you are lying in bed, sitting, and standing. Move slowly when getting up from the bed to avoid any dizziness.
You will be able to eat or drink once you are completely awake.
The insertion site may be sore or painful. Pain medicine may be taken if needed.
Your arm may be placed in a sling overnight. Your provider will give you specific instructions on any activity restrictions and about immobilizing your arm after the procedure.
You will have a chest X-ray to make sure the lung was not injured during the procedure, and to check the device position.
You may be prescribed antibiotics to protect you from an infection around your pacemaker or at the incision site.
Your healthcare provider will see you in your room while you are recovering. The healthcare provider will give you specific instructions and answer any questions you may have.
Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room or allowed to go home. It’s common to spend at least one night in the hospital after pacemaker implantation.
Arrange to have someone drive you home from the hospital following your procedure.
You should be able to return to your normal daily routine within a few days. Your healthcare provider will tell you if you will need to wait before returning to your normal activities. Do not do any lifting or pulling for a few weeks. You may need to limit movement of the arm on the side that the pacemaker was placed.
You will most likely be able to go back to your usual diet, unless your healthcare provider tells you differently.
It will be important to keep the insertion site clean and dry. You will be given instructions about bathing and showering.
Your healthcare provider will give you specific instructions about driving.
Ask your healthcare provider when you will be able to return to work. The nature of your work, your overall health, and your progress after surgery will determine how soon you may go back to work.
Call 911 if you have severe, unrelenting chest pain or trouble breathing.
Contact your healthcare provider right away if you have any of the following:
- Fever of 100.4°F (38°C) or higher
- Increased pain, redness, swelling, or bleeding or other drainage from the insertion site
- Chest pain/pressure, nausea and/or vomiting, profuse sweating, dizziness, lightheadedness, fainting, or lack of energy
- Palpitations, rapid or pounding heartbeat
- Swelling in the arms or hands on the side of the incision
- You have hiccups that will not stop
- You have muscle twitching in your abdomen
- Shortness of breath
After a pacemaker insertion, regularly scheduled appointments will be made to ensure the pacemaker is working the way it should. The healthcare provider uses a special computer, called a programmer, to review the pacemaker's activity and adjust the settings when needed.
Your healthcare provider may give you other instructions after the procedure, depending on your particular situation.
Things to keep in mind
Always consider the following precautions. Discuss these in detail with your healthcare provider, or call the company that made your device:
- Always carry an ID card that states you have a pacemaker. In addition, you may want to wear a medical ID bracelet or necklace indicating that you have a pacemaker.
- Let security screeners know you have a pacemaker before going through security detectors at the airport or court house. In general airport detectors are safe for pacemakers, but the small amount of metal in the pacemaker and leads may set off the alarm. If you are selected for additional screening by hand-held detector devices, politely remind the screeners that the detector wand should not be held over your pacemaker for longer than a few seconds, as these devices contain magnets that may affect the function or programming of your pacemaker.
- You should not have a magnetic resonance imaging (MRI) imaging test (unless you have a specially designed pacemaker).
- You should avoid large magnetic fields such as power generation sites and industrial sites such as automobile junkyards that use large magnets.
- Do not use short-wave or microwave diathermy that uses high-frequency, high-intensity signals (this may be used in physical therapy to treat muscles). The signals can interfere with or damage your pacemaker.
- Turn off large motors, such as cars or boats, when working close to them, they may create a magnetic field.
- Avoid high-voltage or radar machinery, such as radio or television transmitters, electric arc welders, high-tension wires, radar installations, or smelting furnaces.
- If you need a surgical procedure in the future, be sure to let the surgeon know that you have a pacemaker well before the operation. Also ask your cardiologist's advice on whether anything special should be done before and during the surgery, the electrocautery device that controls bleeding may interfere with the pacemaker. Sometimes the pacemaker's programming will be temporarily changed (using a magnet) during the surgery to minimize the possibility of interference from the electrocautery.
- When involved in a physical, recreational, or sporting activity, protect yourself from trauma to the pacemaker. A blow to the chest near the pacemaker can affect its functioning. If you are hit in that area, you may want to see your healthcare provider to make sure your pacemaker is working the way it should be.
- Cell phones in the U.S. with less than 3 watts of output do not seem to affect pacemakers or the pulse generator, but as a precaution, keep cell phones at least 6 inches away from your pacemaker. Do not carry a cell phone in your breast pocket over your pacemaker.
- Always consult your healthcare provider when you feel ill after an activity, or when you have questions about beginning a new activity.
- Always contact your healthcare provider if you have any questions about using certain equipment near your pacemaker.
Before you agree to the test or the procedure make sure you know:
- The name of the test or procedure
- The reason you are having the test or procedure
- What results to expect and what they mean
- The risks and benefits of the test or procedure
- What the possible side effects or complications are
- When and where you are to have the test or procedure
- Who will do the test or procedure and what that person’s qualifications are
- What would happen if you did not have the test or procedure
- Any alternative tests or procedures to think about
- When and how will you get the results
- Who to call after the test or procedure if you have questions or problems
- How much will you have to pay for the test or procedure
January 16, 2018
Link, MS. Electrical Therapies:Automated External Defibrillators, Defibrillation Cardioversion, and Pacing 2010.Guidelines for CPR and Emergency Cardiovascular Care. Circulation (2010); 122(3); pp. s706-s719, Cardiac implantable electronic device interactions with electromagnetic fields in the non-hospital environment, Up To Date, Pacing system malfunction: Evaluation and management, Up To Date, Permanent cardiac pacing: Overview of devices and indications, Up To Date, Morody, F., Cecil Medicine. Elecrophysiologic Intervention Procedures and Surgery, Complications (2011) 24th ed., 376, Nordbeck, P., Magnetic resonance imaging safety in pacemaker and implantable cardioverter defibrillator patients: How far have we come? European Heart Journal (2015) 36(24); 1505-1511
Kang, Steven, MD,Snyder, Mandy, APRN