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Pacemaker Insertion

Overview

A pacemaker is a small device that's placed under the skin of your chest or abdomen to help control abnormal heart rhythms. This device uses electrical pulses to prompt the heart to beat at a normal rate. Pacemakers are used to treat heart rhythms that are too slow. These abnormal heart rhythms are called arrhythmias.
 

Why do I need a Pacemaker Insertion?

The heart has its own electrical system that controls the speed and the rhythm of every heartbeat. With each heartbeat, an electrical signal spreads from the top of the heart to the bottom. As it travels, the electrical signal causes the heart to contract in an organized manner and pump blood. 

Electrical signals normally begin in a group of cells called the sinus-atrial (SA) node. As these signals spread from the top to the bottom of the heart, they coordinate the timing of heart cell activity. First, the two upper chambers of the heart, called atria contract. This contraction squeezes blood into the lower chambers of the heart, which are called ventricles. The ventricles then contract and send blood to the rest of the body. The combined contraction of the atria and ventricles is a heartbeat.
Pacemaker 1(copy)(copy)
  The heart and its blood flow
 
Pacemaker2(copy) Sometimes the heart beats too slowly (Bradycardia). During Bradycardia, enough blood is not supplied to the body, due to failure of the hearts chambers to contract properly.This could happen due to SA node not functioning properly, or by a condition called heart block. In this condition, a problem exists with the electrical pathway between the atria and ventricles. Electrical signal sent out by the SA node may not reach the ventricles or is delayed.

Faulty electrical signaling in the heart causes arrhythmias. A pacemaker uses low-energy electrical pulses to correct faulty electrical signaling. Pacemakers can speed up a slow heartbeat,

Pacemakers can also coordinate the electrical signaling between the upper and lower chambers of the heart. The device will make sure the ventricles contract normally if the atria are quivering instead of beating in a normal rhythm (a condition called atrial fibrillation). 
An example showing heart block  
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What does a Pacemaker do?

 
A pacemaker system monitors and treats the abnormal heart rhythm.

Pacemakers can be temporary or permanent.
  • Temporary pacemakers are used in emergency settings, or when the underlying cause of the abnormal heart beat is expected to resolve itself.
  • They are also used to re-establish a normal heart rhythm until a permanent pacemaker is installed.
  • Temporary pacing may be required among heart attack patients, severely symptomatic patients with Bradycardia, patients with Tachycardia, after open-heart surgery and other settings.
A person with a temporary pacemaker will stay in the hospital as long as the pacemaker is in place. Your procedure at Mercy Angiography refers to a permanent devices, unless your doctor specifically tells you otherwise.

A permanent pacemaker is used when a slow heart rate becomes chronic. A permanent system consists of a pulse generator (also called a device), which is implanted on your chest and one or more leads which is implanted in the chambers of your heart (Atrial or ventricle) and are connected to the device.
Pacemaker3















 
Placement of Pacemaker Leads

The Generator
Pacemaker4(copy)
  • The generator is a small computer which runs on a battery, safely concealed in the devices case.
  • The device continuously monitors your heart functions and delivers electrical energy (charge) to pace your heart when it senses a slow rhythm.
  • Together with monitoring your heart rhythm a device can also store information about your heart. Your doctor than can review this information via a computer programme. This helps the doctor better assess the heart rhythm and determined weather the programmed treatment is appropriate. If necessary the device's setting can be changed with the programme.
Pacemaker Device  

The Leads
  • A pacemaker lead is an insulated wire connected to the pulse generator and implanted in your heart.
  • Heart signal is carried via a lead to the pulse generator which then carries energy from the pulse generator back to the heart to coordinate your heart rhythm as the need arises.
Pacemaker5
  Pacemaker Leads
There are two types of pacemakers available: Single chamber and Dual chamber. Your cardiologist will discuss with you which kind of pacemaker is appropriate for you.

Single-chamber Pacemakers
A single chamber pacemaker typically uses one lead placed either in the right atrium or right ventricle to pace the heart. This type of pacemaker is often selected for a person whose SA node sends out signals too slowly.

Dual-chamber Pacemakers
Dual chamber pacemakers typically use two leads, one placed in the right atrium and the second one placed in the right ventricle. The electrical pulses delivered to the heart are timed so that the atria are stimulated to contract just before the ventricles. The timing ensures the atria and the ventricles are beating "in sync" with one another.

A dual chamber pacemaker can be selected for many different reasons. For some, SA node signals are too slow and electrical pathway to the ventricles gets partially or completely blocked. And for others, the timing of the Atria and Ventricle contractions are uncoordinated (asynchronous).
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How is a Pacemaker Inserted?

The procedure will be conducted in an angiography suite (“cath lab”) at Mercy Angiography, which is in the Mercy Hospital at 98 Mountain Road, Epsom in Auckland. Your specialist will be assisted by nurses and other highly trained staff. 

You will be awake during the procedure but lightly sedated.
 


 
  • The doctor makes a small insertion near your collar bone, to gain access to the vein.
  • The pacemaker lead is then inserted into the vein, into the heart, where the tip of the lead rests directly against the heart’s inner wall.
Pacemaker6(copy)
  A single chamber pacemaker insertion
 
Pacemaker7(copy)

 
  • Should the cardiologist decide that the presenting symptoms require a Dual-chamber pacing, another lead will be implanted.
  • One lead is positioned in the atrial chamber and the other in the ventricular chamber.
A dual chamber pacemaker insertion  
 
  • After the lead(s) are correctly positioned, the device and the leads are tested to determine correct functionality.
  • After successful testing, the device is then placed in position, which is usually below the collarbone, just underneath the skin.
  • The incision is then closed with sutures. 

 
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What will I experience during the procedure?

  • An intravenous catheter (IV line) for administration of fluids and medication will be inserted into a vein on the back of your hand or in your arm.
  • You will feel a slight prick when the needle is inserted into your vein for the intravenous line (IV) and when the local anaesthetic is injected through your groin.
  • You will be given mild sedation through your IV to make you feel relaxed.
  • You may feel slight pressure when the catheter is inserted but no serious discomfort.
  • As the contrast material passes through your body you may get a warm feeling on one side of your face.
  • While you are in hospital your pain will be well controlled with medication infused through your IV line.
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How should I prepare for my procedure?

  • Fasting: You will likely be instructed not to eat or drink anything after midnight before your procedure.  Your doctor will tell you which medications to take in the morning.
  • Medications: Please inform your doctor of all the medications you are taking. Your doctor may advise you to stop taking some medications temporarily a few days prior to the procedure.
  • Allergies or previous reactions to contrast (x-ray dye): Please inform Mercy Angiography staff at the time of booking your procedure if you have any known history of allergies, particularly allergies to x-ray contrast and seafood.
  • Diabetes: If you are diabetic you should inform your doctor at the time of booking. You may need to discuss your insulin dose with your specialist.
Please bring with you any medication and any recent blood test results or chest x-rays. 
 
On the day of your procedure, please make your way to the Mercy Hospital Reception where they will be expecting you. You will be admitted to a hospital ward and brought down to Mercy Angiography for your procedure at the appropriate time.

For directions to the Mercy Hospital, click here.
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What happens after my procedure?

As you recover, you will find that your pacemaker may allow you to return back to active lifestyle. However it is important to follow your doctor’s instructions in order to avoid any unnecessary complications.

  • Report any redness, swelling or drainage from your incision.
  • Avoid lifting any heavy objects for the period  instructed by your doctor.
  • Walk, exercise, and bathe accordingly as instructed by your doctor.
  • Avoid wearing tight clothes that could irritate the skin over your device.
  • Contact your doctor if you develop a fever that does not go away in two or three days.
  • Avoid rubbing the device or the surrounding chest area.
  • If directed by your doctor, limit arm movements that could affect your lead system.
  • Tell your other doctors, dentists, and emergency personnel that you have a pacemaker.
  • Contact your doctor if you notice anything unusual or unexpected, such as new symptoms, or  symptoms like the ones experienced before getting pacemaker insertion.

Medications 
It is important to discuss instructions regarding any medications with your doctor.

Activities and Exercise 
Your doctor will advise you regarding the level of suitable activitiy following your procedure, as well as answer any questions you may have regarding lifestyle changes, travel, exercise, work, hobbies and resuming sexual intimacy.

Follow-up Visits 
The pacemaker will automatically monitor and treat your heart rhythm. It is important to follow your doctor’s instructions and keep up with your scheduled follow-up appointments, even if you are feeling well.

The pacemaker contains many programmable features and keeping your appointments can help your doctor programme the pacemaker to best meet your individual needs.

 

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What if the battery or my device needs to be replaced?

Pacemaker Battery 

  • The pacemaker uses battery energy to monitor and pace the heart rhythms as needed.
  • The pacemaker battery is safely sealed inside the device, and just like any other battery operated device, the pacemaker battery also gets used up over time.
  • The battery life depends upon the setting that has been used to programme the device and the number of pacing therapies given.

At every follow-up visits the doctor or nurse checks the battery life and when the battery energy decreases, the device needs to be replaced.

Replacing the Device 

  • The doctor will surgically open the pocket of skin where the device is located.
  • The old pacemaker is disconnected from the leads and the leads are tested to ascertain proper functionality.
  • On successful testing, the leads are connected to the new pacemaker.
Final tests are carried out to make sure the pacemaker is working properly before suturing the pocket of skin.

Replacing the device is considered minor operation and normal activities can be resumed soon thereafter.
 
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What are the risks?

Your doctor will go through the risks associated with this procedure before your consent to go ahead with the procedure is signed.

Unlike any surgical procedure, pacemaker insertion also can cause post  implant adverse events such as:
  • chronic nerve damage,
  • erosion,
  • fluid accumulation,
  • formation of haemotomas or cysts,
  • infection,
  • pneumothorax, 
  • lead dislodgement and/or
  • interference that prevents the device from pacing.
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