Pacemaker Implant Procedure

What is a pacemaker?

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). A pacemaker may also be used to prevent patients from having fainting spells (syncope), and to help patients with congestive heart failure and hypertrophic cardiomyopathy.

Electrical system of the heart

The atria (upper chambers of the heart) and ventricles (lower chambers of the heart) work together, taking turns contracting and relaxing to pump blood through the heart. The electrical system of the heart controls this process.

The electrical impulse normally 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. This is a pathway of fibers that conduct electricity. From here, the impulse travels into the muscular walls of the ventricles, causing them to contract. This entire sequence makes up a complete heartbeat and repeats 60 to 100 times per minute.

Why do I need a pacemaker?

If the electrical pathway described above is interrupted for any reason, it causes changes in the heart rate and rhythm. A pacemaker is used to restore a normal heart rate and rhythm.

Pacemakers are used to treat patients with bradyarrhythmias (slow heart rhythms) that may be caused by problems in the heart's conduction system (such as the SA node, AV node or His-Purkinje network).

Pacemakers are also used to treat patients with syncope (unexplained fainting spells), heart failure and hypertrophic cardiomyopathy.

Is the procedure safe?

A pacemaker implant is generally a very safe procedure. However, there are risks with all invasive procedures. Special precautions are taken to decrease your risks. Please talk to your doctor about the risks and benefits of the procedure.

Before the procedure

Should I take my medications?

Ask your doctor which medications you should stop taking and when to stop taking them. Do not stop taking any medication unless your doctor tells you to.

If you take Coumadin, the results of your INR test (a blood test to evaluate the blood clotting) must be within a suitable range before the implant procedure can be performed. You will likely need to stop taking aspirin or Coumadin (warfarin) a few days before the procedure.

Your doctor may also ask you to stop taking other medications, such as those that control your heart rate.

If you have diabetes, ask your nurse how to adjust your diabetes medications or insulin.

Can I eat?

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 need to take medications, take only small sips of water with your pills. Do not swallow any water when you brush your teeth.

What should I wear?

• Remove all makeup and 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. The clothing you wear that morning will be returned to the person who comes with you to the hospital.

What should I bring?

You will not need a robe or toiletries when you first arrive. You can leave these items with the person who comes with you to the hospital.

Bring a one-day supply of your prescription medications. Do not take these medications without first talking with the doctor or nurse.

You may find it helpful to listen to guided imagery or music. Please remember to bring the appropriate audio player.

Where is the procedure performed?

In most cases, the pacemaker implant procedure takes place in a special room in the Pacemaker Lab. If an epicardial pacemaker implant approach is used, the procedure takes place in a surgical suite.

During the procedure

Before the procedure begins, a nurse will help you get ready. 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 pacemaker insertion site sterile:

• You will get an antibiotic through your IV.
• We will remove the hair from your chest, if needed.
• We will clean the procedure area.
• We will cover you from your neck to your feet with sterile drapes.
• We will put a soft strap across your waist and arms to keep your hands from touching the sterile area.

Will I be awake?

You will get medication to relax you and make you feel drowsy, but you will not be put to sleep with anesthesia.

Will I be monitored?

We will keep track of your heart rhythm and blood pressure throughout the procedure.

Where is the pacemaker implanted?

A pacemaker can be implanted using the endocardial or epicardial approach.

The endocardial (transvenous) approach is the most common method. The doctor numbs the area with local anesthetic (pain-relieving medication). An incision is made in the chest where the leads and pacemaker are inserted. The lead(s) is inserted through the incision and into a vein, then guided to the heart with the help of the fluoroscopy machine.

The lead tip attaches to the heart muscle, and the other end of the lead (attached to the pulse generator) is placed in a pocket created under the skin in the upper chest.

Monitors During the Procedure

Defibrillator/pacemaker/cardioverter: Attached to one sticky patch placed on the center of your back and one on your chest. This allows the doctor and nurse to pace your heart rate if it is too slow, or deliver energy to your heart if the rate is too fast.

Electrocardiogram or EKG: Attached to several sticky electrode patches placed on your chest, as well as inside your heart. Provides a picture on the monitors of the electrical impulses traveling through the heart.

Blood pressure monitor: Connected to a blood pressure cuff on your arm. Checks your blood pressure throughout the procedure.

Oximeter monitor: Attached to a small clip placed on your finger. Checks the oxygen level of your blood.

Fluoroscopy: A large X-ray machine will be positioned above you to help the doctors see the leads on an X-ray screen during the procedure.

The epicardial approach is a less common method in adults, but more common in children. During this surgical procedure, general anesthesia is used to put you to sleep. The surgeon attaches the lead tip to the heart muscle, and the other end of the lead (attached to the pulse generator) is placed in a pocket created under the skin in the abdomen.

Recovery time after an epicardial approach is longer than recovery after an endocardial approach. But, your doctor may use a minimally invasive technique that shortens your hospital stay and recovery.

Your doctor will determine which pacemaker implant method is best for you.

How are the leads tested?

After the leads are in place, they are tested to make sure they work properly and can increase your heart rate. This lead function test is called pacing. Small amounts of energy are delivered through the leads into the heart muscle. This energy causes the heart to contract.

Once the leads have been tested, the doctor will connect them to the pacemaker. The rate and settings of your pacemaker are determined by your doctor. After the pacemaker implant procedure, the doctor to programs the final pacemaker settings.

What will I feel?

You will feel a burning or pinching sensation when the doctor first injects the local anesthesia. The area quickly becomes numb. You may feel a pulling sensation as the doctor makes a pocket in the tissue under your skin for the pacemaker.

When the leads are being tested, you may feel your heart rate increase or your heart beat faster. Please tell your doctor what symptoms you are feeling. You should not feel pain. If you do, tell your nurse right away.

How long does the procedure last?

The pacemaker implant procedure takes 2 to 5 hours.

After the procedure

Will I have to stay in the hospital?

You will stay in the hospital overnight and will likely be able to go home the next day.

How will I feel?

You may feel discomfort at the pacemaker implant site during the first 48 hours after the procedure.

Before you go home, the doctor will tell you what medications you can take for pain relief. Please tell your doctor or nurse if your symptoms are prolonged or severe.

What should I expect?

While you are in the hospital, a telemetry monitor will keep constant track of your heart rhythm. The monitor consists of a small box connected by wires to your chest with small, sticky patches, called electrodes. The box displays your heart rhythm on several monitors in the nursing unit.

What tests are done after the procedure?

You will have a chest X-ray after the pacemaker implant to check your lungs and the position of the pacemaker and lead(s). Before you go home, you will go to the Device Clinic.

What happens at the Device Clinic?

You will sit in a reclining chair. Electrodes will be placed on your chest and connected via wires to a computer. A nurse will place a small device, called a programmer, directly over the pacemaker.

The programmer allows the nurse to change the pacemaker settings and to make sure the pacemaker and leads are working properly. You may feel your heartbeat get faster or slower. Although this is normal, please tell your nurse about this and any symptoms you may have.

Your doctor will review the results of the device check and determine the proper settings for the pacemaker.

We will talk to you about your instructions for incision care, activity guidelines and follow-up appointments.

If you have a biventricular pacemaker, you may need an echocardiogram during the Device Clinic evaluation or at your next follow-up appointment.

Before you leave the hospital, you will get a temporary ID card that lists the type of pacemaker and leads you have, the date of implant and the doctor who performed the implant. Carry this card with you at all times in case you need medical care. You will receive a permanent card from the pacemaker company within three months of the implant procedure.

Ask your doctor if you need to take the same medications you took before the procedure.

Can I drive myself home?

No. For your safety, a responsible adult must drive you home.

Action checklist

Before

• Do not eat or drink anything after midnight the night before the procedure.
• Talk to your doctor about the medications you should take before the procedure.
• Do not bring valuables to the hospital.

After

• You will be admitted to the hospital overnight.
• Your doctor will discuss your medications, home-going instructions and follow-up schedule.
• Make sure you have a driver at the hospital to take you home on the day you are discharged.