Permanent Pacemaker

Implantable device to normalize your heartbeat and prevent blackouts

A permanent pacemaker is a small sealed electronic device, which contains a battery and electronic circuitry. The pacemaker is connected to the heart with one or two wires called leads. The pacemaker provides a sort of ‘safety net’; if the heartbeat is normal, the pacemaker is in monitoring mode and does not stimulate the heart. If heart rate drops below a programmed level, which could cause problems, such as tiredness, dizziness or blackouts, the pacemaker will give out small electrical impulses to which the heart responds by pumping. Most pacemakers can also detect increase in physical activity and speed up heart rate accordingly. Pacemakers are used to treat slow heart rhythms (bradycardia) and depending on the underlying problem can be single chamber (with one lead going to the right ventricle, one of the bottom heart chambers) or dual chamber devices (with two leads to the right atrium and ventricle, i.e. top and bottom heart chamber).

A healthy heart beats 50-100 times per minute and with every heart beat, blood is being pumped around the body to supply all organs with oxygen. Heart has four chambers, two top priming chambers (atria) and two bottom pumping chambers (ventricles). Under normal circumstances, each beat starts in the natural pacemaker called sinoatrial or SA node in the right atrium. The impulse then spreads across the top chambers and down via a junction called atrioventricular or AV node which lies between atria and ventricles. Then, it travels along a specialized tissue called left and right bundle to the heart muscle cells that respond to the stimulation by contraction which causes the whole heart to pump.

Sometimes the electrical system in the heart does not work well and there is a problem in transmission of the electric signal which can cause the heart to beat too slowly. There is no medication that can make the heart beat faster and if the problem is serious, it needs to be rectified with pacemaker implantation.

Private pacemaker implants are performed at the Lister Hospital. You may need to stay overnight in the hospital. You may not drive home, so please arrange someone to collect you.

Indications

•Heart block

This is a situation when the AV node between top and bottom heart chambers is diseased and does not transmit properly the electrical impulses from atria to ventricles. This usually results in a very slow heart beat with symptoms of tiredness, lightheadedness or blackouts. Complete heart block can progress to a complete heart standstill and cardiac arrest. A pacemaker is required to restore the electrical connection between heart chambers and thus normal heart rate.

•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 rhythms. Sometimes, a part of sick sinus syndrome is irregular heart rhythm called atrial fibrillation which usually requires blood thinning medication (warfarin) even with pacemaker fitted.

•Pace and ablate

Sometimes, atrial fibrillation with very troublesome symptoms cannot be controlled with medicines and a special procedure called catheter ablation is used to destroy the AV node. This means that electrical impulses can no longer travel to the bottom heart chambers which abolishes the symptoms but pacemaker is necessary to make the heart beat and pump.

Risks and complications

Pacemaker insertion is very safe. However, like any surgical procedure, there is a small degree of risk involving:

-Bruising, bleeding and infection of the wound; if significant, a wound revision or removal of the implanted device is necessary

-Pneumothorax, a perforation of the lung which lets air into the chest cavity. Often it rectifies itself without treatment, sometimes insertion of a small drain is necessary

-Tamponade, a bleeding in to the pericardial sac which surrounds heart which also requires insertion of a drain

-Lead dislodgement – the pacemaker wire can move and would need to be repositioned

Before the procedure

You will need a blood test about a week before the procedure. Anticoagulants, i.e. blood thinning drugs (warfarin, sinthrome) and also clopidogrel will need to be stopped 5 days before the procedure. You can drink water, clear tea and black coffee (without milk) up to 2 hours before the procedure. Milk, food, sweets, tea or coffee with milk can be taken up to 6 hours before the procedure. Chewing gum and smoking not permitted on day of surgery. Please take all your regular medication (except diabetic medication and insulin) as usual with a sip of water. Please bring the actual list of medication including dosage with you. A doctor will explain the procedure to you and will answer any questions you may have prior to you signing the consent form. A small needle will be put in your arm. Shaving the implant site may be required. You need to let the doctor know if you are left or right handed as this will decide which side the pacemaker is placed.

During the procedure

The procedure will take place in the operating theatre. You will be asked to lie on an operating trolley. Monitoring equipment to check your heart rhythm, blood pressure and oxygen saturation (level of oxygen in blood) will be attached. You will be given antibiotic and sedation, which will make you relaxed and sleepy. Before the procedure starts, I will clean the skin with some antiseptic solution and cover you with sterile surgical drapes, leaving a small window over the shoulder by the collarbone, where the pacemaker will be implanted. Local anaesthetic will be injected under the skin just below the collarbone to numb the area. I will then make a small incision to gain access to the large veins, which lead directly to the heart. One or two leads will be passed along the vein inside the heart. The leads will be secured into correct position under x-ray and then sutured to the breast muscle. The leads are then connected to the pacemaker box which will be placed into a ‘pocket’ under the skin. The wound will then be stitched with absorbable suture and a special glue will seal the skin.

After the procedure

After the procedure, you will be taken to the recovery area and then back to a ward where you will be able to eat and drink. Your heart rhythm will be monitored and you will be given regular antibiotics for the first 24 hours after the procedure to minimize the risk of infection. As the wound can feel quite bruised and sore, especially for the first day or two, it is recommended that you have regular painkillers. It is important that you tell your nurse immediately if you have any problems.

The following day you will have chest x-ray and the pacemaker will be checked by a physiologist who will answer any questions about the device. If everything is fine, you will be allowed home. You will be given a pacemaker identification card, which has details of the make and model of your pacemaker. You should always carry this card with you. If you require any further treatment in the future it is important that you show this card to the health professional treating you.

The wound should be kept clean and dry for the first week. For a first month you should avoid lifting the arm on the side of the pacemaker above the shoulder level. 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 GP as these may be a sign of wound infection. You will be probably able to feel the pacemaker box under the skin. It is very important that you don’t try to move the box or leads, but please let a doctor or physiologist know if there is any discomfort.

 You must inform the Driving and Vehicle Licensing Agency (DVLA) that you have had a pacemaker implanted. The DVLA have guidelines for pacemaker patients and there may be some restrictions in place. It is very important that you discuss this with your doctor or physiologist or doctor who will explain this in more detail.

 Electromagnet interference will not damage your pacemaker but may temporarily interfere with its settings. Most devices that you use in your normal daily activities will not affect your pacemaker as long as they are in good working order. Devices that can interfere with pacemaker include magnets (stereo speakers), magnetic resonance scanners, TENS stimulators and some heavy machinery. Mobile phones should be held at least 6 inches from the pacemaker, ideally on the opposite side and you should walk through doorway security systems rather than dwell in the area. Show your pacemaker ID card at the airport and ask for hand search.

 Your pacemaker should be checked regularly and you will be invited to attend your pacemaker clinic at least once a year and may be asked to attend more often if necessary. During each visit, the physiologist will examine the settings and the battery life of your device and change the parameters as appropriate. The wound will also be checked and there will be opportunity to ask any questions regarding pacemaker. The pacemaker battery lasts up to 10 years and will not be allowed to completely run down. You will be admitted in due course for a box change which is a similar procedure to a pacemaker implant but normally without any intervention to the leads that remain in place.