Pacemaker Implantation: Surgery Procedure, Type & Treatment

A Pacemaker Implantation is a surgical procedure to place (implant) a small battery-operated electronic device known as a pacemaker into the chest. The pacemaker provides electrical pulses to the heart to keep it beating regularly and not too slowly. This help stabilizes abnormal heart rhythms and prevents problems that can disrupt or endanger an individual’s life.

Anatomy and Physiology of the Human Heart

The human heart is one of the most essential organs of the body responsible for sustaining life. The human heart functions throughout an individual’s life span and is one of the most robust and hardworking muscles in the human body. 

The human heart is located in the thoracic cavity between the lungs, slightly towards the left of the sternum (breastbone) and it rests on the diaphragm. It consists of several layers of tough muscular tissue, the myocardium. The outside and inside of the heart are covered by thin layers of tissues known as pericardium and endocardium, respectively. These muscles are powered by electrical impulses that trigger the heart's function.

It is the primary organ of the circulatory system as it pumps blood throughout the human body. The heart's cavity is divided into the right and left heart, which is further subdivided into two chambers. The upper chamber is known as an atrium (or auricle), and the lower chamber is known as a ventricle. The upper chambers (atria) act as the receiving chambers for blood entering the heart, and the muscular ventricles pump the blood out of the heart.

The main function of the heart is to pump blood throughout the body. The heart also:

1. Pumps blood to deliver oxygen, hormones, glucose and other components to various body parts, including the human heart.
2. Ensures that optimum blood pressure is maintained in the body.

Generally, pacemaker implantation is recommended by the doctor to correct a chronic slow or irregular heartbeat or heart rate problem. The conditions treated with a pacemaker include:

1. Brady-arrhythmia: slow heart rhythm caused by a disease in the heart's conduction system
2. Syncope: episodes of fainting
3. Hypertrophic cardiomyopathy: a complex heart disease that affects the heart muscle
4. Tachy-Brady syndrome: alternating fast and slow heartbeats
5. Heart block: abnormal rhythm
6. Heart failure
7. Coronary artery disease
8. History of a heart attack

The doctor or cardiologist will first test to check whether the patient is a good candidate for the pacemaker. Generally, pacemaker implantation is recommended for patients who have an irregular heartbeat. A pacemaker may also be used for  

1. A heartbeat that pauses
2. A heartbeat that is too fast
3. Some types of heart failure

The above heart conditions may be caused by a variety of factors, such as:

1. Age-related changes to the heart tissue
2. Heart damage due to prior heart injury or heart disease.
3. Congenital heart conditions
4. Medications that slow the heart rate
5. Having certain health conditions such as 
   1. Pericarditis: inflammation of the tissue encompassing the heart
   2. Myocarditis: an inflammation of the heart muscle
   3. Hypothyroidism: a medical condition in which the thyroid gland develops too little thyroid hormone
   4. Systemic sclerosis: a rare condition that can cause inflammation and scarring of the skin and internal organs

Pacemaker implantation is a straightforward procedure that is performed on an outpatient basis or as part of a stay in the hospital. The surgery takes about 2 to 3 hours to complete, depending on factors such as the patient’s age and the patient’s medical condition. According to the heart condition, the doctor will determine what type of pacemaker would be best for the patient. Additionally, the doctor will determine the lowest heart rate at which the pacemaker should be set. There are two types of pacemakers:

1. Leadless pacemaker: This is a self-sustaining device without connecting leads (wires) and generator
2. Biventricular pacemaker: This is also called cardiac resynchronisation therapy (CRT). It is characterised by the insertion of electrodes in the left and right ventricles of the heart to treat heart failure.

Pacemaker implantation is performed under general anaesthesia (medication used to reduce the sensation in the body) by a specialized team of anaesthetist, cardiologists, and other medical staff. The following steps are carried out during the procedure:

1. For surgery, the patient will be asked to lie down on the back.
2. The patient then will be covered with a sterile drape.
3. The nurse inserts an intravenous (IV) line in the hand or arm so that medication can be injected and IV fluids can be administered if necessary.
4. As part of the procedure, an electrocardiogram (ECG or EKG) small and adhesive electrodes will be attached to the patient to monitor the heart's electrical activity. The healthcare staff or a nurse will also monitor the vital signs (heart rate, blood pressure, breathing rate, and oxygenation level).
5. Large electrode pads will also be placed on the front and the back of the patient's chest.
6. The surgeon will then administer general anaesthesia to the patient.
7. Once the anaesthesia sets in, the surgeon will make an incision (cut) at the incision site (under the collarbone).
8. A sheath (a plastic tube) will be inserted into the blood vessel under the collarbone. Then, the pacer lead wire will be inserted into the blood vessel and advanced into the heart through the sheath.
9. Through the introducer, the lead wire will be inserted into the blood vessel. Once in the blood vessel, the surgeon will insert the lead wire into the heart.
10. Once the surgeon inserts the lead wire inside the heart, it will be tested to confirm the proper position and functioning. A surgeon may insert one, two, or three lead wires, depending on the type of device they choose for the condition.
11. Fluoroscopy (a particular type of X-ray that will be displayed on a TV monitor) may be used to aid in testing the position of the leads.
12. The surgeon will slide the pacemaker generator under the skin through the incision after the lead wire is attached to the generator. A generator is generally installed on the non-dominant side. (for right-handed people, the device will be placed in the upper left chest. However, if the patient is left-handed, the device will be placed in the upper right chest).
13. The patient will be monitored through an electrocardiogram (ECG) to ensure that the pacemaker is functioning correctly.
14. Sutures (stitches), adhesive strips, or special glue will then be applied to close the incision
15. A sterile dressing will also be applied to the incision site.
16. Post-surgery, the patient will be shifted to a recovery room to monitor vitals and post-operative recovery.

Before the pacemaker implantation, the doctor/surgeon will discuss and prepare the patient for the surgery. These steps often involve:

Before Pacemaker Implantation

Before the surgery, the patient is evaluated by a doctor. The doctor will access current, past medical and family history. The doctor may also do some additional tests to understand the patient’s health condition. These tests include:

1. Physical examination: A focused pre-anaesthesia physical examination involves an evaluation of the airway, lungs and heart, with documentation of vital signs.
2. Blood tests: The doctor may recommend a blood test to measure the blood clotting time. These tests include complete blood count (CBC), creatinine and electrolytes, and fasting glucose (test to check for diabetes).
3. Electrocardiogram (ECG or EKG): It is an image of the electrical impulses travelling through the heart muscle. Graph paper records ECGs, which are recorded using electrodes (small, sticky patches) attached to the chest, arms, and legs.
4. Stress test: This test is used to register arrhythmias (improper beating of the heart) that begin or are worsened with exercise. This test is also effective in determining if an underlying heart condition or coronary artery disease is associated with an arrhythmia.
5. Echocardiogram: This is a type of ultrasound used to present a view of the heart to ascertain if there is a heart muscle or valve condition that may be causing an arrhythmia. The test can be completed at rest or while doing any activity.
6. Medications:
   1. If the patient takes a medicine called Coumadin, the patient must have a satisfactory result on his/her INR examination (a blood test to assess blood clotting) before an implant can be placed.
   2. Typically, the doctors will instruct the patient to stop taking aspirin or Coumadin (warfarin) a few days before the procedure.
   3. The doctor may also request the patient to stop taking other medicines, such as those that regulate or control the heart rate.
   4. The patient should not stop any of the medicines without initially consulting his/her doctor. The patient should ask the doctor about the medications that one needs to stop consumption.
   5. In the case of diabetic patients, he/she should consult a doctor on how to adjust the diabetes medicines or insulin.

On the day of Pacemaker Implantation

1. The patient will need to sign a consent form to provide permission to do the surgery. The patient or his/her family member should read this form thoroughly and should also ask questions if something is not clear.
2. The healthcare staff will ask the patient to remove any jewellery or other objects interfering with the surgery.
3. The patient will need to change his/her clothing and will be given a gown to wear.
4. The patient will be asked to empty his/her bladder before the surgery.
5. If there is excessive hair at the surgery site, the healthcare staff may also shave it.
6. A soft strap will be placed across the wrist that will include the patient’s details.
7. Healthcare staff will connect the patient to several monitors to observe the heart rhythm and blood pressure during the procedure. In addition, the nurse will constantly monitor the vitals during the surgery.
8. Once the patient has been prepared and ready for the surgery, he/she will be taken to the operating room.

The patient almost always recovers to a healthier life with far fewer problems after the procedure. A patient who has undergone pacemaker implantation can expect the following after the surgery:

The recovery process at the hospital

1. Post-surgery, the patient will be moved to the hospital ward so that he/she can recover.
2. The patient immediately should tell the nurse if he/she is feeling any chest pain, tightness, or other pain at the incision site.
3. Once the period of bed rest is over, the patient can get up with the help of assistance. However, one should move gently while getting up from the bed to avoid any dizziness from the period of bed rest.
4. The incision site may be sensitive or painful. Therefore, pain medicines may be administered if necessary.
5. As soon as the pulse, blood pressure, and breathing are regular and the patient is alert, he/she will be shifted to the hospital room or sent home.
6. If the surgery is performed on an outpatient basis, the patient may be allowed to leave after he/she has finished the recovery process. However, for observation, spending at least one night in the hospital is common after pacemaker implantation.
7. The patient should have a relative or a friend drive him/her home from the hospital after the surgery.

Recovery process/expectation after hospital discharge

1. Activity: 
   1. In a couple of days after the implantation, the patient should be able to resume his/her daily routine. If he/she needs more time to return to normal activities, the doctor will let the patient know. For a few weeks, the patient should not lift or pull anything. 
   2. A pacemaker may require that the patient limit the motion of the arm on the side where it is implanted, depending on the doctor's preferences.
2. Diet: The patient can probably resume his/her usual diet unless instructed by the doctor.
3. Wound care (dressing): It will be essential to keep the incision site clean and dry. The patient will be given specific instructions about bathing and showering.
4. Work: The patient should ask the doctor when they can return to work. The patient will be able to return to work depending on the type of occupation, overall health, and recovery progress of patient.

First follow-up appointment

1. The cardiologist will recommend the first follow-up within four to six weeks post-discharge.
2. The cardiologist will check how the patient is recovering during the follow-up.
3. The cardiologist might also change the medication or advise the patient to continue with the previous medication for some more time, depending on the condition and recovery of the surgical area.
4. The cardiologist will advise the patient for further timely follow-ups as well.
5. The patient will need to attend routine check-ups to ensure the pacemaker is functioning correctly. Majority of pacemakers store information about normal heart rhythms.
6. The doctor can review this information in follow-up appointments to determine whether the pacemaker and the heart are functioning normally.

A pacemaker can significantly improve the quality of life of an individual if he/she has problems with a slow heart rate. The device can be lifesaving for some people. Below mentioned are some of the benefits of pacemaker implantation:

1. Alleviate many of the symptoms caused by heart rhythm problems, including chest pain, confusion, palpitations, nausea, confusion and more.
2. Prevent unpleasant symptoms like fainting that are caused by arrhythmias.
3. Save an individual’s life by preventing his/her heart from stopping.

Generally, pacemaker implantation has few complications which a patient can discuss with the doctor/surgeon before the surgery. Following are some possible risks and complications of pacemaker implantation:

1. Allergic reactions to anaesthesia
2. Blood clots
3. Bleeding
4. Infection
5. Malfunctions of the pacemaker or its leads
6. Malfunctions caused by sources outside of the body
7. Abnormal heart rhythms

When is consultation with the doctor needed?

The patient can consult the doctor if he/she experiences:

1. Fever or chills
2. Increased pain, redness, swelling, bleeding or other drainages from the insertion site
3. Chest pain/pressure, nausea and/or vomiting, profuse sweating, dizziness and/or fainting
4. Palpitations

Severe outcomes can be expected if the surgery for pacemaker implantation is delayed, such as:

1. Heart failure
2. Chest pain (angina pectoris)
3. Low blood pressure (hypotension)
4. High blood pressure (hypertension)
5. Fainting (syncope)

The cost of pacemaker implantation ranges from ₹80,000 to ₹2,00,000. The cost varies based on the following factors:

1. Age of the patient
2. Type of the procedure done
3. Type of the pacemaker implanted
4. The medical condition of the patient
5. The type of hospital facility availed - individual room or shared