Procedure Description
The treatment approach and selection of procedure is dependent upon your health condition and the opinion of your treating surgeon. Steps followed in Pacemaker Implantation:
- Once the anaesthesia sets in, the surgeon will make an incision (cut) at the incision site (under your collarbone).
- A sheath (a plastic tube) will be inserted into the blood vessel under your collarbone. Then, the pacer lead wire will be inserted into the blood vessel and advanced into the heart through the sheath.
- 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.
- 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 your condition.
- 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.
- 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 your upper left chest. However, if you are left-handed, the device will be placed in your upper right chest).
- You will be monitored through the electrocardiogram (ECG) to ensure that the pacemaker is functioning correctly.
- Applied sutures (stitches), adhesive strips, or special glue to close the incision
- A sterile dressing is applied
Figure: Right atrial and right ventricular leads as visualized under x-ray during a pacemaker implant procedure. The atrial lead is the curved one making a U shape in the upper left part of the figure.
What to Ask and Tell Your Doctor?
- What safety precautions should I take after the implantation surgery?
Any device that produces a strong electromagnetic field, such as an induction hob, can interfere with a pacemaker. As long as you use common household electrical equipment at least 15 cm (6 inches) away from your pacemaker, you will not have a problem.
- How does a pacemaker work?
Pacemakers are small devices that weigh between 20 and 50 grams and are about the size of a matchbox. A pacemaker consists of a pulse generator supported by a battery and a small computer circuit, and some wires known as pacing leads attach to your heart. Through the wires, the pulse generator sends electrical impulses to your heart. When your heart misses a beat, the pacemaker senses it and sends a signal at a steady rate.
- Can a pacemaker improve my quality of life?
If you have problems with a slow heart rate, a pacemaker can improve your quality of life. In some cases, the device is lifesaving.
Additionally, tell your doctors about the following:
- Tell your doctor if you are intolerant/sensitive or allergic to any medicines, latex, iodine, tape, or anaesthetic agents (local and general).
- Inform your doctor if you think you might be pregnant or if you are pregnant.
- Make sure your doctor is aware of any medications (prescription and over the counter) and herbal supplements you are taking.
- Tell your doctor if you have heart valve disease, as you may need to receive an antibiotic before the procedure.
- You should inform and discuss with your doctor if you have a family history of bleeding diseases or are taking anticoagulants (blood-thinners), aspirin, or any other medications that affect blood clotting. A portion of these medicines may need to be stopped before the surgery.
What to Expect Before Surgery?
Pre-anaesthetic check-up:
- The doctors will take your current, past medical and family history.
- Physical examination: A focused pre-anaesthesia physical examination involves an evaluation of the airway, lungs and heart, with documentation of vital signs.
- Laboratory tests such as:
- CBC (complete blood count)
- Creatinine and electrolytes
- Fasting glucose (test for diabetes)
- Chest cardiograph
Medicines:
- If you take a medicine called Coumadin, you must have a satisfactory result on your INR examination (a blood test to assess blood clotting) before an implant can be placed.
- Typically, the doctors will instruct you to stop taking aspirin or Coumadin (warfarin) a few days before the procedure.
- Your doctor may also request you to stop taking other medicines, such as those that regulate or control your heart rate.
- Do not stop any of your medicines without initially consulting your doctor. Ask your doctor which medicines you should stop taking and when to stop taking them.
- If you have diabetes, consult a doctor on how to adjust your diabetes medicines or insulin.
Tests:
- Blood test: Your doctor may recommend a blood test to measure the time your blood takes to clot.
- Electrocardiogram (ECG or EKG): It is an image of the electrical impulses travelling through the heart muscle. Graph paper is used to record ECGs, which are recorded using electrodes (small, sticky patches) attached to your chest, arms, and legs.
- Stress test: This is a test 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.
- 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.
Anaesthesia:
- Local anaesthesia will be given to you during the surgery. If your child is having this surgery, they might be given general anaesthesia.
- You will need to stay in the hospital overnight. Then, the next day after the implantation, you will be able to go home.
- Before the procedure, you will need to fast for some time. Your doctor will instruct you on the length of time you will need to fast.
- Fasting includes mints, gums, water, etc. If you are taking medicines, only take them with small sips of water. While brushing your teeth, do not consume any water.
Pacemaker:
According to your heart condition, your doctor will determine what type of pacemaker you need. Additionally, your doctor will determine the lowest heart rate at which your pacemaker should be set.
Types of pacemakers:
- Leadless pacemaker - This is a self-sustaining device without connecting leads (wires) and generator
- 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.
What happens on the Day of Surgery?
- The hospital will need you to sign a consent form that provides your permission to do the surgery. Do read this form thoroughly and ask questions if something is not clear.
- The healthcare staff will ask you to remove any jewellery or other objects interfering with the surgery.
- You will need to change your clothing and will be given a gown to wear.
- You will be asked to empty your bladder prior to the surgery.
- If there is excessive hair at the surgery site, it may be shaved off.
- Healthcare staff will connect you to several monitors to observe your heart rhythm and blood pressure during the procedure. In addition, the nurse constantly monitors you during the surgery.
- Once you have been prepared and ready for the surgery, you will be taken to the operating room.
What to Expect During Surgery?
- The surgeon will place you on your back on the operating table.
- Prior to the procedure, an intravenous (IV) line will be started in your hand or arm so that medication can be injected and IV fluids can be administered if necessary.
- Medicine will be administered through your IV to relax you and make you feel sleepy, but you will be awake during the complete procedure of implantation.
- As part of the procedure, you'll be attached to an electrocardiogram (ECG or EKG) monitor that records the heart's electrical activity and monitors the heart using small, adhesive electrodes. The healthcare staff or a nurse will monitor your vital signs (heart rate, blood pressure, breathing rate, and oxygenation level).
- You will be covered with sterile drapes
- A soft strap will be placed across the wrist & arms. This prevents your hands from coming into contact with the sterile area.
- They will also place large electrode pads on the front and back of the chest.
- A local anaesthetic will be administered inside the skin at the injection site.
- The procedure will be completed in two to five hours.
- After the surgery is completed, a sterile dressing will be applied to promote healing.
What to Expect After Surgery?
At Hospital:
- The healthcare staff will transfer you to the recovery room for observation or return you to your hospital room. A nurse will monitor your vital signs.
- Immediately tell your nurse if you feel any chest pain, tightness, or other pain at the incision site.
- Once the period of bed rest is over, you can get out of bed with assistance. However, you should move gently while getting up from the bed to avoid any dizziness from the period of bed rest.
- The incision site may be sensitive or painful. Therefore, pain medicines may be administered if necessary.
- As soon as your pulse, blood pressure, and breathing are regular and you are alert, you will be shifted to your hospital room or sent home.
- If the surgery is performed on an outpatient basis, you may be allowed to leave after you have finished the recovery process. However, for observation, spending at least one night in the hospital is common after pacemaker implantation.
- You should have a relative or a friend drive you home from the hospital after your surgery.
At Home:
Activity:
- In a couple of days after the implantation, you should be able to resume your daily routine. If you need more time to return to normal activities, your doctor will let you know. For a few weeks, do not lift or pull anything.
- A pacemaker may require that you limit the motion of the arm on the side where it is implanted, depending on your doctor's preferences.
Diet:
- Unless your doctor gives you instructions otherwise, you can probably resume your usual diet.
Wound care (dressing):
- It will be essential to keep the incision site clean and dry. You will be given specific instructions about bathing and showering.
Work:
You should ask your doctor when you can return to work. You will be able to return to work depending on your occupation, overall health, and your progress.
First Follow up Appointment
You must remember the following:
- You will receive specific instructions about a follow-up schedule when you get discharged from the hospital.
- You'll need to attend routine check-ups to make sure your pacemaker is functioning correctly. Majority of pacemakers store information about your normal heart rhythms.
- Your doctor can review this information in follow-up appointments to determine whether the pacemaker and your heart are functioning correctly.
