Pacemaker implant

What is a pacemaker?

A pacemaker is an implantable system comprising of highly sophisticated wire(s) and a generator (which is also the battery unit) that detects, analyses, and stimulates the heart to beat when it is too slow. The pacemaker will only work when the heart is going slow and is not intended to fix irregular or fast rhythms. In many cases, medications are used in conjunction with pacemakers to control fast abnormal rhythms.

The pacemaker wires are usually placed within the heart through veins located just under your collarbone / clavicle. It is usually placed on left side but can be performed from right as well. The wires are then connected to the generator / battery unit and placed in a small pocket over the chest muscle under the skin.

Do I need a pacemaker?

The electrical system does not work normally in some people. The electrical impulses are either too slow, delayed or do not get transmitted from the atria (control centres) to the ventricle (pump). This could occur due to medications or randomly without warning or gradually worsen over time.

Some examples of slow rhythm include “sick sinus syndrome”, “sinus node dysfunction”, “chronotropic incompetence” and “heart block”. The term heart block refers to block or delay in the electrical communication system. If you satisfy the above criteria, you may qualify for a pacemaker.

What are symptoms of bradyarrhythmia? 

With slow heart rhythm, you can experience unexpected dizziness, collapse, loss of consciousness, decreased exercise capacity or breathlessness.

 Are there different types of pacemakers?

Yes, there a different type of pacemakers. In general pacemakers can have 1, 2 or 3 wires. Most common Is the two-wire system called a dual chamber pacemaker. Pacemaker leads can be placed right at the surface or deep into the thick and muscular ventricular septum called deep septal or left bundle branch pacing or conduction system pacing.

Different companies manufacture these devices with their own unique offerings. Common pacemaker brands are Medtronic, St Jude Medical, Boston Scientific, Biotronik, Sorin to name a few.

 What are the risks of having a pacemaker?

They include but are not limited to the following.

Common risks and complications (more than 5%) include:

• Bruising / bleeding at the pacemaker site
• Large collection of blood (Haematoma) – this can take several weeks to settle
• Pain at the pacemaker site

Uncommon risks and complications (1- 5%) include:

• The pacemaker / device lead(s) can move. The lead will need to be put back into place by repeating this procedure
• Bad bruising if you are taking blood thinning drugs such as Warfarin, Xarelto, Eliquis, Dabigatran Aspirin, Clopidogrel (Plavix or Iscover) or Dipyridamole (Persantin or Asasantin)
• Unexpected device failure. There is a risk of battery (generator) or lead failure. This is uncommon but means the battery or lead will need to be removed and a new one put in
• Infection of the pacemaker site. This will need treatment with antibiotics and/or removal of the pacemaker

Rare risks and complications (less than 1%) include:

• A punctured lung (pneumothorax). This may require a tube to be inserted into the chest to reinflate the lung
• Blood clot in the subclavian vein (Deep vein thrombosis)
• A hole is accidentally made in the heart or heart (perforation) – This will need surgery to repair
• Blood clot in the lung (pulmonary embolus)
• Heart attack
• A stroke. This can cause long term disability
• Death is possible due to the procedure or other heart problems
• Tricuspid regurgitation
• Infection of heart valve and other infections

What are the costs associated with a pacemaker implant?

If you are having this procedure in a public hospital as a public patient, the cost is covered by Medicare.  If you are having this procedure in a private hospital, there is no additional out of pocket cost for our specialists. The usual hospital excess applies. Some anaesthetists have an out-of-pocket cost that we encourage you to discuss prior to your planned procedure.

 How do I prepare for a pacemaker implant procedure?

You will receive a letter with instructions and steps required prior to your procedure including, date of admission (Time of admission may be provided by the hospital directly in some cases), fasting instructions, medications to stop and items to bring with you. You will usually need recent blood test for your kidneys and blood count prior.

In General, do not eat or drink for 6 hours before your procedure. Ask your doctor about taking your usual medications. Blood thinners maybe discontinued for 24hrs. If you take SGLT2 (dapagliflozin / empagliflozin) medicine for heart failure or diabetes, you will need to stop taking them at least 3 days before your surgery. Leave any personal items of value such as jewellery at home.

What happens when you arrive at the hospital?

Once you arrive at the hospital for your procedure, you will usually be directed to the cardiac catheter laboratory / operating theatre admission area where you will be formally admitted as a hospital patient. You will be asked to change into hospital gown and put away all your valuable belongings. You will have some basic tests such as ECG, have your vitals recorded, upper chest shaved and have a cannula inserted into your arm to assist with the procedure.

What happens during the procedure?

Pacemaker insertion is very common and takes approximately 1 hour for a standard dual chamber device. Other special procedures such as CRT and deep septal pacing can take longer. Procedure is usually performed in the catheter laboratory or operating theatre. You will be lying on a narrow bed under the X-ray machine arm that can move in and out of position.

Pacemakers are generally performed under sedation. Medication to make you sleepy will be given through the cannula to keep you relaxed during the procedure. General anaesthesia may be considered in some cases and may require an arterial line to monitor your blood pressure. Antibiotics are usually given prior to the procedure.

The upper chest is usually shaved again if needed, cleaned with a special antiseptic wash and once dry, a long sterile drape is placed over the site. The drape covers you from head to toe. You will have someone to assist you if needed. Once you are comfortable, local anaesthetic is administered at the incision site which numbs the area. You’ll feel an initial sharp and burning or pricking sensation when the local anaesthetic is injected but it quickly becomes numb in less than a minute. You may feel a pulling / pushing sensation during the operation which is normal.

A 5 to 8cm cut is made just below your collarbone. The tissue under the skin is carefully dissected and a space is created just above the chest muscle. Usually, a needle is advanced into the vein deeper in the chest under the clavicle. Special dye (Contrast) injection maybe required to identify the vein. The pacing leads are then guided into the vein and advanced into the correct chamber of your heart using X-ray scan. They are secured to the heart tissue either by a tiny screw at the end of the wire (Active lead) or soft hooks (Passive lead). The leads are secured to the underlying muscle with permanent sutures over a special cuff on the wire called suture sleeve.

The other ends of the leads are connected to the pacemaker, which is placed in the small pocket created over the muscle. The wound is closed with absorbable sutures and a water-resistant dressing applied on top of the wound.

You’ll usually need to stay in hospital overnight and may have a chest Xray that night. A pacemaker check is performed the next morning. People can usually go home the next day if tests are all normal.

What happens after a pacemaker implant?

At the end of your procedure, a simple dressing is applied over the pacemaker site. You may have a larger dressing applying pressure at the site overnight. You’ll be watched closely in a recovery area, and depending on how you feel, you might need to rest in bed for a while. You will be admitted to the ward for observation overnight with rhythm monitoring. A chest X-ray may be performed in some cases. People are usually discharged the next day after a pacemaker check.

 

What happens after discharge?

Wound Care:

1. The dressing on your wound should be left in place for two weeks. You may shower, as it is waterproof, but you cannot submerge yourself in a bath or pool.
2. Two weeks after the operation, please go to your GP to have the dressing removed. Do not remove or change the dressing before this time.
3. If the wound becomes red, hot, swollen, more painful or starts to drain fluid, see your local doctor immediately, or call the rooms on 9500-0296.

Special Issues:

1. DRIVING: You may drive after two weeks. You can find out more about the driving restrictions from the Austroads website {link to website: https://austroads.com.au/drivers-and-vehicles/assessing-fitness-to-drive}
2. MOVEMENT OF SHOULDER: Please minimise the use of the shoulder on the side of the operation for one month.  Do not raise your arm to above shoulder height, do not use the     arm to push out of a chair, and no heavy lifting for one month.  This is to ensure that the       flexible wires connecting the pacemaker to your heart do not move.  After a month these    will be firmly stuck in position by the body’s healing process.
3. It is normal to take Paracetamol (Panadol) regularly for the first few days at home.

Other Special Issues:

As outlined in the information booklet that you would receive from the pacemaker company, these relate to things such as mobile phone use, use of machinery and certain medical tests or procedures you may need in the future, some of which may either interfere with the pacemaker, or need the pacemaker to be adjusted beforehand.

The device / generator can sometimes move down slightly over time. If it is not too much and the wires are not pulled back, this is of no concern.

Airline Travel:

You will be given a card with the details of your pacemaker on it, please keep this in your wallet.  A permanent card (resembling a credit card) will be sent to you in about two months.  Show this to the security check at the airport, they will search you with a wand rather than walking through the usual metal detector gate.

Follow Up:

You will be sent an appointment to see me for a pacemaker check in my rooms in 2 months.  Usual follow up thereafter is 6-12 monthly appointments to keep track of the device function. It is recommended that you continue your usual follow up with other treating specialists and medical practitioners involved in your care as usual. If you do not receive an appointment, please call the rooms.

Do I have to take it easy once I have a pacemaker?

Most people with a pacemaker lead normal active lives, including your normal sexual activities. You can participate in your physical activity after two weeks. Many pacemakers allow for increased heart rate when exercising.

How long do pacemakers last?

The wires can last for decades but as with most things there is wear and tear over time. The battery lasts about 10-15 years depending on a few factors. The battery unit is replaced at that time (generator change).

 Can I have an MRI scan after a pacemaker?

Yes, MRI scans can usually be performed with newer pacemaker models. There are some exceptions to this rule including abandoned leads and special scenarios. You will have to wait for at least 6 weeks before an MRI scan. Check with your doctor about the details.

 Can I use a cell phone or microwave oven if I have a pacemaker?

Microwave ovens, electric blankets, remote controls for TV and other common household appliances won’t affect your pacemaker. You can use a cell phone, too, if you take these steps:

• Hold the phone to the ear on the side of your body opposite from your pacemaker.
• When your phone is on, try to keep it at least six inches away from your pacemaker. For example, don’t carry your phone in your breast pocket over your pacemaker.

Remote monitoring:

We can monitor the function of your pacemaker while you are at home via remote monitoring. This can be through the transceiver that you place near your bed or through your smart phone. All important information is stored within your pacemaker and the remote monitor communicates with your pacemaker wirelessly overnight at a prespecified time. It will do so every night and transmit information 1-6 monthly to a team of technologists who analyse that information. If there is an urgent issue, information will be transmitted that night and the doctor will usually be informed the next day.

Generally, almost all people will be offered remote monitoring to keep track of your device while you are at home. There is a free service and a paid service (External 3^rd party – Remote Rhythm Management). Please feel free to discuss this with your doctor.

Please contact the rooms if you have any questions or concerns at any time. I am happy to hear from you if you have any questions or concerns.

In recommending this procedure your doctor has balanced the benefits and risks of the procedure against the benefits and risks of not proceeding. Your doctor believes there is a net benefit to you going ahead. This is a very complicated assessment.