What is a pacemaker?
A pacemaker is a device, about the size of 4 stacked silver dollars, which is implanted under the skin and has wires (leads) that pass into the heart. It sends a very small electrical impulse through the leads into the muscle of the heart about once every second to stimulate contraction of the heart. Its main purpose is to make sure a person’s heart rate does not become too slow.
What are the indications for the procedure?
A pacemaker is useful for anyone who has symptoms due to a slow heart rate. At very low heart rates (in the 20s and 30s) a person can develop lightheadedness, fainting, shortness of breath and congestive heart failure. With rates in the 40s and 50s a person can still feel lightheaded and weak. A pacemaker in people with slow heart rates can dramatically improve symptoms.
Sometimes people have a normal heart rate that occasionally drops very low or they have short periods (several seconds) where the heart stops beating. This can result in sudden loss of consciousness with the danger of falling and injury. A pacemaker in this situation will prevent these episodes from occurring.
Atrial fibrillation is a common rhythm problem that results in rapid heart rates. If the atrial fibrillation is intermittent, the intervening periods of normal heart rhythm can be uncomfortably slow especially if we use medications that slow the heart rate down. A pacemaker in this situation provides protection against slow heart rates so that we can increase the doses of drugs that keep the atrial fibrillation from racing too fast.
How is it done?
When we’re ready to start you’ll be brought into the cardiac catheterization lab (much like an operating room with x-ray cameras) and you’ll lie on a table while our technicians prepare the area on your body where we’ll be working. In most patients we place the pacemaker just below the collarbone on the left chest wall. We can also implant the pacemaker on the right if there is a reason the left side can’t be used (e.g. a patient with a left arm dialysis fistula or previous surgery for breast cancer). The technicians will cover your chest and face with a drape to protect the sterile area where we’ll work (the drape over the face can bother some patients—we can provide more sedation to you if you think this will be a problem). After providing you with some sedating medication we numb the area of skin with local anesthetic. We make an incision about an inch and a half long and then create an area under the skin where we can place the pacemaker. We pass the wires (leads) into a vein which leads directly into the right atrium and ventricle of the heart. Once we place and secure the leads in the heart we test them electrically to make sure we have good conduction and adequate position to pace the heart. We attach the leads to the pacemaker and place it under the skin. We close the skin with absorbable suture so that you will not need stitches removed. You will stay in the hospital overnight so that we can observe your heart rhythm and check the status of your pacemaker and leads in the morning. There is a small chance that one of the leads will pull free from where we put it within the first few hours after surgery. We are able to easily detect this on the morning after surgery and return to the cath lab to fix it if necessary.
If all goes well you are discharged from the hospital on the day after surgery.
How do you prepare for the procedure?
Pacemaker insertion is done on both hospitalized and ambulatory patients. As an outpatient having this done electively you will first visit with the cardiologist in the office to go over the procedure and discuss the risks and alternatives. Since you will be asked to sign document of consent be sure to ask any question and raise any concern you may have. You will need to have basic blood work done and this can be drawn in the office.
Unless instructed otherwise you should be fasting on the morning of the procedure. In general we want you to take your usual morning medications with the exception of any we’ve told you not to take (please talk to our nurses or schedulers if you have any questions about this).
We do this procedure in the hospital at CUMC - Bergan Mercy, Midlands, Mercy Council Bluffs, Immanuel and Lakeside. You’ll receive specific instructions on where to show up and what time to be there.
What are the risks of the procedure?
The risk of bleeding and bruising accompanies any invasive procedure. The risk of infection of the pacemaker site is about 1-4% nationally. Because the vein we use to gain access to the heart lies very near the lung there is the possibility of puncturing and collapsing the lung, necessitating the placement of a chest tube. There is a small risk of leads perforating the muscle in the heart and causing potentially life-threatening bleeding around the heart.
These complications are uncommon and we can take measures to treat them when they arise. We take all these potential complications very seriously and take great precautions to avoid them.