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  Pacemaker (PM)

What is a pacemaker?

A pacemaker is an implanted device that monitors your heartbeat and prevents your heart from beating too slowly. It consists of a box (‘pulse generator’) attached to one or two wires (‘leads’). The pulse generator is usually placed underneath the skin or muscle beneath your collarbone. The lead or leads pass inside the large veins of your chest from the generator to your heart. The leads transmit information about your heartbeat to the generator. If your heart beats too slowly the pacemaker sends out a tiny electrical impulse to ‘pace’ the heart, i.e. to make it beat at an appropriate speed. If your heart then speeds up again, this is detected by the pacemaker, which then stops pacing your heart.

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What does pacemaker implantation involve?

A pacemaker is usually implanted under local anaesthetic; you can also have some sedation to make you feel sleepy and more relaxed. The procedure generally takes about an hour and is performed in a ‘cardiac catheterisation laboratory’. Your heart rhythm, blood pressure and the oxygen level in your blood are monitored continuously. The doctor puts local anaesthetic under the skin below your collar bone. The anaesthetic stings for a few seconds as it gets to work but the area rapidly goes numb. An incision about 3-4 cms long is made below the collarbone. The next stage of the procedure is for the doctor to find a vein through which the leads are passed to the heart. Once the leads are in the veins they can be positioned in the heart. This is not in any way uncomfortable although you may feel a few extra heart beats for a short period. Care is taken to find the ideal position for the lead or leads and you will hear numbers being called out, referring to measurements made through the leads. When the doctor is happy that the leads are in the best position, they are stitched in and a pocket is created to house the pulse generator. This pocket may be underneath the skin or deeper, under the muscle of the chest wall. Finally the incision is closed up with stitches. For the skin stitch some doctors use a dissolvable suture while others prefer a suture that is taken out at your doctor’s surgery after 7 days. You will be told which you have.

Can complications occur?

This procedure cannot be performed without some element of risk; you need to understand the risks before you sign the consent form.  It is important that you understand that these risks are potential and unpredictable.  The majority of patients, however, have no problems.  The potential risks are listed below for your information:

Pneumothorax (air leak around the lungs): this occurs in approximately 1 in 100 patients. The veins used to get the pacemaker wires to your heart lie very near to the lung. It is possible to nick the lung on the way past causing an air leak. Sometimes this resolves on its own. Occasionally a chest drain is needed; if so your stay in hospital may be delayed by several days.

Pericardial effusion (blood leak around the heart): this occurs in approximately 1 in 500 patients. When the wire is positioned in the heart it can cause a fluid collection around the outside of the heart. Sometimes this resolves on its own but occasionally a drain is needed; very rarely an operation is needed. If so your stay in hospital may be delayed by several days.

Infection: this occurs in approximately 2 in 100 patients. Antibiotics are given routinely to help prevent this. In the unlikely event that the pacemaker does become infected, it will probably need to be removed and a new pacemaker implanted.

Haematoma (severe bruising): this occurs in approximately 4 in 100 patients. Rarely this bruising may need drainage.  Patients taking blood thinning drugs are more prone to haematoma formation.

Wire displacement: this occurs in approximately 2 in 100 patients. This causes the pacemaker to pace inappropriately.  In most cases the wires need to be repositioned requiring further surgery.

Death: this is fortunately an extremely rare complication

What to expect after pacemaker implantation

You can expect your shoulder and arm to be sore for a few days afterwards. Simple pain-killers like paracetamol are usually helpful. It is important to keep the arm and shoulder moving, to avoid a ‘frozen shoulder’; however you should be gentle and not use the arm for heavy lifting for a few weeks, until your first pacemaker check. Try not to lift your arm above shoulder height again until the first check. You should avoid getting the wound wet for about a week after the implant. The wound usually appears a little bruised for several days afterwards. Although the bruising may become more prominent after you go home, any discomfort and redness around the wound should get better rapidly. If you have concerns about the wound it is important that you contact us directly.

Follow-up after pacemaker implantation

After discharge from hospital you will need to be followed up regularly. The first visit is usually about six weeks after implant and usually every 9-12 months thereafter although there is some variation. At these visits your pacemaker is checked to make sure that it is working well and to make any adjustments necessary to the way it is programmed. This visit usually lasts about twenty minutes.

What happens when the battery runs down?

Many factors determine how long a pacemaker battery will last. Currently available generators typically last about 7-10 years under standard conditions. The pacemaker battery behaves in a predictable fashion. By following you up regularly we can determine accurately when the pacemaker generator will need replacing. The pacemaker will be functioning perfectly normally throughout this time and you will be readmitted in a planned fashion to replace the pacemaker generator. When the generator is replaced the procedure is similar to that of the original pacemaker implant although we aim to use the original leads and simply attach a new generator.

Is there anything you should avoid with a pacemaker?

In almost every respect life with a pacemaker is completely normal. Household appliances and mobile telephones do not interfere with your pacemaker’s function, although you should not keep your mobile telephone in a pocket directly over the pacemaker. You will receive a pacemaker card giving full information about your pacemaker. If you are flying you should hand this card to security to show you have a pacemaker and you will not have to go through the security gate. If you are concerned about interference from a particular piece of equipment at home or at work, ask your consultant or the cardiac physiologists in the pacemaker clinic.

Driving after a pacemaker

You should not drive for one week after pacemaker implantation if you hold an ordinary (group 1) licence or six weeks if you hold a vocational (group 2) licence. The DVLA rules are revised periodically and the current rules can be viewed at http://www.dvla.gov.uk/drivers/dmed1.htm.

 


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