Pacemaker

Definition:
A pacemaker is a small device that sends small electrical impulses to the heart muscle to maintain a suitable heart rate or to stimulate the lower chambers of the heart (ventricles). A pacemaker may also be used to treat fainting spells (syncope) and congestive heart failure.

Types of Pacemakers

The types of pacemakers are listed below. Your doctor will decide what type of pacemaker you need based on your heart condition. Your doctor also determines the minimum rate (lowest heart rate) to set your pacemaker. When your heart rate drops below the set rate, the pacemaker generates (fires) an impulse that passes through the lead to the heart muscle. This causes the heart muscle to contract, creating a heartbeat.

The atria and ventricles work together, alternately contracting and relaxing to pump blood through the heart. The electrical system of the heart is the power source that makes this possible.

Normally, the electrical impulse begins at the sinoatrial (SA) node, located in the right atrium. The electrical activity spreads through the walls of the atria, causing them to contract.

Next, the electrical impulse travels through the AV node, located between the atria and ventricles. The AV node acts like a gate that slows the electrical signal before it enters the ventricles. This delay gives the atria time to contract before the ventricles do.

From the AV node, the electrical impulse travels through the His-Purkinje network, a pathway of specialized electricity-conducting fibers. Then the impulse travels into the muscular walls of the ventricles, causing them to contract. This sequence occurs with every heartbeat (usually 60 - 100 times per minute). Click here to learn more.

Why do I need a pacemaker?

If the electrical pathway described above is interrupted for any reason, changes in the heart rate and rhythm occur that make a pacemaker necessary.

Pacemakers are used to treat:

• Bradyarrythmias - slow heart rhythms that may occur as a result of disease in the heart's conduction system (such as the SA node, AV node or HIS-Purkinje system).
• Pacemakers are also used to treat syncope (unexplained fainting spells), heart failure and hypertrophic cardiomyopathy.

Click here for more information about abnormal heart rhythms.

Is the procedure safe?

A pacemaker implant is generally a very safe procedure. However, as with any invasive procedure, there are risks. Special precautions are taken to decrease your risks. Please discuss your specific concerns about the risks and benefits of the procedure with your doctor.

• If you take Coumadin, the results of your INR test (a blood test to evaluate the blood clotting) must be within a suitable range before the implant procedure can be performed. Usually you will be instructed to stop taking aspirin or Coumadin (warfarin) a few days before the procedure.
• Your doctor may also ask you to stop taking other medications, such as those that control your heart rate.
• If you have diabetes, ask the nurse how to adjust your diabetes medications or insulin.
• Do not discontinue any of your medications without first talking to your health care provider. Ask your doctor which medications you should stop taking and when to stop taking them.

Can I eat?

• Eat a normal meal the evening before your procedure. However, DO NOT eat, drink or chew anything after 12 midnight before your procedure. This includes gum, mints, water, etc.
• If you must take medications, only take them with small sips of water.
• When brushing your teeth, do not swallow any water.

What should I wear?

• Remove all makeup and nail polish.
• Wear comfortable clothes when you come to the hospital. You will change into a hospital gown for the procedure.
• Please leave all jewelry (including wedding rings), watches and valuables at home. The clothing you are wearing that morning will be returned to the person who accompanies you.

What should I bring?

• You will not need a robe or toiletries when you first arrive. Your family member can keep these items to give you after the procedure.
• Bring a one-day supply of your prescription medications. Do not take these medications without first talking with the doctor or nurse.
• You may bring guided imagery tapes or music and the appropriate player.

Where is the procedure performed?

In most cases, the pacemaker implant procedure takes place in a special room in the Pacemaker Lab. When the epicardial pacemaker implant approach is used, the procedure will take place in a surgical suite. (See epicardial approach)

• Before the procedure begins, a nurse will help you get ready
• You will lie on a bed and the nurse will start an intravenous line (IV) into your arm or hand. This is so you may receive medications and fluids during the procedure.

To keep the pacemaker insertion site sterile and to prevent infection:

• An antibiotic will be given through the IV at the beginning of the procedure
• The left or right side of your chest will be shaved
• A special soap will be used to cleanse the area
• Sterile drapes are used to cover you from your neck to your feet
• A soft strap will be placed across your waist and arms to prevent your hands from coming in contact with the sterile area

Will I be awake?

A medication will be given through your IV to relax you and make you feel drowsy,but you will not be asleep during the procedure.

Will I be monitored?

The nurse will connect you to several monitors that allow the health care team to check your heart rhythm, blood pressure and other measurements during the procedure. The nurse continually monitors you during the procedure.

Where is the pacemaker implanted?
A pacemaker can be implanted using the endocardial or epicardial approach.

Endocardial (transvenous approach) - most common method

• A local anesthetic (pain-relieving medication) is given to numb the area. An incision is made in the chest where the leads and pacemaker are inserted.
• The lead(s) is inserted through the incision and into a vein, then guided to the heart with the aid of the fluoroscopy machine.
• The lead tip attaches to the heart muscle, while the other end of the lead (attached to the pulse generator) is placed in a pocket created under the skin in the upper chest.

Epicardial approach - less common method in adults, but more common in children

• This procedure is performed by a surgeon in a surgical suite. General anesthesia is given to put you to sleep.
• The surgeon attaches the lead tip to the heart muscle, while the other end of the lead (attached to the pulse generator) is placed in a pocket created under the skin in the abdomen.
• Although recovery with the epicardial approach is longer than that of the transvenous approach, minimally invasive techniques have enabled shorter hospital stays and quicker recovery times.

The doctor will determine which pacemaker implant method is best for you.

After the leads are in place, they are tested to make sure they function properly and can increase your heart rate. This lead function test is called "pacing." Small amounts of energy are delivered through the leads into the heart muscle. This energy causes the heart to contract.

Once the leads have been tested, the doctor will connect them to the pacemaker.

The rate and settings of your pacemaker are determined by your doctor. After the pacemaker implant procedure, the doctor uses an external device (programmer) to program the final pacemaker settings.

What will I feel?

You will feel an initial burning or pinching sensation when the doctor injects the local numbing medication. Soon the area will become numb. You may feel a pulling sensation as the doctor makes a pocket in the tissue under your skin for the pacemaker.

When the leads are being tested, you may feel your heart rate increase or your heart beat faster. Please tell your doctor what symptoms you are feeling. You should not feel pain. If you do, tell your nurse right away.

How long does the procedure last?

The pacemaker implant procedure may last from 2 to 5 hours.

Yes. You will be admitted to the hospital and stay overnight after the procedure. Usually you will be able to go home the day after your pacemaker was implanted.

What should I expect?

• In your hospital room, a special monitor called a telemetry monitor, will continually monitor your heart rhythm. The telemetry monitor consists of a small box connected by wires to your chest with sticky electrode patches. The box displays your heart rhythm on several monitors in the nursing unit. The nurses will be able to observe your heart rate and rhythm.
• You will also have a holter monitor, a small recorder attached to your chest with sticky electrode patches. The holter monitor records your heart rhythm for 12 hours to ensure that the pacemaker is functioning properly. Before you are discharged, the holter monitor will be removed, and the results will be given to your doctor.
• A chest x-ray will be done to check your lungs as well as the position of the pacemaker and lead(s).

You will also visit the Device Clinic.

Pacemaker check at the Cleveland Clinic Heart Center Device Clinic

What happens in the Device Clinic?

• You will sit in a reclining chair. Small sticky patches (electrodes) will be placed on your chest and connected via wires to a computer. A nurse will place a small device, known as a programmer, directly over the pacemaker. The programmer allows the nurse to change the pacemaker settings, and to check the pacemaker and lead function. You may feel your heart beat faster or slower. Although this is normal, please tell the nurse what symptoms you are experiencing.
• The results of the device check are reported to your doctor, who then determines the appropriate settings for the pacemaker. The holter monitor results are also reviewed. Homegoing instructions are reviewed.
• If you have a biventricular pacemaker, an echocardiogram may be performed as part of the Device Clinic evaluation or at your next follow-up appointment.

How will I feel?

You may feel discomfort at the pacemaker implant site during the first 48 hours after the procedure. The doctor will tell you what medications you can take for pain relief. Please tell your doctor or nurse if your symptoms are prolonged or severe.

Your doctor will discuss the results of the procedure and answer any questions you have. You will receive specific instructions about how to  care for yourself after the procedure including medication guidelines, wound care, activity guidelines, pacemaker care and maintenance, and  a follow-up schedule.

You will also receive a temporary ID card that indicates what type of pacemaker and leads you have, the date of implant and the doctor who  performed the implant. CARRY THIS CARD WITH YOU AT ALL TIMES in case medical care is needed. Within three months you will receive a permanent card from the pacemaker company.

Medications:Ask your doctor if you can continue taking your previous medications.

Will I be able to drive myself home?

No. For your safety, a responsible adult must drive you home. Ask your doctor when you may resume driving.

Learn more about homegoing instructions after your pacemaker  If you have any questions, please ask.

• Learn more about homegoing instructions after your pacemaker
• Learn more about abnormal heart rhythms
• Learn more about biventricular pacemaker
• Find a Cleveland Clinic Heart Center doctor who performs this procedure