Pacemaker Implantation

A pacemaker is a small sealed device, roughly the size of two stacked coins, containing a battery and a computer. It sits under the skin below the collarbone, usually on the left, and connects to the heart through one or two thin insulated wires threaded down a vein.

It watches every beat and does nothing while the heart is managing on its own. When a beat fails to arrive within the interval it has been programmed to allow, it delivers a tiny electrical impulse, far too small to feel, that starts one. Over a day it may pace every beat or almost none, depending on what your heart does.

The number of wires depends on what has to be paced. A single wire sits in the lower chamber; two wires allow the upper and lower chambers to be coordinated so the heart fills properly before it contracts. A leadless device, small enough to sit entirely inside the heart with no wires and no chest pocket, suits selected patients. Your cardiologist will explain which is planned for you and what it has been set to do.

You come in on the day, having fasted for a few hours. Blood tests and clotting are checked, and you are told which medicines to hold. Antibiotics are given before the procedure starts.

The skin below your collarbone is numbed with local anaesthetic, so you are awake throughout. A cut of four to five centimetres is made, a small pocket is created under the skin, and the wires are passed through a vein under continuous X-ray guidance to the correct position inside the heart. You will feel pressing and pulling and should feel no sharp pain; say so if you do, since more local anaesthetic can be given at any point.

Before closing, the team tests each wire electrically, measuring how well it senses your own beats and how little energy it takes to pace one. Those numbers decide the final position, and the testing is why the procedure takes 45 to 90 minutes. The device is then connected, tucked into the pocket and the skin closed with stitches under the surface. A chest X-ray afterwards confirms the wires have not moved and that the lung is fine, the device is checked once more, and you go home the same day with a card recording the make and model.

The wound is sore for about a week and tablets manage it. Keep it completely dry for five days and do not pick at the dressing. A firm ridge and some bruising around the device are normal for a few weeks.

The arm on the side of the device is the part that needs discipline. For four to six weeks do not raise that elbow above shoulder height, do not lift more than a couple of kilograms with it, and avoid swimming, racquet sports and any pulling or throwing action. The wires anchor themselves into the heart wall over those weeks, and vigorous arm movement before they have settled is what pulls one out of place. Gentle everyday use of the arm is encouraged, because complete immobility stiffens the shoulder.

Do not drive for at least a week, and longer where your cardiologist says the underlying problem requires it; the rules depend on why the device was implanted and what you drive, so ask specifically. Desk work restarts within a week, physical work at six weeks. You will be seen at around six weeks to check the wound and interrogate the device, and then every six to twelve months for life.