What to expect during the procedure - Pacemaker

Having a pacemaker implanted is a relatively straightforward process.

It's usually done under local anaesthetic. This means you'll be awake.

The procedure usually takes about 1 hour. Most people can leave hospital on the same day or a day after surgery.

You'll need to arrange for someone to pick you up from hospital and take you home.

There are two methods of fitting a pacemaker:

• transvenous implantation
• epicardial implantation

Transvenous implantation

This is the most common method of fitting a pacemaker.

Before the procedure

You'll get a local anaesthetic as an injection. This means you'll be awake during the procedure. But you won't feel any pain

When you get the injection you'll feel an initial burning or pricking sensation.

The area will soon become numb. But you may feel a pulling sensation during the operation.

Before the procedure, a thin tube called an intravenous (IV) line will be attached to one of your veins. Medicine to make you drowsy (sedative) may be given through the IV line to keep you relaxed during the procedure.

During the procedure

1. The cardiologist will make a 5cm to 6cm (about 2 inch) cut just below your collarbone. This is usually on the left side of the chest.
2. They will insert the wires of the pacemaker (pacing leads) into a vein.
3. The pacing leads are guided along the vein into the correct chamber of your heart using x-ray scans. They then become lodged in the tissue of your heart.
4. The other ends of the leads are connected to the pacemaker. This is fitted into a small pocket created by the cardiologist. This will be between the skin of your upper chest and your chest muscle.

The procedure usually takes about 1 hour.

But it may take longer if you're having:

• a biventricular pacemaker with 3 leads fitted
• other heart surgery at the same time

After the procedure

You'll be attached to a special monitor. This is so the medical team can keep an eye on your heart rhythm. The monitor is a small box connected by wires to your chest with sticky electrode patches.

The box displays your heart rhythm on monitors in the nursing unit. The nurses will observe your heart rate and rhythm in the recovery unit for a period of time.

You'll have a chest x-ray to check your lungs and the pacemaker and leads.

You may feel some pain or discomfort during the first 48 hours after having a pacemaker fitted. You'll be given pain-relieving medication.

Tell your healthcare team if your symptoms don't go away after a few days or are severe.

Epicardial implantation

Epicardial implantation is a less widely used method of fitting a pacemaker.

In this method the pacing leads are attached to the outer surface of your heart (epicardium). This is done through a cut in your abdomen, below the chest.

Epicardial implantation is often used in:

• children
• people who have heart surgery at the same time as a pacemaker implantation
• people who have problems with venous access (accessing the bloodstream through the veins)

Before the procedure

You'll be given a general anaesthetic. This means you'll be unconscious throughout the procedure.

During the procedure

1. The surgeon will make a cut in your abdomen, below the chest.
2. This is to create a pocket under your skin where the pacemaker box will sit.
3. The surgeon will attach the tip of the pacing lead to your heart. They'll attach the other end of the lead to the pacemaker box.

The procedure usually takes between 1 and 2 hours. But it can take longer if you're having other heart surgery at the same time.

After the procedure 

You will be monitored after the procedure by your healthcare team. Recovery after epicardial implantation usually takes longer than after transvenous implantation.

Implantable cardioverter defibrillators (ICDs)

Implantable cardioverter defibrillators (ICDs)are mostly fitted transvenously, along a vein.

This is done by transvenous implantation. This is the same way a pacemaker is fitted.

But ICDs can also be fitted under the skin (subcutaneous implantation).

Subcutaneous implantation

Subcutaneous implantation is either done:

• using general anaesthesia
• with local anaesthesia and sedation

During the implantation

1. The cardiologist will create a pocket in the left side of the chest where the ICD will be put.
2. They will place the pacing lead and electrodes under the skin along the breast bone. These connect to the device.
3. The cardiologist will close the cut. They will then test and adjust the sensing, pacing and recording functions of the ICD.

Having an ICD put in can take between 1 to 3 hours. It depends on the type of device you're having fitted.

After the implantation

An overnight stay in hospital is sometimes needed, but not always.

Testing and setting the pacemaker

When the leads are in place, the cardiologist will test them. They'll do this before they connect them to the pacemaker or ICD. This is to make sure they work and can increase your heart rate. This is called pacing.

Small amounts of energy go through the leads into the heart. This causes the heart to contract and pull inwards.

When the leads are being tested, you may feel your heart beat faster. Tell the medical team about any symptoms you feel.

Your doctor will fix the settings of your pacemaker. They'll decide how much electrical energy you'll need to stimulate your heartbeat.