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Pacemaker

Pacemaker:  What is it, Pre-Surgery Preparation, Post-Surgery Care | National Heart Centre Singapore

Pacemaker - What it is

A pacemaker is a 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).

The primary purpose of a pacemaker is to maintain an adequate heart rate, either because the heart's natural pacemaker is not fast enough, or because there is a block in the heart's electrical conduction system.

Pacemaker - Symptoms

Pacemaker - How to prevent?

Pacemaker - Causes and Risk Factors

The atria (top chamber of the heart) and ventricles (bottom chamber of the heart) work together, alternating contracting and relaxing to pump blood through the heart. The electrical system around the heart makes this possible.

The normal conduction of the heart 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).

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 brady-arrythmias, 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 network). 

Are there different types of pacemaker? The pacemaker consists of two parts: first, a box which houses the electronics (the “device”), and second, one or more wires which connect the box to the heart muscle (the “leads”).


The types of pacemakers are listed above. 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. 

Risks
A device implant is generally a safe procedure. However, as with any invasive procedures, there are risks. Special precautions are taken to decrease your risks.
Your doctor will discuss your risk with you as every individual is different. In general however, the risk of implanting a pacemaker is low - only 1% or less of serious complications. These include (but are not limited to):
  • Infection of the pacemaker which, if serious, may need removal of the pacemaker altogether
  • Bleeding
  • Pneumothorax (“collapsed lung”)
  • Cardiac perforation
  • Device malfunction
All of these complications are treatable.

Pacemaker - Diagnosis

Pacemaker - Treatments

Who and where will the pacemaker implantation be done?
A specialist doctor called an Electrophysiologist will perform the procedure. The procedure will be done in the Electrophysiology Lab.

Is the procedure done under general anaesthetic?
A combination of local anaesthetic (to numb the implant site) and sedation will be used so you do not experience pain or undue discomfort during the procedure. Medication will be given through your IV to relax you and make you feel drowsy, but you will not be asleep during the procedure. Note that this is not open heart surgery; opening up the chest is not needed.

How long does the procedure take? What should I expect?

Most cases will take around 60 to 90 minutes.

You will be taken to a special area called the Electrophysiology Laboratory to have the pacemaker implanted:

You will lie on a bed and the Electrophysiology Lab staff will connect monitoring equipment to your chest. They will also start an IV (intravenous) drop in a vein in your arm or hand. The IV is used to deliver antibiotic medication and fluids during the procedure.

The doctor will then clean the chest using a special soap, and cover you using sterile drapes from your neck to your feet. He or she will then inject local anaesthetic to the skin and give you sedation before implanting the pacemaker.

The pacemaker is implanted through a small (approximately 5 cm) incision in the upper chest, usually on the left side. After the incision is made, the pacemaker “lead” is placed under X ray guidance into the heart; the pacemaker box is then connected to the other end of the lead and secured under the skin incision, in a little “pocket”.

At this point, the doctor would test the device to make sure it is working properly. Once he or she is satisfied with the device, the skin will be sutured up and you will be woken up and returned to the ward.

How will the device be implanted?

The pacemaker is usually implanted using the endocardial (transvenous) approach. During the procedure, a local anesthetic (pain-relieving medication) is injected to numb the area, and you will be awake during the procedure.

Small incisions are made in the chest where the lead (or leads) and device are inserted. The lead is inserted through the incision and into a vein, then guided to the heart with the aid of the fluoroscopy machine. The lead tip is attached to the heart muscle, while the other end of the lead is attached to the pulse generator. The generator is placed in a pocket created under the skin in the upper chest.

Pacemaker - Preparing for surgery

 
If I decide to have a pacemaker, when will I be admitted for the implantation procedure? How long can I expect to be admitted for?

Your doctor will arrange a date for you to be admitted to the hospital. Usually you are admitted on the day of the procedure; occasionally, you will be admitted the day before.  Most patients can expect to be discharged the following day; occasionally, your hospital stay may be longer if the procedure is difficult or complicated.

Do I continue to take my medications till the day of the procedure?

Your doctor should already have instructed you on what to do before the procedure.

Please check with your doctor before discontinuing any medications. The following information is a general guide only.

If you are on warfarin, this will normally need to be discontinued around 5 days prior to the procedure, and a blood test (“INR”) taken to confirm that your blood clotting is normal prior to implantation. Please check with your doctor before discontinuing your medications.

If you are taking aspirin or clopidogrel (Plavix), you may be asked to discontinue one or both of these prior to implantation; however, please confirm this with your doctor.

You can normally continue taking your other medications as usual.

If you have diabetes, liase with the nurse to adjust your diabetic medications or insulin accordingly.

Can I eat before the procedure?

In most cases, you will be told to 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?

When getting ready, please do not wear makeup and remove 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.

What happens before the procedure? 

Before the procedure begins, a nurse will help you get ready. You will be given a hospital gown to change into. You may keep your clothes in a locker or you may give them to a family member.

You will lie on a bed and the nurse will start an IV (intravenous) line in a vein in your arm or hand. The IV is used to deliver medications and fluids during the procedure.

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

  • 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 may be placed across your waist and arms to prevent your hands from touching the sterile area 

In rare cases, when the endocardial approach cannot be used, the epicardial (surgical) approach is used (more common in children). With this approach, general anesthesia is given to put you to sleep during the procedure and the generator is placed in a pocket created under the skin in the lower abdomen.

The hospital recovery time is generally 3 to 5 days with the epicardial approach, although minimally invasive techniques may be used to allow a shorter hospital stay and quicker recovery time. 

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

Pacemaker - Post-surgery care

What can I expect immediately after the pacemaker is implanted?

You will return from the Electrophysiology Laboratory with pressure dressing over the site of the pacemaker implant. If you have any pain, please inform your nurse so you can be given enough painkillers.

You will stay overnight in the hospital and usually will be able to go home the day after the device is implanted. Wound care will be taught and outpatient appointment will be given to ensure proper wound healing. 


What tests will be done after the procedure?

A chest x-ray will be done after the device implant to check your lungs as well as the position of the device and lead(s).

The following day, an Electrophysiology Technician will confirm your pacemaker is working properly; this is done on the ward, from outside the body.

If there are no problems, you can expect to be discharged the following day with a return appointment in 1 week. You may also be given a short course of antibiotics to prevent infection.


Do I need long term follow up?

You will need long term follow up. Initially you will be seen at 4 to 6 week intervals to check the pacemaker is functioning as intended. If there are no problems, the follow up interval may be lengthened to every 3 months or more.

Are there any special precautions I must take after an pacemaker is fitted? Do I need to modify my lifestyle in any way?

After the pacemaker is implanted, you will need to keep the implant site clean and dry while the overlying skin heals. On discharge from the ward, the nurses will arrange regular dressing changes.

For 2-3 weeks after implantation, you should also avoid raising your arm on the side of the implant above shoulder level to avoid dislodging the lead or device. After two to three weeks have elapsed, the lead and device should be secure so that this is no longer an issue and you can move your arm normally.

There are few restrictions from having a pacemaker. Most sports are permitted except contact sports such as rugby where vigorous impact could damage the pacemaker.

Swimming is permitted but we do advise common sense precautions such as not swimming in deep water alone.

Will I be able to drive myself home after the procedure?

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

The pacemaker is battery-powered. How often does the battery need changing and how is it changed?

Most pacemakers will last around 5 to 10 years depending on the type and model of your pacemaker. We will check on the battery status during your regular clinic follow ups. The battery life of your pacemaker depends on how often it is used and the power output. Changing the battery is similar to implanting a new device except the pacemaker leads (the wires which connect the device to the heart which can last typically up to 20 years) do not need to be changed.


What instructions will I receive before I leave the hospital?

Your doctor will discuss the results of the procedure and answer any questions you have. Be sure to ask the doctor if you can continue taking your previous medications.

You will receive specific instructions about how to care for yourself after the procedure including medication guidelines, wound care, activity guidelines, device care and maintenance, and a follow-up schedule.

Should I carry my identification card (ID) with me all the time?

Yes. Your ID card contains pertinent information about yourself, type of pacemaker and your physician.

This is made available quickly in the event of an emergency. If you lose your card, please ask for a replacement. 

FAQ
What is electromagnetic interference (EMI) and should I be concerned with EMI at my workplace?

Things that use electricity and magnets have electromagnetic fields around them and may cause Electromagnetic Interference (EMI). These fields are usually weak and will not affect your pacemaker.

However, strong electromagnetic fields have the potential to alter the function of your pacemaker. A strong magnetic field can “blind” the pacemaker to send pacing beats when your heart does not need it. If you move away from the source of EMI, your pacemaker will return to normal. Most office and shop equipment are unlikely to interfere with your pace maker.

If you are uncertain, please do consult with your doctor.


Which devices interfere with a pacemaker? Is it a problem if I walk through airport, shopping or courtroom security metal detectors?

Airport screening devices are unlikely to affect your pacemaker but they may detect the metal housing of your device and set off the security alarm. If it does, inform the security personnel that you have a pacemaker implanted and show them your identification card. 

Passing through the metal detector portal will not harm your device; however do not linger near it as the magnetic field may temporarily interrupt the normal function of the device. 

Properly maintained electrical household items are unlikely to interfere with your pacemaker.


Are medical procedures safe?

Always mention to the medical personnel about your pacemaker implantation and show them your identification card. With proper precautionary measures prior procedures, most medical procedures and dental procedures are unlikely to interfere with your pacemaker except Magnetic Resonance Imaging (MRI), which is not recommended.

Alert your doctor if you are scheduled for medical procedures, including dental procedures as your pacemaker may need to be reprogrammed before the procedure to lower the chance of interference or damage to the pacemaker’s function.


My doctor has advised me to have a “scan”. Is this safe if I have a pacemaker implanted?

Ultrasound scans (including echocardiograms), as well as X ray scans (including CT scans) do not affect the function of your pacemaker; you may proceed with these normally.

However, you should not have MRI (magnetic resonance imaging) scans if your pacemaker is not MRI compaitable. Please inform the doctor or radiologist prior the scan.


Can I travel with my pacemaker?

Most people with pacemakers can travel freely unless they are restricted by their underlying medical condition or other unrelated conditions.


Can I use my mobile phone?
Mobile phones are unlikely to interfere with your pacemaker if proper precautions are followed. 
  • At least 6 inches should be maintained between your mobile phone and your pacemaker.
  • When using your phone, you should hold it to the ear opposite the side of the body in which the pacemaker is implanted.
  • When set to receive calls, your mobile phone should not be carried in a shirt pocket on the same side as the pacemaker.

Pacemaker - Other Information

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