Pacemaker Surgery: All About Pacemakers

1
What Is a Pacemaker?

Heart Valves and Chambers
Heart Valves and Chambers. Image: © ADAM

A pacemaker is a device that helps regulate the the rhythm of the heart as well as the rate at which it beats. It may be used temporarily, such as after open heart surgery, or placed permanently, with a minimally invasive procedure.

A normal heart beats at a steady pace, but there are many conditions that can make the heart beat irregularly. The rate may be too fast or too slow, or the heart may no longer beat in the normal "lub-dub" fashion. If the heart is not beating properly, a pacemaker can be used to regulate the rhythm.

A pacemaker sends an electrical impulse to the muscle of the heart telling it when to beat. If one of the chambers of the heart is working improperly, the pacemaker can be attached there, or to multiple chambers if necessary.

Conditions that can be treated with a pacemaker include atrial fibrillation and bradycardia (slow heart rate). In some cases, the pacemaker can help insure the left and right atrium or ventricles contract at the same time. There is also a defibrillator/pacemaker combination available, which is used to treat abnormal tachycardia (an irregular and overly fast heart rate).

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Types of Pacemakers

heart with pacemaker, pacemaker, pacemaker surgery, pacemakers, heart pacemaker, pacemaker surgery,
Heart With Pacemaker. Image © National Institutes of Health

There are two primary types of pacemakers: a standard pacemaker that triggers the chambers of the heart, and an internal defibrillator/pacemaker combination known as a cardioverter defibrillator.

The standard type of pacemaker sends an electrical impulse via special wires that are attached to the heart. This replaces the signal that is sent by the heart, which is faulty in patients who need a pacemaker.

A second type of pacemaker, the internal defibrillator/pacemaker combination (AICD), sends an electrical impulse to the heart to control the heart’s rate and rhythm, just as a standard pacemaker does. In addition to that function, it can also deliver a “shock” to stop a “lethal rhythm,” a heart rhythm that does not allow the heart to effectively function.

The idea of the shock is the same as the “shock with paddles” that you may have seen on television. However, because the device is attached to the heart with wires, the shock is much less powerful than what you may imagine.  It is, however, very painful and has been compared to being kicked in the chest by a mule. 

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3
The Risks of Pacemaker Surgery

Pulmonary, lungs, breathing, pulmonary disease
Normal Heart & Lung Anatomy. Image: ADAM

In addition to the general risks of surgery and the risks of anesthesia, pacemaker surgery presents its own risks. While less than 5% of patients experience problems after pacemaker surgery, it is important to be aware of potential complications.

Risks of Pacemaker Surgery

  • Nerve damage at the incision site
  • Damage to the tissues or blood vessels around the heart or the incision site
  • Pneumothorax (collapsed lung)
  • Bruising at the site of placement (this is an expected effect of surgery)
  • Faulty pacemaker that does not function as intended after the surgery (very rare)
  • Faulty lead wires that connect the pacemaker to the heart (very rare)
  • Lead wires that become dislodged after surgery due to activity or poor placement
  • Infection in the incision
  • The pacemaker may have to be replaced in the future

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4
What Happens During The Pacemaker Procedure

Surgery to implant a pacemaker is considered a minimally invasive procedure. It is not an open heart surgery, although it can be combined with an open heart surgery if necessary.

The procedure is typically performed in an operating room or in a cardiac catheterization lab. Local anesthesia is given to numb the area of the chest where the procedure is performed, allowing the patient to remain awake while the surgery is performed without pain. In addition to numbing the area, a sedative may be given to help the patient relax or reach a twilight sleep state.

Once the anesthesia takes effect, the chest will be prepared with a special solution to remove germs that may be on the skin, and the area will be covered with sterile drapes to keep the incision as clean as possible.

The procedure begins with the insertion of the wires that attach the device to the heart. The wires are threaded through and into the heart where they are placed using a type of x-ray imagining that allows the doctor to see exactly where the wires are at all times.

Once the wires are in place, an incision is made in the chest or abdomen, and the actual pacemaker device is placed under the skin. The wires, which are connected to the heart, are attached to the pacemaker. The pacemaker is then tested to make sure it is working effectively.

Once the physician determines that the wires are in the correct place and the pacemaker is functioning properly, the incision is closed with sutures or adhesive strips and medication is given to wake the patient.

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5
After Pacemaker Surgery

While the actual surgery to place a pacemaker is a minor procedure, an overnight stay in the hospital is typically required. This is done so that the function of the heart can be closely monitored in the hours after surgery.

You can expect to spend the night in a room that allows your heart to be monitored continuously. You will most likely have four patches on your chest with wires attached to them. This allows staff to monitor your heart’s function, in the form of a continuous EKG, without being in your room.

If the pacemaker is working properly after surgery, you should be able to return home the next day. You will need to care for your incision for several weeks as it closes, monitoring it for signs of infection as well as healing.

You may be able to feel the pacemaker under your skin as the pacemaker is typically placed just below the skin. This area will be sore after surgery, but as time passes the pacemaker should become less noticeable. During your recovery you may want to sleep on your back or side, as the area may be bruised or tender.

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Life After Pacemaker Surgery

Once you have healed from your pacemaker placement surgery, you may notice a dramatic improvement in your energy level and stamina. The pacemaker will help your heart work efficiently, which should alleviate symptoms of fatigue, and allow you to be more active.

If your pacemaker is also an implanted defibrillator, you may periodically experience “shocks” as the device works to keep your heart in a healthy rhythm.  These shocks should be reported to your cardiologist, and if they become frequent, you may require care in the Emergency Room.

After surgery, you will want to avoid magnetic fields whenever possible. This is because magnets can interfere with the function of the device and can cause serious problems with your heart. You should avoid placing small electronics such as a phone in your breast pocket, as they can interfere with the device. Tests that utilize magnets, such as an MRI, can disrupt the function of the pacemaker and will not be possible with a pacemaker in place. 

You should notify any physician or healthcare provider that you might see, whether they are a heart specialist or not, that you have a pacemaker.

In addition, strenuous activity or anything that would cause significant impact on the device should be avoided. The pacemaker is somewhat protected as it lies under the skin; however, a sharp blow could damage it. For example, playing a contact sport such as hockey could result in damage, and other high-impact sports could potentially cause the wires to move from their position in the heart.

You will have to see your physician regularly after the pacemaker is inserted to make sure the device is working properly and potentially for the computerized memory to be downloaded. This can be done very easily through the skin, and should be painless. Long term, your pacemaker may need maintenance, which your doctor will determine during your regular visits.

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Sources

Sources:

What Is an Implantable Cardioverter Defibrillator. National Heart Lung and Blood Institute. Accessed May, 2009 http://www.nhlbi.nih.gov/health/dci/Diseases/icd/icd_whatis.html

What Is a Pacemaker? National Heart Lung and Blood Institute. Accessed May, 2009http://www.nhlbi.nih.gov/health/dci/Diseases/pace/pace_whatis.html

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What To Expect During Pacemaker Surgery. National Heart Lung and Blood Institute. Accessed May, 2009http://www.nhlbi.nih.gov/health/dci/Diseases/pace/pace_duringsurgery.html

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