A permanent pacemaker is a small sealed electronic device containing a battery and electronic circuitry. The pacemaker is connected to the heart with one or two wires called leads. The pacemaker provides a sort of ‘safety net’; if the heartbeat is normal, the pacemaker is in monitoring mode and does not stimulate the heart. If the heart rate drops below a certain level, which could cause problems, such as tiredness, dizziness or blackouts, the pacemaker will give out small electrical impulses to which the heart responds by pumping. All pacemakers can also detect an increase in physical activity and speed up heart rate accordingly. Depending on the underlying problem, the pacemaker can be a single chamber device (VVIR) with one lead going to the right ventricle, one of the bottom heart chambers or a dual-chamber device (DDDR) with two leads to the right atrium and ventricle, i.e. top and bottom heart chamber.

A healthy heart beats 50-100 times per minute, and with every heartbeat, blood is pumped around the body to supply all organs with oxygen. The heart has four chambers, two top priming chambers (atria) and two bottom pumping chambers (ventricles). Under normal circumstances, each beat starts in the natural pacemaker called the sinus node in the right atrium. The impulse then spreads across the top chambers and down via a junction called the atrioventricular or AV node, which lies between the atria and ventricles. Then it travels along a specialized tissue called the left and right bundle to the heart muscle cells that respond to the stimulation by contraction, which causes the whole heart to pump.

Sometimes the electrical system in the heart does not work well, and there is a problem in the transmission of the electric signal, which can cause the heart to beat too slowly. No medication can make the heart beat faster, and if the problem is serious, it needs to be rectified with pacemaker implantation.

Indications

• Heart block
  This is when the AV node between the top and bottom heart chambers is diseased and does not transmit the electrical impulses properly from the atria to ventricles. This usually results in a very slow heartbeat with symptoms of tiredness, lightheadedness or blackouts. Complete heart block can progress to a complete heart standstill and cardiac arrest. A pacemaker is required to restore the electrical connection between heart chambers and thus normal heart rate.
  
  
• Sick sinus syndrome
  This is a condition where the natural pacemaker does not function properly and results in the heart beating either too slowly, too fast or irregularly. An implanted pacemaker supports the slow heart rate, and medicine is usually given to control the fast rhythms. Sometimes, a part of sick sinus syndrome is an irregular heart rhythm called atrial fibrillation, which usually requires blood-thinning medication (anticoagulation) even with a pacemaker fitted.
  
  

Risks and complications

• Bruising, bleeding and infection of the wound; if significant, a wound revision or removal of the implanted device is necessary.
• Pneumothorax, a perforation of the lung which lets air into the chest cavity. Often it rectifies itself without treatment, sometimes insertion of a small drain is necessary.
• Tamponade, bleeding into the pericardial sac surrounding the heart, requires the insertion of a drain.
• Lead dislodgement – the pacemaker wire can move and need to be repositioned.
   

Before the procedure

You will need a blood test about a week before the procedure. Anticoagulants, i.e. blood-thinning drugs and antiplatelet medication, i.e. clopidogrel, prasugrel or ticagrelor, will need to be stopped 5 days before the procedure. You can drink water, clear tea and black coffee (without milk) up to 2 hours before the procedure. You can consume milk, food, sweets, tea or coffee with milk up to 6 hours before the procedure. Chewing gum and smoking are not permitted on the day of surgery. Please take all your regular medication (except diabetic medication and insulin) as usual with a sip of water. Please bring the actual list of medication, including dosage, with you. Dr Ruzicka will explain the procedure to you and answer any questions you may have before signing the consent form. A small cannula will be inserted into your arm. Shaving the implant site may be required. The pacemaker is usually implanted on the left side of the chest just below the collar bone, but in left-handed people can be implanted on the right side.

During the procedure

The procedure will take place in the operating theatre. The physiologists will attach monitoring equipment to check your heart rhythm, blood pressure and oxygen saturation (oxygen level in the blood). You will be given antibiotics and sedation, which will make you relaxed and sleepy. Before the procedure starts, The operator will clean the operating site with an antiseptic solution and you will be covered with sterile surgical drapes, leaving a small window for the implantation. A local anaesthetic will be injected under the skin just below the collarbone to numb the area. The operator will then make a small incision to gain access to one of the large veins, which lead directly to the heart and pass one or two leads into the heart. The leads will be secured into the correct position under x-ray and then sutured to the breast muscle. The leads are then connected to the pacemaker generator and placed under the skin. The operator will then stitch the wound with absorbable sutures, and a special glue will seal the skin.

After the procedure

After the procedure, you will be taken to the recovery area and then back to a ward where you will be able to eat and drink. Your heart rhythm will be monitored, you will have a chest x-ray, and the pacemaker will be checked by a physiologist who will answer any questions about the device. If everything is fine, you will be allowed home the same day. You will be given a pacemaker identification card, which has details of the make and model of your pacemaker. You should always carry this card with you. If you require any further treatment in the future, show this card to the health professional treating you.

The wound can feel quite bruised and sore, especially for a couple of days, and you can use simple painkillers, such as paracetamol or ibuprofen. The wound should be kept clean and dry for the first week. For the first month, you should avoid lifting the arm on the side of the pacemaker above the shoulder level. If you notice any redness, soreness or swelling of the area or any signs of bleeding or oozing from the wound, report this immediately to your GP as these may be a sign of wound infection. You will be probably able to feel the pacemaker box under the skin. You mustn’t try to move the box or leads, but please let a doctor or physiologist know if there is any discomfort.

You must inform the Driving and Vehicle Licensing Agency (DVLA) that you have had a pacemaker implanted. The DVLA have guidelines for pacemaker patients, and there may be some restrictions in place. You must discuss this with your doctor or physiologist, or doctor, who will explain this in more detail.

Electromagnet interference will not damage your pacemaker but may temporarily interfere with its settings. Most devices you use in your normal daily activities will not affect your pacemaker as long as they are in good working order. Devices that can interfere with pacemakers include magnets (stereo speakers), magnetic resonance scanners, TENS stimulators and some heavy machinery. Mobile phones should be held at least 6 inches from the pacemaker, ideally on the opposite side, and you should walk through doorway security systems rather than dwell in the area. Show your pacemaker ID card at the airport and ask for a hand search.

Your pacemaker will be checked regularly, either in a pacemaker clinic or remotely. During each pacemaker check, the physiologist will examine your device's settings and battery life and change the parameters as appropriate. The wound will also be checked, and there will be an opportunity to ask any questions regarding the pacemaker. The pacemaker battery lasts up to 10 years and will not be completely run down. You will be admitted in due course for a box change which is a similar procedure to a pacemaker implant but normally without any intervention to the leads that remain in place.