• Reference Number: HEY-452/2020
• Departments: Cardiology
• Last Updated: 24 July 2020

Introduction

This leaflet has been produced to give you general information. Most of your questions should be answered by this leaflet. It is not intended to replace the discussion between you and the healthcare team, but may act as a starting point for discussion. If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team.

What is a pacemaker?

A pacemaker is a small battery powered device, which paces your heart by sending an electrical impulse, telling your heart when to pump. Each normal heartbeat begins in the natural pacemaker of your heart (the sino-atrial or SA node). If this is not working properly or there is a problem with the message getting through your heart, this can cause your heart to beat too slowly, too quickly or irregularly. An artificial pacemaker can treat some abnormal heart rhythms.

Most pacemakers are programmed to work just when they are needed (on demand) and some send impulses all of the time (fixed rate). You cannot feel the electrical impulses that the pacemaker delivers. The pacemaker is fitted just below your collar bone and is usually very comfortable. Simple pacemaker boxes are approximately 0.5cm (0.2 inches) in thickness and weigh around 20 – 50 grams depending on the type used.

A pacemaker system consists of a pulse generator (also called the pacemaker box or battery) and one or more electrode leads. Pacemakers with one lead are called single chamber pacemakers. Pacemakers with two leads are called dual chamber pacemakers and pacemakers with three leads are called biventricular pacemakers (also sometimes referred to as CRT devices). The type of pacemaker you have implanted depends upon the reason you need to have one fitted. The medical team will discuss with you which is the most suitable type of pacemaker for your condition.

Why do I need a pacemaker?

You may need to have a pacemaker if:

• your heart’s natural pacemaker isn’t working properly
• the natural electrical activity of your heart is slower than it should be
• you are having fainting or dizzy episodes caused by a very slow heartbeat
• the lower parts of your heart (the ventricles) are beating out of time with one another
• you have Atrial Fibrillation (AF) and have trouble controlling your heart rate with medication so need an AV node ablation

Can there be any complications or risks?

The risks from having a pacemaker implanted are small. Bruising around the operation area (pacemaker insertion site) is common, but please be assured that this usually resolves within a week or so and is nothing to be concerned about.  Rarely, infection around the pacemaker can occur; the intravenous antibiotics given prior to the procedure aim to prevent this complication. It is possible for the lining of the lung to be punctured during the procedure, which can result in the lung collapsing (pneumothorax).  This occurs in only approximately 1 in 100 cases and may be treated by inserting a tube into the chest (chest drain) to allow the lung to re-inflate.  This does not leave any long term damage or ongoing problems. Other potential rare complications will be discussed during your pre assessment appointment.

How do I prepare for the pacemaker implant?

Please read the information leaflet.  Share the information it contains with your partner and family (if you wish) so that they can be of help and support.  There may be information they need to know, especially if they are taking care of you following this examination.

Pre-admission

You will be required to attend the pre-assessment clinic usually between one and four weeks before your procedure date.  At this appointment you will see a nurse practitioner who will take a full medical history, perform a physical examination and explain the procedure and address any questions/concerns you may have before asking you to sign your consent form.

Then you will see a nurse who will perform a baseline nursing assessment. This consists of various questions, such as information about your next of kin, how you usually manage at home, any mobility problems or other issues that we may need to be aware of in order to make your admission as safe and comfortable as possible.

You will then see a clinical support worker who will take some blood samples and swabs for MRSA (a type of bacteria responsible for infection) screening.

Before you leave the hospital an electrocardiograph (ECG) will be performed.

Fasting

You may eat a light meal before admission and drink, up to the procedure.

Medication

Some medications may have to be stopped before the procedure. The nurse at your pre-admission appointment will tell you if this is necessary for you. It is very important that you bring all of your current medications or a current prescription with you to any appointment.

What to bring into hospital with you

• It is advisable to bring slippers or something similar to allow you to walk around the ward safely and a dressing gown.
• An overnight bag with nightwear & toiletries.
• Spectacles if worn.
• All medication in its original packaging.
• Something to pass the time while you wait for / after the procedure (books, knitting, music to listen to etc)

What will happen?

You should report to the second reception in Cardiology Outpatient Building at the time stated on your admission letter. Once the receptionist has checked you in will be shown to a bed on the day ward and asked to change into a theatre gown and disposable pants.

The nurse who is looking after you for the shift will then check that none of the information you were asked at pre-assessment has changed and your blood pressure, temperature and blood oxygen level will be recorded.

You will have a cannula (a small plastic tube) inserted into your hand or arm and a safety check list will be completed. The cannula allows the staff to administer drugs directly into your blood stream and the checklist is to ensure that you are safely transferred into the Cardiac Catheterisation Laboratory (Cath Lab). You will be given intravenous antibiotics through the cannula before the procedure to reduce the risk of infection. A small area around the collar bone will be shaved if necessary.

The nurses on the ward will not be able to give you an exact time for your procedure until the doctor has seen all of their patients and decided upon the order of the list. Sometimes this means that you may have to wait until the afternoon before your procedure will take place so it is advisable to bring something to pass the time whilst you wait.

When it is time for your procedure a nurse from the Cath Lab will come to the ward to collect you. They will go through the safety checklist again before accompanying you into the Cath Lab.

What will happen during the procedure?

The procedure is performed in the Cath Lab under a local anaesthetic. You will be awake for the procedure, but the insertion site will be numb. Once inside you will be helped onto the X-ray table and asked to lie flat on your back with one pillow for your head.

The upper part of your body and your head will be covered with sterile theatre towels and the skin around the neck and shoulder area will be cleaned with a cold antiseptic solution. The area where the pacemaker box is to be fitted will be injected with a local anaesthetic to numb the area so the procedure will not be painful.

A small pocket is made under the skin to make room for the pacemaker box.

Using the vein lying under the collar bone to gain access to the heart, one or more electrodes (leads) are carefully directed to the correct position(s) in the heart chamber(s).  X-rays are used to guide the procedure. The lead (or leads) is then connected to the pacemaker box. The pacemaker box is fitted into the pocket made earlier. The skin is then closed, usually with dissolvable stitches or glue. The procedure may take up to one hour, although it can take considerably longer for a CRT pacemaker for heart failure to be implanted. 

Cardiac radiology

As mentioned earlier your doctor needs to use X-rays to help with your procedure.

There are many benefits associated with the use of x-rays, such as your doctor being able to see what their eyes cannot. X-rays involved with cardiac and interventional procedures lets your doctor see moving pictures of your heart, veins and lots of other organs, so that they can safely insert dyes, stents and other medicines. This is much safer than using invasive techniques such as surgery.

X-rays are exceedingly safe, there is a degree of risk involved – you will receive a small dose of radiation which carries a low (less than one in one thousand) chance of side effects. Your doctor will never take an X-ray unless the benefit to you exceeds the risk. This dose of radiation will be equivalent to what you receive in about four years from natural background radiation that is present in the surrounding environment. 

What will happen afterwards?

When the procedure is over, you will return to the ward area for a period of rest.

You will be placed on a heart monitor to check your heart rhythm for a few hours after you have had the pacemaker put in. Your nurse will also take your blood pressure every so often and keep checking your wound to make sure it is not bleeding and there is no unusual swelling.

Most people are well enough to go home the day of the procedure. If you live alone it is a good idea to try and arrange for someone to stay with you overnight but this will be discussed with you in more detail at pre-assessment. Rarely it may be necessary for you to stay overnight and be discharged early the next morning.

Before discharge the pacemaker will be tested and a chest X-ray may be performed. In some cases, if you live locally and are discharged after 6.00pm you may be asked to return to the ward for a pacemaker check the morning after your procedure. 

Advice

You should not drive yourself home following the procedure. It is recommended that you do not drive for at least one week after pacemaker implantation. Specific instructions are available on the DVLA website.

Avoid heavy lifting, raising your arm above shoulder height and physical activities especially golf and swimming for 4 – 6 weeks. You may return to work when your doctor feels you are fit to do so, this is normally after 4 – 6 weeks.

Any changes to your medication will be discussed with you prior to leaving hospital.

It is important you tell other doctors and your dentist that you have a pacemaker.

You do not need antibiotics for any dental or surgical procedure unless you have another problem with a heart valve. If in doubt ask your doctor.

You will be given further advice about returning to your usual activities when you are discharged.

Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the Pacing Department (01482) 461535 or 461536 or the Nurse Practitioners (01482) 461647

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

• you must be able to give your consent
• you must be given enough information to enable you to make a decision
• you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.