Pacemakers

Your doctor has recommended that you receive a pacemaker for a heart rhythm disturbance. Pacemakers have been successfully implanted since the early 1950's, and millions of people have benefitted from their use. Advancements in technology have improved pacemaker electronic circuitry, decreased their size and weight, and extended the length of battery life. Pacemakers no longer need to be implanted in the operating room; the procedure may be performed in the electrophysiology (EP) lab under local anesthesia.

There have also been advances made in the different functions which pacemakers provide. Certain pacemakers can pace both the top and bottom chambers of the heart (atria and ventricles) in order to more closely simulate a normal heart beat. The development of rate-responsive pacemakers allows for a more active lifestyle by permitting greater exercise tolerance.

The heart, a muscle, has an electrical system which is responsible for causing it to contract and relax. Each heartbeat is initially stimulated by a network of cells called the SA node, located in the upper right chamber of the heart. This is the natural pacemaker of the heart. The impulse then travels through the A-V node, which separates the top and bottom chambers of the heart and acts as a gate-keeper. From here, the impulse travels to the bundle of His, where it divides and travels down the right and left bundle branches to stimulate the bottom chambers, or ventricles, to contract. This is responsible for the major pumping action of the heart, supplying blood to all the cells of the body. Any disturbance in one or more of these areas can impair the delivery of blood to the tissues of the body.

There are several situations that can occur in which your doctor would recommend a pacemaker. In one situation, the natural pacemaker cells or the SA node may send impulses out too slowly, resulting in a rhythm that is too slow. This is called "Sick Sinus Syndrome". Another situation may result from impulses being blocked at some point along the electrical pathway in the heart. This is called heart block, and can also result in a rhythm which is too slow. Other people have conduction problems called "carotid sinus hypersensitivity", which means your heart rate may drop when there is pressure on your neck. If any of these situations occurs, you may feel symptoms such as unusual tiredness, lightheadedness, or loss of consciousness. Other people have increased shortness of breath with activity.

Procedure
Prior to coming to the hospital for the procedure, you may need to have a chest x-ray, ECG, and some blood tests performed. If you are taking a blood thinner, you will be asked to stop taking it several days before the procedure. You will not be able to eat or drink anything after midnight the day before the procedure. You may take your routine medications with small sips of water the morning of the procedure, unless otherwise instructed by your doctor.

You will be asked to arrive at the hospital about two hours before the time the procedure is scheduled. This enables the nurses to prepare you to be sent to the EP lab. This preparation includes starting an intravenous line (IV), scrubbing your chest with antibacterial soap, giving you an antibiotic, having you sign the consent, and obtaining your past medical history. You will then be transported to the EP lab, where the nurses will prepare you for the procedure. You will receive a mild sedative through your IV to help you relax. Several pillows will be placed under your legs to help the blood return to your heart, which allows the doctor to easily visualize your venous system. The procedure table is cushioned so you will be more comfortable. Your arms will be secured at your side so that you don't accidently raise them up and contaminate the sterile field. You will need to wear a surgical cap; all members of the EP lab will be dressed in surgical attire. Your heart rhythm, blood pressure, and oxygen status will be monitored continuously during the procedure.

The nurses in the EP lab will then scrub the skin on your chest with special solution. A special antibacterial adhesive will be placed over the site where the incision is to be made. You will be sedated throughout the procedure. The doctor will place drapes over the surgical site, and numb the area with a local anesthetic. An incision is made, and the pacemaker lead is placed through a vein which leads directly to the heart. A small pocket is then made in the upper chest area, cleansed with a sterile solution, and the pacemaker generator is placed. The incision is then closed, and a pressure dressing is applied.

The nurses will place your arm in a sling. This will remind you not to raise your arm from your side, and enable the lead to implant in the heart. You will then be transported back to the nursing unit. Generally, you will have to stay in bed until the next day. You will receive some antibiotics through your IV to prevent any infection.

After the Procedure
The pacemaker leads will now be able to sense when your heart goes too slow, and stimulate your heart to beat appropriately. You will need to go for a chest x-ray after the pacemaker is implanted so that lead placement can be checked. Your pacemaker will be programmed by the nurse to meet your body's specific needs. You will usually be able to go home within one to two days after the procedure. Your doctor will need to see you in his office in one to two weeks to assess your incision, and arrange your follow-up in the pacemaker clinic. The doctor will be able to monitor your pacemaker function via telephone transmission. This procedure will be more specifically explained at your office visit.

Before discharge from the hospital you will be given specific instructions regarding showering, driving, returning to work, etc. You will receive a temporary identification card for your wallet.

Once you return home, you will be able to use common household appliances including:

• microwave ovens
• hair dryers
• washers, dryers
• vacuum cleaners
• toasters, blenders
• radios, stereos, televisions

You may ask your doctor about using any specific appliances or equipment not listed above.

Symptoms to Watch For

• redness, swelling, drainage from incision site, alone or with a fever
• dizziness or fainting spells
• prolonged hiccoughing
• prolonged fatigue or weakness
• increased shortness of breath, or swelling of arms, wrists, legs or ankles

If you have any questions or concerns, do not hesitate to discuss these with your doctor.