Insertion of Pacemakers (PCM) or Implantable Cardioverter Defibrillators (ICD)
What is a pacemaker insertion?
A pacemaker insertion is the implantation of a small electronic device
in the chest (just below the collarbone) to help regulate electrical
problems with the heart. When a problem develops, such as a slow heart
rate, a pacemaker may be recommended to ensure that the heartbeat does
not slow to a dangerously low rate.
The heart's electrical conduction system
heart is basically a pump made up of muscle tissue that is stimulated by
electrical currents, which normally follow a specific circuit within the
This normal electrical circuit begins in the sinus or sinoatrial (SA)
node, which is a small mass of specialized tissue located in the right
atrium (upper chamber) of the heart. The SA node generates an electrical
stimulus at 60 to 100 times per minute under normal conditions; this
electrical impulse from the SA node starts the heartbeat.
The electrical impulse travels from the SA node to the atrioventricular
(AV) node in the bottom of the right atrium. From there the impulse
continues down an electrical conduction pathway called the
"His-Purkinje" system into the ventricles (lower chambers) of the heart.
When the electrical stimulus occurs it causes the muscle to contract and
pump blood to the rest of the body. This process of electrical
stimulation followed by muscle contraction is what makes the heart beat.
A pacemaker may be needed when problems occur with the electrical
conduction system of the heart. When the timing of the electrical
stimulation of the heart to the heart muscle and the subsequent response
of the heart's pumping chambers is altered, a pacemaker may help.
What is a pacemaker?
pacemaker is a life-saving medical device composed of three parts: a
pulse generator, one or more leads, and an electrode on each lead. A
pacemaker signals the heart to beat when the heartbeat is too slow or
A pulse generator is a small metal case that contains electronic
circuitry and a battery and regulates the impulses sent to the heart.
The lead (or leads) is an insulated wire that is connected to the pulse
generator on one end, with the other end placed inside one of the
heart's chambers. The lead is almost always placed so that it runs
through a large vein in the chest leading directly to the heart. The
electrode on the end of a lead touches the heart wall. The lead delivers
the electrical impulses to the heart. It also senses the heart's
electrical activity and relays this information back to the pulse
generator. Pacemaker leads may be positioned in the atrium (upper
chamber) or ventricle (lower chamber) or both, depending on the medical
If the heart's rate is slower than the programmed limit, an electrical
impulse is sent through the lead to the electrode and causes the heart
to beat at a faster rate.
When the heart beats at a rate faster than the programmed limit, the
pacemaker generally monitors the heart rate and will not pace. Modern
pacemakers are programmed to work on demand only, so they do not compete
with natural heartbeats. Generally, no electrical impulses will be sent
to the heart unless the heart's natural rate falls below the pacemaker's
A newer type of pacemaker, called a biventricular pacemaker, is
currently used in the treatment of congestive heart failure. Sometimes
in heart failure, the two ventricles do not pump in a normal manner.
When this happens, less blood is pumped by the heart. A biventricular
pacemaker paces both ventricles at the same time, increasing the amount
of blood pumped by the heart. This type of treatment is called cardiac
resynchronization therapy or CRT.
After a pacemaker insertion, regularly scheduled appointments will be
made to ensure the pacemaker is functioning properly. The physician uses
a special computer, called a programmer, to review the pacemaker's
activity and adjust the settings when needed.
Other related procedures that may be used to assess the heart include
resting and exercise electrocardiogram (ECG), Holter monitor,
signal-averaged ECG, cardiac catheterization, chest x-ray, computed
tomography (CT scan) of the chest, echocardiography, electrophysiology
studies, magnetic resonance imaging (MRI) of the heart, myocardial
perfusion scans, radionuclide angiography, and ultrafast CT scan. Please
see these procedures for additional information. Note that although an
MRI is a very safe procedure, a person with a pacemaker generally should
not undergo MRI, as the magnetic fields used by the MRI scanner may
interfere with the pacemaker's function. Any patient with a pacemaker
should always speak with his or her cardiologist before undergoing an
Reasons for the Procedure
A pacemaker may be inserted in order to provide stimulation for a faster
heart rate when the heart is beating too slowly, and when other
treatment methods, such as medication, have not improved the heart rate.
Problems with the heart rhythm may cause difficulties because the heart
is unable to pump an adequate amount of blood to the body. If the heart
rate is too slow, the blood is pumped too slowly. If the heart rate is
too fast or too irregular, the heart chambers are unable to fill up with
enough blood to pump out with each beat. When the body does not receive
enough blood, symptoms such as fatigue, dizziness, fainting, and/or
chest pain may occur.
Some examples of heart rate and rhythm problems for which a pacemaker
might be inserted include:
bradycardia - occurs when the heart beats too slow
tachy-brady syndrome - alternating fast and slow heart beats
heart block - occurs when the electrical signal is delayed or
blocked after leaving the SA node; there are several types of
There may be other reasons for your physician to recommend a pacemaker
Risks of the Procedure
Possible risks of pacemaker include, but are not limited to, the
bleeding from the incision or catheter insertion site
damage to the vessel at the catheter insertion site
infection of the incision or catheter site
pneumothorax – air becomes trapped in the pleural space (outside
the lung but within the chest wall); this can cause breathing
difficulties and in extreme cases may cause the lung to collapse
If you are pregnant or suspect that you may be pregnant, you should
notify your physician. If you are breastfeeding, you should notify your
Patients who are allergic to or sensitive to medications or latex should
notify their physician.
For some patients, having to lie still on the procedure table for the
length of the procedure may cause some discomfort or pain.
There may be other risks depending upon your specific medical condition.
Be sure to discuss any concerns with your physician prior to the
Before the Procedure
Your physician will explain the procedure to you and offer you
the opportunity to ask any questions that you might have about
You will be asked to sign a consent form that gives your
permission to do the test. Read the form carefully and ask
questions if something is not clear.
Notify your physician if you are sensitive to or are allergic to
any medications, iodine, latex, tape, or anesthetic agents
(local and general).
You will need to fast for a certain period of time prior to the
procedure. Your physician will notify you how long to fast,
If you are pregnant or suspect that you are pregnant, you should
notify your physician.
Notify your physician of all medications (prescription and
over-the-counter) and herbal or other supplements that you are
Notify your physician if you have heart valve disease, as you
may need to receive an antibiotic prior to the procedure.
Notify your physician if you have a history of bleeding
disorders or if you are taking any anticoagulant
(blood-thinning) medications, aspirin, or other medications that
affect blood clotting. It may be necessary for you to stop some
of these medications prior to the procedure.
Your physician may request a blood test prior to the procedure
to determine how long it takes your blood to clot. Other blood
tests may be done as well.
You may receive a sedative prior to the procedure to help you
relax. If a sedative is given, you will need someone to drive
you home afterwards.
The upper chest may be shaved or clipped prior to the procedure.
Based upon your medical condition, your physician may request
other specific preparation.
During the Procedure
A pacemaker may be performed on an outpatient basis or as part of your
stay in a hospital. Procedures may vary depending on your condition and
your physician's practices.
Generally, a pacemaker insertion follows this process:
You will be asked to remove any jewelry or other objects that
may interfere with the procedure.
You will be asked to remove your clothing and will be given a
gown to wear.
You will be asked to empty your bladder prior to the procedure.
An intravenous (IV) line will be started in your hand or arm
prior to the procedure for injection of medication and to
administer IV fluids, if needed.
You will be placed on your back on the procedure table.
You will be connected to an electrocardiogram (ECG or EKG)
monitor that records the electrical activity of the heart and
monitors the heart during the procedure using small, adhesive
electrodes. Your vital signs (heart rate, blood pressure,
breathing rate, and oxygenation level) will be monitored during
Large electrode pads will be placed on the front and back of the
You will receive a sedative medication in your IV before the
procedure to help you relax. However, you will likely remain
awake during the procedure.
The pacemaker insertion site will be cleansed with antiseptic
Sterile towels and a sheet will be placed around this area.
A local anesthetic will be injected into the skin at the
Once the anesthetic has taken effect, the physician will make a
small incision at the insertion site.
A sheath, or introducer, is inserted into a blood vessel,
usually under the collarbone. The sheath is a plastic tube
through which the pacer lead wire will be inserted into the
blood vessel and advanced into the heart.
It will be very important for you to remain still during the
procedure so that the catheter does not move out of place and to
prevent damage to the insertion site.
The lead wire will be inserted through the introducer into the
blood vessel. The physician will advance the lead wire through
the blood vessel into the heart.
Once the lead wire is inside the heart, it will be tested to
verify proper location and that it works. There may be one, two,
or three lead wires inserted, depending on the type of device
your physician has chosen for your condition. Fluoroscopy, (a
special type of x-ray that will be displayed on a TV monitor),
may be used to assist in testing the location of the leads.
The pacemaker generator will be slipped under the skin through
the incision (just below the collarbone) after the lead wire is
attached to the generator. Generally, the generator will be
placed on the non-dominant side. (If you are right-handed, the
device will be placed in your upper left chest. If you are
left-handed, the device will be placed in your upper right
The ECG will be observed to ensure that the pacer is working
The skin incision will be closed with sutures, adhesive strips,
or a special glue.
A sterile bandage/dressing will be applied.
After the Procedure
In the hospital
After the procedure, you may be taken to the recovery room for
observation or returned to your hospital room. A nurse will monitor your
You should immediately inform your nurse if you feel any chest pain or
tightness, or any other pain at the incision site.
After the period of bed rest has been completed, you may get out of bed.
The nurse will assist you the first time you get up, and will check your
blood pressure while you are lying in bed, sitting, and standing. You
should move slowly when getting up from the bed to avoid any dizziness
from the period of bed rest.
You will be able to eat or drink once you are completely awake.
The insertion site may be sore or painful, but pain medication may be
administered if needed.
Your physician will visit with you in your room while you are
recovering. The physician will give you specific instructions and answer
any questions you may have.
Once your blood pressure, pulse, and breathing are stable and you are
alert, you will be taken to your hospital room or discharged home.
If the procedure is performed on an outpatient basis, you may be allowed
to leave after you have completed the recovery process. However, if
there are concerns or problems you may stay in the hospital for an
additional day or longer.
You should arrange to have someone drive you home from the hospital
following your procedure.
You should be able to return to your daily routine within a few days.
Your physician will tell you if you will need to take more time in
returning to your normal activities. In addition, you should not do any
lifting or pulling on anything for a few weeks. You may be instructed to
limit movement of the arm on the side that the pacemaker was placed,
based on your physician's preferences.
You will most likely be able to resume your usual diet, unless your
physician instructs you differently.
It will be important to keep the insertion site clean and dry. You will
be given instructions about bathing and showering.
Your physician will give you specific instructions about driving.
Ask your physician when you will be able to return to work. The nature
of your occupation, your overall health status, and your progress will
determine how soon you may return to work.
Notify your physician to report any of the following:
fever and/or chills
increased pain, redness, swelling, or bleeding or other drainage
from the insertion site
Your physician may give you additional or alternate instructions after
the procedure, depending on your particular situation.
The following precautions should always be considered. Discuss the
following in detail with your physician, or call the company that made
Always carry an ID card that states you have a pacemaker. In
addition, you may want to wear a medical identification bracelet
indicating that you have a pacemaker.
Let screeners know you have a pacemaker before going through
airport security detectors. In general airport detectors are
safe for pacemakers, but the small amount of metal in the
pacemaker and leads may set off the alarm. If you are selected
for additional screening by hand-held detector devices, politely
remind the screeners that the detector wand should not be held
over your pacemaker for longer than a few seconds, as these
devices contain magnets and thus may affect the function or
programming of your pacemaker.
You may not have a magnetic resonance imaging (MRI) procedure.
You should also avoid large magnetic fields such as power
generation sites and industrial sites such as automobile
junkyards that use large magnets.
Abstain from diathermy (the use of heat in physical therapy to
Turn off large motors, such as cars or boats, when working on
them (They may create a magnetic field).
Avoid high-voltage or radar machinery, such as radio or
television transmitters, electric arc welders, high-tension
wires, radar installations, or smelting furnaces.
If you are having a surgical procedure performed, inform your
surgeon that you have a pacemaker well before the operation.
Also ask your cardiologist's advice on whether anything special
should be done prior to and during the surgery, as the
electrocautery device that controls bleeding may interfere with
the pacemaker. Sometimes the pacemaker's programming will be
temporarily changed (using a magnet) during the surgery to
minimize the possibility of interference from the
You may have to take antibiotic medication before any medically
invasive procedure to prevent infections that may affect the
When involved in a physical, recreational, or sporting activity,
you protect yourself from trauma to the pacemaker. A blow to the
chest near the pacemaker can affect its functioning. If you are
hit in that area, you may want to see your physician.
Cell phones in the US with less than 3 watts of output do not
seem to affect pacemakers or the pulse generator, but as a
precaution, cell phones should be kept at least 6 inches away
from your pacemaker. Avoid carrying a cell phone in your breast
pocket over your pacemaker.
Always consult your physician when you feel ill after an
activity, or when you have questions about beginning a new
Always consult your physician if you have any questions
concerning the use of certain equipment near your pacemaker.
The content provided here is for informational purposes only, and was
not designed to diagnose or treat a health problem or disease, or
replace the professional medical advice you receive from your physician.
Please consult your physician with any questions or concerns you may
have regarding your condition.
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procedure and related health conditions. We hope you find these sites
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