Pacemaker Implantation Surgery: Everything You Need to Know

A pacemaker is a device that is surgically implanted under the skin of the chest to mimic the electrical pulses that regulate heartbeats. Pacemaker surgery may be an outpatient procedure or an inpatient procedure based on your health and the cause of the rhythm disorder.

A pacemaker is used for long-term correction of a too-slow heartbeat (arrhythmia) or temporarily, such as after open-heart surgery. Implanting a pacemaker is considered a minimally invasive procedure.

This article discusses pacemaker implantation surgery, its purpose, and some of the risks and contraindications. It also goes over what to expect before, during, and after the procedure.

What Is Pacemaker Surgery?

Pacemaker surgery is done to implant a pacemaker device.

A pacemaker is comprised of a pulse generator that houses a battery and circuitry, as well as one to three small electrical leads that are placed in the chambers of the heart. Each electrical pulse emitted by the pacemaker stimulates a heartbeat and is timed to ensure a normal heart rhythm.

Pacemaker surgery is used to treat a wide range of heart rhythm disorders. While typically performed in adults with heart disease, it is also used in children with congenital heart conditions.

Most pacemakers are implanted using local anesthesia, although you may also receive intravenous (IV) sedation to help you relax.

Types

There are different types of pacemakers used to treat different types of arrhythmia. They are broadly categorized as follows:

• Single-chamber pacemakers deliver the electrical impulse to a single chamber of the heart. They are most often used to pace the right ventricle in people with chronic atrial fibrillation and require pacing to maintain an adequate heart rate.
• Dual-chamber pacemakers are used when the timing of the chamber contractions is misaligned. The device corrects this by delivering synchronized pulses to the right atrium and right ventricle (lower chamber).
• Biventricular pacemakers, also called cardiac resynchronization therapy, are for people with heart failure. They work to ensure synchronous contraction of the right and left ventricles causing them to pump together and improve cardiac function.

There are also combination devices called automated implantable cardioverter-defibrillators (AICDs) that contain both a pacemaker and a defibrillator. In addition to regulating heart rhythm, AICDs deliver a jolt of electricity when needed to correct ventricular tachycardia or ventricular fibrillation (irregular heartbeats).

Contraindications

Pacemaker surgery is a common and effective procedure but one that may not be appropriate for everyone. The decision to implant the device is made on a case-by-case basis based on a review of the benefits and risks of treatment.

Pacemakers are generally contraindicated if a heart rhythm disorder is identified during a cardiac evaluation but is not causing symptoms.

People with sleep apnea may experience bradycardia during sleep; because this can often be successfully resolved by treating the underlying condition, a pacemaker is not usually considered beneficial.

Potential Risks

In addition to the general risks of surgery and anesthesia, pacemaker surgery presents its own risks and concerns. Although the surgery is considered to be low risk, around 3% of pacemaker recipients will experience some form of complication ranging from mild and treatable to potentially life-threatening.

Risks and complications of pacemaker implantation surgery include:

• Electrode lead dislodgment
• Phlebitis (venous inflammation)
• Hemothorax (accumulation of blood between the chest wall and lungs)
• Pneumothorax (collapsed lung)
• Post-operative infection
• Cardiac perforation and tamponade
• A severe thromboembolic event in which the formation of a blood clot can lead to stroke, heart attack, pulmonary embolism, or deep vein thrombosis (DVT)

According to a 2019 study in the Journal of Clinical Medicine, pneumothorax and lead dislodgment were the two most common complications, occurring at a rate of 3.87% and 8.39%, respectively.

Severe complications, like stroke, occur in less than 2% of cases and usually in people with pre-existing risk factors.

Purpose of Pacemaker Surgery

Having a pacemaker implanted often helps you feel better so you can return to your daily routine without symptoms like dizziness, palpitations, breathlessness, difficulty exercising, and fainting.

Pacemaker implantation can improve your quality of life, though it is important to maintain communication with your healthcare team after implantation and follow up with your provider as required.

In addition, your life expectancy may improve. Research has found that life expectancy in people with pacemakers who do not have significant underlying medical conditions (e.g., heart failure, atrial fibrillation, or other serious non-cardiac conditions) approaches that of the general population. 

The indications for a pacemaker have increased in recent decades. According to the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Rhythm Society (HRS), pacemakers are appropriate for the following conditions and medical needs:

• Sinus node dysfunction: Abnormally fast or slow heartbeats emanating from the atria of the heart
• Acquired atrioventricular block: Abnormal heart rhythms when the electricity generated in the atrium is not able to conduct down to the ventricles.
• Chronic bifascicular block: Heart rhythm problems caused by a block in the fascicles, which are located in the lower chambers of the heart.
• Tachycardias: Both atrial and ventricular
• Heart rhythm problems caused by myocardial infarction (heart attack)
• Heart rhythm problems caused by congenital heart disease
• Heart rhythm problems caused by hypertrophic cardiomyopathy (the abnormal thickening of a portion of the heart)
• Vasovagal syncope: Fainting caused by a neurologic overreaction to certain triggers
• Cardiac resynchronization therapy in people with severe systolic heart failure
• Post-heart transplant measures to maintain normal heart rhythms

With that said, being diagnosed with any of these conditions does not mean you will get (or should get) a pacemaker.

To determine the need, a healthcare provider will perform tests to decide if the condition is Class I (in which the benefits outweigh the risks), Class IIa (benefits may outweigh the risks), Class IIb (benefits are equal to or greater than the risks), or Class III (risks may outweigh the benefits).

To classify the severity, pre-operative tests may be performed, including:

• Electrocardiogram: A non-invasive procedure used mainly to assess the structural and hemodynamic components of the heart.
• Holter monitoring: A portable type of ECG used to monitor heart rhythms over periods of time
• Echocardiogram: A non-invasive test that measures heart rate based on echoed sound waves
• Cardiac stress test: A procedure that measures heart rate while performing exercise on a treadmill or stationary cycle

How to Prepare

Pacemaker implantation is a common surgery but one that requires preparation. Once a pacemaker has been recommended, you will meet with a cardiologist or general surgeon to discuss the procedure, how to prepare, and what to expect.

Location

Pacemaker surgery takes place in an operating room or cardiac catheterization lab of a hospital or specialized surgical center.

The room will be equipped with an ECG machine, a mechanical ventilator, and a "crash cart" used in the event of a cardiac emergency. It will also have a fluoroscope—a machine that uses X-rays to produce live images of the heart to guide the placement of the pacemaker leads.

What to Wear

If the surgery is performed on an outpatient basis, you should wear clothes you can get into/out of easily. You will be asked to change into a hospital gown and to remove any hairpieces, eyewear, dentures, hearing aids, and tongue or lip piercings.

If the surgery requires an overnight hospital stay for observation purposes, bring only what you need for the stay, including toiletries, daily medications, a comfortable robe and slippers, your cell phone and charger, and an extra pair of socks and underwear. Leave any valuables at home.

Food and Drink

You will need to stop eating at midnight the night before your surgery. On the day of the surgery, you are allowed a few sips of water to take your morning pills, if applicable.

Within four hours of the operation, nothing should be taken by mouth, including water, chewing gum, or sweets. Most pacemaker surgeries are performed in the morning to accommodate the prolonged fasting period.

Medications

Medications that promote bleeding must be avoided before pacemaker surgery. Some may need to be stopped a day or so beforehand, while others may need to be avoided for a week or more before and after surgery. These include:

• Anticoagulants (blood thinners) like Coumadin (warfarin) 
• Antiplatelet medications, such as Plavix (clopidogrel)
• Nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin, Advil (ibuprofen), Aleve (naproxen), Celebrex (celecoxib), and Mobic (meloxicam)

What to Bring

You will need to bring a driver's license or some other form of government ID to register at hospital admissions. You will also be asked for your insurance card. Although most facilities will bill for their services, some may ask for the upfront payment of copay or coinsurance costs.

Call in advance to ensure that the facility accepts your insurance and that all providers, including the anesthesiologist, are in-network providers. If upfront payment is requested, ask what form of payment the office accepts.

You will also need to bring someone with you to drive you home. Even if only local anesthesia is used, your arm will be in a sling for 24 to 48 hours after the procedure. This, along with the aftereffects of IV sedation, makes driving hazardous.

What to Expect on the Day of Surgery

On the morning of the surgery, you will need to wash with an antiseptic wash provided by your healthcare provider. Avoid putting on any lotions, makeup, creams, nail polish, or fragrance.

You'll meet an anesthesiologist and an operating nurse who are part of the team accompanying the cardiologist or general surgeon performing the procedure.

Before the Surgery

When you arrive at the hospital, you will be asked to register, fill out a medical history form, and sign a consent form stating that you understand the aims and risks of the procedure.

After this, you are led to the back to change into a hospital gown. A nurse will record your height, weight, and vital signs, and perform a panel of blood tests to ensure there are no conditions that contraindicate surgery.

Other pre-operative procedures include:

• Chest shaving: If your chest is hairy, the implantation site will need to be shaved. Do not shave the area yourself.
• ECG monitoring: Adhesive electrodes are placed on various parts of your chest to connect to the ECG machine.
• Pulse oximetry: A device called a pulse oximeter is clamped onto a finger to monitor your blood oxygen levels.
• IV prep: The intravenous tube, called a catheter, is inserted into a vein in your arm or wrist to deliver medications and fluid.

During the Surgery

Once you are prepped, you are wheeled into the operating room and placed on a table in an upward-facing (supine) position under the fluoroscope.

Local anesthesia is given to numb the surgical site. A sedative may also be delivered through the IV line to help you relax and place you in a "twilight sleep" (referred to as monitored anesthesia care (MAC). To reduce the risk of infection, an intravenous antibiotic will also be delivered.

Once the anesthesia takes effect, the chest will be swabbed with an antibacterial solution and the body covered with sterile drapes.

An incision is then made on the chest near the shoulder (usually the left) to place the pacemaker. Using the fluoroscope, the healthcare provider will implant one or more leads into the appropriate chambers of the heart. The end of leads are secured.

Once the pacemaker is properly positioned under the skin, the device is tested. The incision is closed with sutures or adhesive strips, and a sling is placed on your arm to immobilize the arm and shoulder and prevent lead dislodgment.

After Surgery

After surgery, you are wheeled to the recovery room. Most people wake up from anesthesia with MAC in 10 minutes or so, although the effects of the drugs can persist for four to six hours. When you awaken, the nurse will monitor your condition and may offer you a light snack and drink.

It is not unusual to feel some pain and discomfort around the implantation site immediately after surgery. Your healthcare provider will provide medications to help control these symptoms at home. If you feel sick from the anesthesia, the nurse may be able to provide you with anti-nausea medications.

Once your vital signs are stable, you will either be wheeled to your hospital room for overnight observation or allowed to leave in the care of a friend or family member if you are an outpatient.

Recovery

As the local anesthesia begins to wear off, you are likely to feel more pain and pressure around the wound. This can be controlled with over-the-counter Tylenol (acetaminophen) or a short course of prescription opioid painkillers.

In addition to painkillers, your healthcare provider may prescribe a course of oral antibiotics (for less than 10 days) to help prevent infection.

Bruising in the area where the pacemaker was placed is normal and common. The device will create an area of raised skin on the chest that can be felt and/or seen; this will be permanent.

With proper care and wound management, most people who have undergone pacemaker surgery are able to return to normal activity within four weeks.

Healing

You will need to wear your arm sling for 24 to 48 hours as directed by your healthcare provider (including while you sleep).

It is important to keep the wound as dry as possible for the first five days until the wound is sufficiently healed. Avoid bathing or showering for the first day. Thereafter, take a bath instead of a shower or ask your practitioner for a disposable adhesive patch (called AquaGard) to create a watertight barrier when showering.

Your wound dressing should be changed daily for the first five to seven days using a sterile pad and alcohol-free topical antiseptic provided by your healthcare provider. Check the wound daily and call your practitioner if there are any signs of infection or abnormal healing.

After seven to 10 days, you will need to see your healthcare provider to have the stitches removed and the wound checked.

Physical Activity

Upon your return home, you should move as little as possible, in part to prevent lead dislodgment but also to reduce pain. Even after the stitches are out, you will need to avoid raising the arm nearest to the pacemaker for the next one to two weeks.

Do not drive until the healthcare provider gives you the OK, and avoid strenuous exercises or the lifting of heavy objects. You will be given the go-ahead to resume sex once your wound site heals (around one to two weeks).

Once you're cleared to get back to your normal routine, it is important to keep physically active to improve blood circulation and maintain the normal range of motion in the shoulder. Speak with your cardiologist about an appropriate exercise plan or ask for a referral to a qualified physical therapist.

High-impact sports should be permanently avoided as heavy blows can damage the device.

Follow-Up Care

Once you have healed, you may notice a dramatic improvement in your energy levels and stamina. The pacemaker helps your heart work efficiently, reducing fatigue and allowing you to be more active.

One of the keys to sustaining good health is routine visits with your cardiologist. Most healthcare providers will want to schedule the first follow-up within six months of the implantation and then every six to 12 months thereafter, depending on the type of pacemaker used.

This helps ensure that the pacemaker is working properly and that adjustments are made when needed to prolong the life of the device.

Your cardiologist may also ask you to check and write down your pulse at home. This is done to ensure your pacemaker is working well and keeping your heart rate within an appropriate range.

Be sure you are clear on when and how to get in touch with your practitioner after taking your pulse.

Lifestyle Adjustments

After your pacemaker is implanted, you will need to avoid magnetic fields, as they can interfere with the function of the device.

For example, refrain from placing small electronics, such as your cell phone, in your breast pocket and going through metal detectors.

You'll receive a medical ID card that provides details about your pacemaker including the type, manufacturer, date of implant, and the healthcare provider's name who implanted it. You should carry this with you at all times.

Alternatively, consider purchasing a custom medical ID bracelet that has the pacemaker information engraved on it.

This is helpful not only in emergency care situations in which you cannot convey your medical history, but also in situations that may expose you to magnetic fields, such as:

• When a magnetic resonance imaging (MRI) scan is recommended for any reason (alert your healthcare provider and radiologist)
• Security checks—You can show your card or bracelet to security staff at an airport so that they can check you using a manual search or a screening wand instead of a walk-through scanner.

Summary

Pacemaker implantation is a minimally invasive procedure to implant a pacemaker device, which can help treat a number of conditions that cause problems with heart rhythm. A pacemaker can help improve symptoms like palpitations, breathlessness, and trouble exercising.

The pacemaker is implanted during a procedure involving local anesthesia. You may also receive a sedative. The surgeon will make a small incision on your chest near your shoulder and implant one or more leads into your heart. Depending on your condition and overall health, you may be able to go home on the same day, or you may be kept in the hospital overnight for observation.