A pacemaker may be indicated in the following situations:
- People with temporary, intermittent, or persistent conditions that interfere with their heart’s ability to initiate or properly distribute electrical signals,
- People with congenital, as well as acquired, heart problems such as arrhythmias that result in bradycardia (an excessively slow heartbeat).
- People receiving drug therapy for other heart conditions, such as beta-blockers, to prevent related bradycardia, and
- People with recurrent syncope (fainting).
The patient needs little preparation other than to communicate how he or she is feeling on the day of the operation and inform the physician about all medications taken within the past month. In most cases, patients are advised to avoid eating 12 hours prior to the surgery.
Patients likely to receive a pacemaker are those who have a high risk of developing an atrioventricular (AV) conduction problem, a partial or complete interruption of the electrical impulse from the atria to the ventricles. Patients include those who have:
- Permanent or intermittent AV block,
- Exercise-induced AV block,
- Sinus node dysfunction,
- A history of atrial fibrillation, atrial flutter, tachycardia (very rapid heartbeat) associated with AV dysfunction, or bradycardia associated with congestive heart failure,
- A history of asystole (lack of heartbeat) with fainting, or
- Recurrent fainting.
Because pacemaker implantation usually is a relatively straightforward, minimally invasive procedure, there are very few heart patients for whom receiving a pacemaker would be inappropriate.
Insertion of a temporary pacemaker, an external device, is usually done while the patient is in the hospital for a related heart condition. This procedure can take place at the patient’s bedside. First, the physician administers a sedative and a local anesthetic to prevent pain at the insertion site, which is cleaned and shaved to prevent infection. Next a catheter is inserted, usually into a vein in the neck or groin area, and guided to the heart. The catheter used for this purpose has metal tips that can deliver electrical signals to pace the heartbeat.
A permanent pacemaker insertion is considered minor surgery, and can be done on an inpatient or an outpatient basis in a hospital setting. The patient is given a local anesthetic, and the insertion site is cleaned and shaved. In most cases, the pacemaker is inserted beneath the skin on the front of the chest under the clavicle (collarbone). The physician will incise the chest wall just below the clavicle to create a small pocket, into which the pacemaker is placed. Wires attached to the pacemaker (pacemaker leads) are then passed through a vein in the upper chest and directed to the right atrium or right ventricle. The leads, which are used to stimulate the contractions of the heart, are then attached to the inner surface of the heart chamber using small screws or tines. Following insertion, the skin is closed with sutures or staples.
A hospital stay of one to two days may be required for the physician to confirm that the patient’s condition is stable and the pacemaker in functioning. All patients will be advised not to twist or otherwise manipulate the pacemaker or interfere with the healing of the incision site.
The physician may also perform one or more tests to make sure the pacemaker and leads are in the proper location and working correctly. Tests may include an X ray, electrocardiogram (records heart’s electrical activity), and echocardiogram (sound waves create a moving picture of the heart).
