Definition & Overview

The insertion of a new or replacement pacemaker is a minimally invasive procedure performed under local anaesthesia. It can be performed using the transvenous technique where the electrode is inserted through one of the veins of the heart.

A pacemaker is an important and life-saving device that is placed either in the chest or abdomen to correct abnormal heart rhythms. It uses an electrode that makes use of electrical impulses to stimulate the heart to beat at a normal rate.

Pacemakers are used to treat arrhythmias. An arrhythmia is a heart disorder characterised by either too slow (bradycardia) or too fast (tachycardia) heartbeats. These are caused by the heart’s poor electrical conduction system. An electrode is useful in such cases as it is designed to reestablish the heart’s normal rhythm.

The device has a pulse generator that holds the battery and a tiny chip (tiny computer). This stores the programme that “teaches” the heart to beat normally. It also has leads or wires that send generated impulses to the heart muscle to make it contract. They also record the electrical activity of the heart.

A pacemaker’s battery life can last for years. When the battery wears out, the device is taken out and replaced.

The installation of a permanent pacemaker (either new or replacement) is done in an operating room or cardiac catheterisation lab.

Who Should Undergo and Expected Results?

The insertion of a permanent pacemaker is indicated for patients diagnosed with arrhythmias. The procedure to replace the pacemaker, on the other hand, is indicated if the installed pacemaker is not functioning properly or when its battery has worn out.

The replacement or installation of a new pacemaker allows for an improved quality of life of patients suffering from unstable heartbeats. By normalising the heart rhythm, pacemakers can treat symptoms including fainting, lightheadedness, and fatigue. This device corrects irregularities the moment they happen by sending electric impulses to the heart muscle. This continues as long as the pacemaker detects a pacing problem. Most pacemakers in use today are designed to automatically adjust the heart rate based on the patient’s level of physical activity. As such, they can allow patients to resume a more active lifestyle.

How is the Procedure Performed?

Before the procedure is performed, the patient is administered with antibiotics via IV to reduce the risk of postoperative infections. The area where the pacemaker is inserted is then cleaned and injected with local anaesthetic. The anaesthesia numbs the area and prevents patients from feeling pain during the procedure.

The incision is then made in the collarbone, which allows doctors to avoid most of the vital organs near the heart and provides an easy access to the heart muscle.

The surgeon then inserts the pacemaker leads into the large subclavian vein in the shoulder. The three leads are put together and guided toward the target heart muscle into the right atrium.

The pacing generator is placed right below the skin beneath the collarbone. On some occasions, pacemaker leads are placed or inserted through a surgical incision in the chest wall using an invasive procedure called thoracotomy. With this technique, the pacing generator is placed right in the abdominal area.

As soon as the pacing generator is in place, the threaded leads are connected to the battery. When this is done, the surgeon sews up the wound.

A fluoroscopic examination is also carried out to properly guide the leads to the target area and avoid puncturing or injuring nearby organs.

Surgeons use either a single-chamber or dual-chamber pacer depending on the severity of the arrhythmia.

Possible Risks and Complications

The installation of a pacemaker is almost always a safe procedure. Generally, patients only develop a mild reaction to local anaesthetics.

Others experience skin burns due to the prolonged use of fluoroscopes, which happens when surgeons took time in installing the leads into the right place.

Other risks and possible complications include the following:

  • Bleeding
  • Haematoma, or the swelling of clotted blood within nearby tissues
  • Phlebitis, or the inflammation of the walls of the veins
  • Local infection
  • Puncture or injury to heart arteries
  • Haemothorax, or the presence of blood in the pleural cavity
  • Pneumothorax, or the presence of air or gas in the space between the chest wall and the lungs
  • Catheter-related thrombosis
  • Pulmonary embolism
  • Air embolism
  • Puncture or damage to the atrial wall, which may lead to pericardial tamponade or pressure around the heart due to the presence of excess fluid in the pericardial cavity
  • Lost guide wire
  • Anaphylaxis, or the acute reaction to some tools and drugs used during the procedure including the medicines inserted through IV
  • Chylothorax, a type of pleural effusion (presence of excess amount of fluid in the pleural cavity)

    References:

  • Zhan C, Baine WB, Sedrakyan A, Steiner C. Cardiac device implantation in the United States from 1997 through 2004: a population-based analysis. J Gen Intern Med. 2008 Jan. 23 Suppl 1:13-9.

  • Bernstein AD, Daubert JC, Fletcher RD, et al. The revised NASPE/BPEG generic code for antibradycardia, adaptive-rate, and multisite pacing. North American Society of Pacing and Electrophysiology/British Pacing and Electrophysiology Group. Pacing Clin Electrophysiol. 2002. 25:260.

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