How are Pacemakers Implanted?
Pacemaker insertion is often performed under local anaesthesia. Depending on whether the individual is right handed or left-handed, the device is often placed in a pocket on the non-dominant side. What this means is that if an individual is right-handed, the pacemaker will be inserted on the left-hand side and vice versa.
Pacemaker insertion is performed with the individual awake and under local anaesthesia. If required, patients may request a small amount of sedation if they feel nervous.
The site where an incision is to be made is cleaned with antiseptic solution and the patient is covered in sterile drapes. local anaesthetic is injected into the skin and subcutaneous tissues.
A small incision of about 1 to 1.5 inches is made just under the collar bone near the shoulder joint. A pocket is created by separating out the tissues and a vein called the subclavian vein is located using a needle that is attached to a syringe filled with saltwater (normal saline).
Once this vein is located, a wire is passed into the vein and along this the required number of pacemaker leads are passed.
The procedure is performed under x-ray guidance so the doctor can visualise the heart and the leads at all times.
Once the cardiologist is satisfied that the leads are in place, the leads are sutured to the nearby tissues and the ends of the leads are attached to the pulse generator box. This box is then placed in a small pocket underneath the skin and tissues which are sutured close.
After the Procedure
Pacemaker implantation is performed as a day case procedure. Patients are admitted on the day of the procedure and are discharged the following day.
A chest x-ray may be performed the day after the procedure to confirm the position of the leads and to ensure that the pacemaker has not moved overnight.
Prior to discharge, a pacemaker check is conducted to check the battery, the position of the leads and the amount of electricity being passed through the leads. These pacemaker checks are performed from time to time for a number of years.
For a few days after insertion of the pacemaker, patients are advised not to lift anything heavy and to avoid strenuous exercise. The wound needs to heal adequately and a follow-up appointment may be arranged to ensure this has happened.
A small amount of bleeding or bruising at the site is common. Patients may experience some pain and this can be easily treated with painkillers.
Risks of Pacemaker Implantation
As mentioned above, some individuals may notice a small amount of bleeding and bruising at the site of the pacemaker implant. This often passes after a few days.
Any pain can be easily treated with over-the-counter medication such as Paracetamol (Dolo, Crocin) or Non-Steroidal Anti-Inflammatory Drugs ( Ibuprofen).
Rarely, an infection may occur at the site of the surgical incision. If this happens, it is essential that the patient to see the doctor for a complete assessment.
Minor infections can be treated with antibiotics where as deeper infections that have extended into the pocket may require surgical drainage.
Another rare complication that may occur during pacemaker insertion is accidental puncture of the lung.
As a needle is inserted into this subclavian vein (that lies under the collar bone and close to the lung), it is sometimes possible for the tip of the needle to damage the lining of the lung.
When this happens, a small amount of air may enter the space around the lung resulting in a condition called a pneumothorax. This pneumothorax can be easily detected on a chest x-ray.
If the pneumothorax is small, no treatment is required and the air gets absorbed by itself. However, if the pneumothorax is large, patients may require the insertion of a chest drain to remove the air through a tube.
Finally, another rare complication that may occur is puncture of the heart muscle during placement of the pacemaker leads. This usually requires emergency management.
It is uncommon for any of these complications to be life-threatening.