About

x-ray of pacemakerPacemakers and defibrillators are small devices implanted into the body to help regulate the heart through electrical signals. Cardiothoracic surgeons implant these devices keeping the heart beating in a normal rhythm. Wires, called leads, attached to the devices deliver the energy from these devices to the heart. When one or more of these leads needs to be removed, the procedure is called a lead extraction.

Specialists at University of Utah Health Care have over twenty years experience in these procedures. They constantly participate in research to bring the latest in cardiovascular treatments to their patients.

Pacemaker Insertion

What is a pacemaker?

A pacemaker is a small electronic device that helps regulate slow electrical problems in the heart. The pacemaker is usually implanted in the chest, just below the collarbone. Your doctor may recommend this device to keep your heartbeat from slowing down to a dangerously low rate.

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The heart is a pump made up of muscle tissue that is stimulated by electrical currents, which normally follow a specific circuit within the heart. These natural electrical impulses coordinate contractions of the different parts of the heart to keep blood flowing the way it should. A pacemaker may be needed when there are problems with the natural electrical conduction system of the heart.

A pacemaker is made of 3 parts: a pulse generator, 1 or more leads, and an electrode on each lead. A pacemaker signals the heart to beat when the natural heartbeat is too slow or irregular.

Why might I need a pacemaker?

Your doctor may recommend a pacemaker to stimulate a faster heart rate when your heart beats too slow and the problem can't be fixed with other treatments.

Problems with the heart rhythm may mean your heart is not pumping enough blood to the body. If your 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 get enough blood, symptoms such as tiredness, dizziness, fainting, or chest pain may occur.

Some examples of heart rate and rhythm problems for which a pacemaker might be inserted include:

  • Bradycardia. This is when the heart beats too slowly.
  • Tachy-brady syndrome. This is characterized by alternating fast and slow heartbeats.
  • Heart block. This occurs when the electrical signal is delayed or blocked as it travels through the heart muscle. There are several types of heart blocks.

There may be other reasons for your healthcare provider to recommend pacemaker insertion.

What are the risks of pacemaker insertion?

Possible risks of pacemaker insertion include:

  • Bleeding from the incision (cut) or catheter insertion site
  • Damage to the vessel where the catheter is put into the heart
  • Infection of the incision or catheter site
  • Collapsed lung
  • Pericardial effusion (bleeding that can occur from the heart with blood accumulating in the sac (pericardium) surrounding the heart)
  • Lead displacement (when the wires of leads of the pacemaker become disconnected or displaced you may need another procedure to reposition them)

For some people, 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 on your specific medical condition. Be sure to discuss any concerns with your healthcare provider before the procedure.

How do I get ready for pacemaker insertion?

 

  • Your healthcare provider will explain the procedure to you and ask if you have any questions.
  • You will be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if anything is not clear.
  • Tell your healthcare provider if you are sensitive to or are allergic to any medicines, iodine, latex, tape, or anesthetic agents (local and general).
  • You will need to fast (not eat or drink) for a certain period before the procedure. Your healthcare provider will tell you how long to fast, usually overnight or at least 8 hours before the procedure.
  • If you are pregnant or think you might be, or if you are breastfeeding, tell your healthcare provider.
  • Be sure your healthcare provider knows about all medicines (prescription and over-the-counter), vitamins, herbs, and supplements that you are taking.
  • Tell your healthcare provider if you have heart valve disease, as you may need to take antibiotics before the procedure.
  • Tell your healthcare provider if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medicines, aspirin, or other medicines that affect blood clotting. You may need to stop some of these medicines before the procedure.
  • Your healthcare provider may do a blood test before to the procedure to see how long it takes your blood to clot. Other blood tests and a chest X-ray may be done as well.
  • You may get a sedative before the procedure to help you relax. If a sedative is given and there is a possibility that you may be able to go home afterward, you will need someone to drive you home. You will likely spend at least one night in the hospital after the procedure for observation and to be sure that the pacemaker is working the way it should.
  • Based on your medical condition, your healthcare provider may request other specific preparation.

 

What happens during pacemaker insertion?

A pacemaker insertion may be done on an outpatient basis or as part of your hospital stay. Procedures may vary depending on your condition and your healthcare providers practice.

Generally, a pacemaker insertion follows this process:

  1. You will be asked to remove any jewelry or other objects that may interfere with the procedure.
  2. You will be asked to remove your clothing and will be given a gown to wear.
  3. You will be asked to empty your bladder before the procedure.
  4. If there is a lot hair at the incision site, it may be shaved off.
  5. An intravenous (IV) line will be started in your hand or arm before the procedure to give medicine and fluids.
  6. You will lie on your back on the procedure table.
  7. You will be connected to an electrocardiogram (ECG) monitor that records the electrical activity of your heart and monitors the heart during the procedure using small, plastic electrodes that stick to your skin. Your vital signs (heart rate, blood pressure, breathing rate, and oxygen level) will also be monitored during the procedure.
  8. You will get a sedative in your IV before the procedure to help you relax. However, you will likely stay somewhat awake during the procedure.
  9. The skin at the pacemaker insertion site will be cleaned with antiseptic soap.
  10. Sterile towels and a sheet will be placed around this area.
  11. A local anesthetic will be injected into the skin of the chest at the insertion site.
  12. Once the area is numb, the healthcare provider will make a small incision (cut) at the insertion site.
  13. A sheath, or introducer, is put into a large blood vessel, usually under the collarbone. The sheath is a plastic tube through which the pacer lead wire(s) will be threaded into the blood vessel and advanced into the heart.
  14. It will be very important for you to stay still during the procedure so that the catheter does not move and to prevent damage at the insertion site.
  15. The lead wire will be threaded through the introducer into the blood vessel. The healthcare provider will advance the lead wire through the blood vessel into the heart. Fluoroscopy, (a special type of X-ray “movie” that is displayed on a TV monitor), may be used to help check the location of the leads.
  16. Once the lead wire is inside the heart, it will be tested to be sure it’s in the right location and it works. There may be 1, 2, or 3 lead wires inserted, depending on the type of device your healthcare provider has chosen for your condition.
  17. The pacemaker generator will be slipped under your skin through the incision (just below the collarbone) after the lead wire is attached to it. Generally, the generator will be placed on the nondominant 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 chest).
  18. The ECG will be checked to be sure that the pacer is working correctly.
  19. The skin incision will be closed with sutures, adhesive strips, or a special glue.
  20. A sterile bandage or dressing will be applied.

What happens after pacemaker insertion?

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 vital signs.

Let your nurse know right away if you feel any chest pain or tightness, or any other pain at the insertion site.

After the period of bed rest has been completed, you may get out of bed with help. The nurse will be with you the first time you get up, and will check your blood pressure while you are lying in bed, sitting, and standing. Move slowly when getting up from the bed to avoid any dizziness.

You will be able to eat or drink once you are completely awake.

The insertion site may be sore or painful. Pain medicine may be taken if needed.

Your arm may be placed in a sling overnight. Your provider will give you specific instructions on any activity restrictions and about immobilizing your arm after the procedure.

You will have a chest X-ray to make sure the lung was not injured during the procedure, and to check the device position.

You may be prescribed antibiotics to protect you from an infection around your pacemaker or at the incision site.

Your healthcare provider will see you in your room while you are recovering. The healthcare provider 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 allowed to go home. It’s common to spend at least one night in the hospital after pacemaker implantation.

Arrange to have someone drive you home from the hospital following your procedure.

At home

You should be able to return to your normal daily routine within a few days. Your healthcare provider will tell you if you will need to wait before returning to your normal activities. Do not do any lifting or pulling for a few weeks. You may need to limit movement of the arm on the side that the pacemaker was placed.

You will most likely be able to go back to your usual diet, unless your healthcare provider tells you differently.

It will be important to keep the insertion site clean and dry. You will be given instructions about bathing and showering.

Your healthcare provider will give you specific instructions about driving.

Ask your healthcare provider when you will be able to return to work. The nature of your work, your overall health, and your progress after surgery will determine how soon you may go back to work.

Call 911 if you have severe, unrelenting chest pain or trouble breathing.

Contact your healthcare provider right away if you have any of the following:

  • Fever of 100.4°F (38°C) or higher
  • Chills
  • Increased pain, redness, swelling, or bleeding or other drainage from the insertion site
  • Chest pain/pressure, nausea and/or vomiting, profuse sweating, dizziness, lightheadedness, fainting, or lack of energy
  • Palpitations, rapid or pounding heartbeat
  • Swelling in the arms or hands on the side of the incision
  • You have hiccups that will not stop
  • You have muscle twitching in your abdomen
  • Shortness of breath

After a pacemaker insertion, regularly scheduled appointments will be made to ensure the pacemaker is working the way it should. The healthcare provider uses a special computer, called a programmer, to review the pacemaker's activity and adjust the settings when needed.

Your healthcare provider may give you other instructions after the procedure, depending on your particular situation.

Things to keep in mind

Always consider the following precautions. Discuss these in detail with your healthcare provider, or call the company that made your device:

  • Always carry an ID card that states you have a pacemaker. In addition, you may want to wear a medical ID bracelet or necklace indicating that you have a pacemaker.
  • Let security screeners know you have a pacemaker before going through security detectors at the airport or court house. 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 that may affect the function or programming of your pacemaker.
  • You should not have a magnetic resonance imaging (MRI) imaging test (unless you have a specially designed pacemaker).
  • You should avoid large magnetic fields such as power generation sites and industrial sites such as automobile junkyards that use large magnets.
  • Do not use short-wave or microwave diathermy that uses high-frequency, high-intensity signals (this may be used in physical therapy to treat muscles). The signals can interfere with or damage your pacemaker.
  • Turn off large motors, such as cars or boats, when working close to 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 need a surgical procedure in the future, be sure to let the surgeon know that you have a pacemaker well before the operation. Also ask your cardiologist's advice on whether anything special should be done before and during the surgery, 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 electrocautery.
  • When involved in a physical, recreational, or sporting activity, 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 healthcare provider to make sure your pacemaker is working the way it should be.
  • Cell phones in the U.S. with less than 3 watts of output do not seem to affect pacemakers or the pulse generator, but as a precaution, keep cell phones at least 6 inches away from your pacemaker. Do not carry a cell phone in your breast pocket over your pacemaker.
  • Always consult your healthcare provider when you feel ill after an activity, or when you have questions about beginning a new activity.
  • Always contact your healthcare provider if you have any questions about using certain equipment near your pacemaker.

 

Next steps

Before you agree to the test or the procedure make sure you know:

  • The name of the test or procedure
  • The reason you are having the test or procedure
  • What results to expect and what they mean
  • The risks and benefits of the test or procedure
  • What the possible side effects or complications are
  • When and where you are to have the test or procedure
  • Who will do the test or procedure and what that person’s qualifications are
  • What would  happen if you did not have the test or procedure
  • Any alternative tests or procedures to think about
  • When and how will you get the results
  • Who to call after the test or procedure if you have questions or problems
  • How much will you have to pay for the test or procedure

Overview of Pacemakers and Implantable Cardioverter Defibrillators (ICDs)

What is a permanent pacemaker?

A permanent pacemaker, a small device that is implanted under the skin (most often in the shoulder area just under the collarbone), sends electrical signals to start or regulate a slow heartbeat. A permanent pacemaker may be used to make the heart beat if the heart's natural pacemaker (the SA node) is not functioning properly and has developed an abnormally slow heart rate or rhythm, or if the electrical pathways are blocked.

A newer type of pacemaker, called a biventricular pacemaker, is currently used in the treatment of ventricular dyssynchrony (irregular conduction pattern in the lower heart chambers) or heart failure. Sometimes in heart failure, the two ventricles do not pump together 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.

What is an implantable converter defibrillator (ICD)?

An implantable cardioverter defibrillator (ICD) looks very similar to a pacemaker, except that it is slightly larger. It has a generator, one or more leads, and an electrode for each lead. These components work very much like a pacemaker. However, the ICD is designed to deliver two levels of electrical energy: a low energy shock that can convert  a beating heart that is in an abnormal rhythm back to a normal heartbeat, and a high energy shock that is delivered only if the arrhythmia is so severe that the heart is only quivering instead of beating. 

An ICD senses when the heart is beating too fast and delivers an electrical shock to convert the fast rhythm to a normal rhythm. Many devices combine a pacemaker and ICD in one unit for people who need both functions. After the shock is delivered, a "back-up" pacing mode is available if needed for a short while.

The ICD has another type of treatment for certain fast rhythms called anti-tachycardia pacing, a fast-pacing impulse sent to correct the rhythm.

What is the reason for getting a pacemaker or an ICD?

Pacemakers are most commonly advised in patients whose heartbeat slows to an unhealthy low rate. ICDs are advised in specific patients who are at risk for potentially fatal ventricular arrhythmias (an abnormal rhythm from the lower heart chambers, which can cause the heart to pump less effectively). There may be other reasons why your doctor advises placement of a pacemaker or ICD.

When the heart's natural pacemaker or electrical circuit malfunctions, the signals sent out may become erratic: either too slow, too fast, or too irregular to stimulate adequate contractions of the heart chambers. When the heartbeat becomes erratic, it is referred to as an arrhythmia.

Arrhythmias can cause problems with contractions of the heart chambers by:

  • Not allowing the chambers to fill with an adequate amount of blood because the electrical signal is causing the heart to pump too fast.

  • Not allowing a sufficient amount of blood to be pumped out to the body because the electrical signal is causing the heart to pump too slowly or too irregularly.

The heart's electrical system

The heart is, in the simplest terms, a pump made up of muscle tissue. The heart's pumping action is regulated by an electrical conduction system that coordinates the contraction of the various chambers of the heart.

How does the heart beat?

An electrical stimulus is generated by the sinus node (also called the sinoatrial node, or SA node), which is a small mass of specialized tissue located in the right atrium (right upper chamber of the heart). In an adult, the sinus node generates an electrical stimulus regularly (for adults, 60 to 100 times per minute under normal conditions). This electrical stimulus travels down through the conduction pathways (similar to the way electricity flows through power lines from the power plant to your house) and causes the heart's lower chambers to contract and pump out blood. The right and left atria (the two upper chambers of the heart) are stimulated first and contract a short period of time before the right and left ventricles (the two lower chambers of the heart). 

The electrical impulse travels from the sinus node through the atria to the atrioventricular node (also called AV node), where impulses are slowed down for a very short period, then continue down the conduction pathway via the bundle of His into the ventricles. The bundle of His divides into right and left pathways to provide electrical stimulation to the right and left ventricles.

Normally at rest, as the electrical impulse moves through the heart, the heart contracts about 60 to 100 times a minute, depending on a person's age (infants normally have very high heart rates). Each contraction of the ventricles represents one heartbeat. The atria contract a fraction of a second before the ventricles so their blood empties into the ventricles before the ventricles contract.

Under some abnormal conditions, certain heart tissue is capable of starting a heartbeat, or becoming the pacemaker. An arrhythmia (abnormal heartbeat) occurs when:

  • The heart's natural pacemaker develops an abnormal rate or rhythm

  • The normal conduction pathway is interrupted

  • Another part of the heart takes over as pacemaker

In any of these situations, the body may not receive enough blood because the heart cannot pump out an adequate amount with each beat as a result of the arrhythmia's effects on the heart rate. The effects on the body are often the same, however, whether the heartbeat is too fast, too slow, or too irregular. Some symptoms of arrhythmias include, but are not limited to:

  • Weakness

  • Fatigue

  • Palpitations

  • Low blood pressure

  • Dizziness

  • Fainting

The symptoms of arrhythmias may resemble other medical conditions. Consult your doctor for a diagnosis.

What are the components of a permanent pacemaker/ICD?

A permanent pacemaker or ICD has three main components:

  • A pulse generator which has a sealed lithium battery and an electronic circuitry package. The pulse generator produces the electrical signals that make the heart beat. Most pulse generators also have the capability to receive and respond to signals that are sent by the heart itself.

  • One or more wires (also called leads). Leads are insulated flexible wires that conduct electrical signals to the heart from the pulse generator. The leads also relay signals from the heart to the pulse generator. One end of the lead is attached to the pulse generator and the electrode end of the lead is positioned in the atrium (the upper chamber of the heart) or in the right ventricle (the lower chamber of the heart). In the case of a biventricular pacemaker, leads are placed in both ventricles.

  • Electrodes, which are found on each lead.

Pacemakers can "sense" when the heart's natural rate falls below the rate that has been programmed into the pacemaker's circuitry.

Pacemaker leads may be positioned in the right atrium, right ventricle, or positioned to pace both ventricles, depending on the condition requiring the pacemaker to be inserted. An atrial arrhythmia (an arrhythmia caused by a dysfunction of the sinus node or the development of another atrial pacemaker within the heart tissue that takes over the function of the sinus node) may be treated with an atrial permanent pacemaker whose lead wire is located in the atrium.

When the ventricles are not stimulated normally by the sinus node or another natural atrial pacemaker site, a ventricular pacemaker whose lead wire is located in the ventricle is placed/used. It is possible to have both atrial and ventricular arrhythmias, and there are pacemakers which have lead wires positioned in both the atrium and the ventricle.

An ICD has a lead wire that is positioned in the ventricle, as it is used for treating fast ventricular arrhythmias. Commonly, ICDs will have an atrial lead and ventricular lead.

Pacemakers that pace either the right atrium or the right ventricle are called "single-chamber" pacemakers. Pacemakers that pace both the right atrium and right ventricle of the heart and require two pacing leads are called "dual-chamber" pacemakers. Pacemakers that pace the right atrium and right and left ventricles are called "biventricular" pacemakers.

How is a pacemaker/ICD implanted?

Pacemaker/ICD insertion is done in the cardiac catheterization laboratory, or the electrophysiology laboratory. The patient is awake during the procedure, although local anesthesia is given over the incision site, and generally sedation is given to help the patient relax during the procedure. A night or two of hospitalization may be recommended so that the functioning of the implanted device may be observed.

Shown here is a chest X-ray. The large, white space in the middle is the heart. The dark spaces on either side are the lungs. The small object in the upper corner is an implanted pacemaker.

A small incision is made just under the collarbone. The pacemaker/ICD lead(s) is inserted into the heart through a blood vessel which runs under the collarbone. Once the lead is in place, it is tested to make sure it is in the right place and is functional. The lead is then attached to the generator, which is placed just under the skin through the incision made earlier. Once the procedure has been completed, the patient goes through a recovery period of several hours.

There are certain instructions related to having an implanted permanent pacemaker or ICD. For example, after you receive your pacemaker or ICD, you will receive an identification card from the manufacturer that includes information about your specific model of pacemaker and the serial number as well as how the device works. You should carry this card with you at all times so that the information is always available to any health care professional who may have reason to examine and/or treat you.

Patient with four pacemaker and defibrillator leadsRemoving lead wires from pacemakers and defibrillators is a delicate process. They don’t easily pull out, since they get tightly attached to the heart and the veins through which they travel on the way to the heart. The longer leads have been implanted the more tightly attached they get. Special tools and techniques are used to extract leads safely and effectively.

The most common reasons for recommending lead extraction are infection of the pacemaker or defibrillator, malfunctioning leads, and multiple abandoned leads. The need for lead extraction is not always clear-cut and University of Utah physicians can advise patients on the advisability of extraction and alternative approaches.

Cardiothoracic Surgeons

Roger A. Freedman, M.D.

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Roger A. Freedman, M.D. has been a faculty member at the University of Utah for over 20 years. He specializes in the treatment of cardiac arrhythmias, particularly in the implantation and management of implanted pacemakers and defibrillators. Pacemaker and defibrillator lead extraction is a highly specialized technique in which Dr. Freedman is gre... Read More

Specialties:

Cardiac Electrophysiology, Cardiology, Pacemaker and Defibrillator Implantation, Pacemaker and Defibrillator Lead Extraction

Locations:

Idaho Heart Institute (801) 585-1935
Memorial Hospital of Sweetwater County (801) 585-7676
Star Valley Medical Center (801) 585-7676
University Hospital
Cardiovascular Center
(801) 585-7676
William B. Ririe Hospital & Rural Health Clinic (801) 585-7676

Specialties:

Cardiothoracic Surgery, Nurse Practitioner

Locations:

Eccles Primary Children’s Outpatient Services Building (801) 662-1000
University Hospital
Cardiovascular Center
(801) 581-0434

Specialties:

Cardiothoracic Surgery, Physician Assistant

Locations:

A location has not yet been added by this physician.

Specialties:

Cardiothoracic Surgery, Perfusionist

Locations:

A location has not yet been added by this physician.

Specialties:

Cardiothoracic Surgery

Locations:

University Hospital
Cardiovascular Center
(801) 213-2200

Nathan C. Sontum, PA-C, M.H.S.

PA-C for department of CT surgery 2010-Present... Read More

Specialties:

Cardiothoracic Surgery

Locations:

A location has not yet been added by this physician.

Specialties:

Cardiothoracic Surgery

Locations:

A location has not yet been added by this physician.

Scott A. Tatum, PA-C

Scott came to the University almost 9 years ago from private practice. As a trainer and consultant for Endoscopic Vein harvesting, he has effectively introduced and incorporated new technology and procedures into the University healthcare system. As the senior physician assistant in the division of cardiothoracic surgery, Scott has 17 years experie... Read More

Specialties:

Cardiothoracic Surgery, Physician Assistant

Locations:

University Hospital (801) 581-2121

Locations

University Campus
University Hospital
50 N Medical Drive
Salt Lake City, UT 84132
Map
(801) 581-2121
Primary Children's Hospital
100 N Mario Capecchi Dr
Salt Lake City, UT 84132
(801) 662-1000