Pacemakers

Permanent Heart Pacemakers

The usual reason for someone receiving a permanent pacemaker is because the person’s heart beats too slowly to meet the body’s needs and the low heart rate is causing symptoms or puts you at risk of serious injury or harm. The medical term for slow heart beating is “bradycardia”. Bradycardia can cause symptoms such as dizziness, fatigue, or fainting spells. Medical research is also looking at the possibility of using pacemakers to treat other heart conditions such as heart failure or various kinds of heart racing rhythm problems ("tachycardias") but at the present time, pacemakers are primarily used to treat slow heart rhythms.

What are the parts of a pacemaker system?

When a person receives a pacemaker, two basic parts are inserted: the pacemaker generator and one or more pacemaker wires(leads). The pacemaker generator is often called the “pacemaker battery”. In reality, a generator contains not only the battery but all the important wiring and circuitry that makes the pacemaker work properly. Modern pacemakers generators are like miniature computers. Pacemaker generators send out very small sparks of electricity to make the heart beat but these sparks must be delivered to the heart muscle. To do this, pacemaker leads are inserted through the veins and the tips of the leads are attached to the heart. The other end is then hooked into the generator so that the electrical sparks can be sent down the pacemaker lead and cause the heart to beat.

What is done in preparation for a pacemaker implantation?

The first step in implanting a pacemaker is for doctors to establish that a pacemaker is needed. Once this decision is made and the date booked, you will be notified of the date and time. The pacemaker implantation operation is performed at the hospital (London Health Sciences Center-University Campus). Pacemaker implantation is a small operation that can be done as an outpatient in most cases. This means that you do not have to be admitted to hospital and you will usually be able to go home within 2 hours after the operation.

After you arrive at the hospital and check in at the Admitting Department, you will come upstairs to the Heart Unit. You will be met by a nurse who will help you change into a hospital gown, place your valuables in safe-keeping and place you onto a hospital stretcher. Everything will be checked in preparation for the operation. The staff will put an intravenous needle into a hand vein. A doctor will explain the procedure to you, including the risks of the operation (see below). If you are comfortable with the explanation provided, you will be given the consent form to sign that gives permission for the doctor(s) to implant the pacemaker.

What is done in a pacemaker implant procedure?

At the proper time, you will be taken to the procedure room and transferred from the stretcher to the operating table. The shoulder will be exposed by lowering the hospital gown and nurses who are wearing masks and gowns will clean the skin near the shoulder with an iodine or alcohol solution. The area will be covered by a sterile drape to keep the area clean during the operation. You will be given drugs through the intravenous to help you relax, sleep and lessen any pain that you may feel during the operation.

The doctor will then inject anesthetic drugs to “numb” or “freeze” the skin where the pacemaker will be implanted. Just like dental freezing, the anesthetic stings or burns as it is injected but works quickly to numb the whole area so that you should feel minimal pain during the rest of the operation.

Once the skin area is numb, the doctor will make a 1-2 inch incision in the skin and make a pocket under the skin for the generator. The doctor will also use a needle to find the vein under the collarbone. One or more pacemaker leads will be inserted down the vein and guided by X-rays into the right places in the heart. These leads will be hooked or screwed into the muscle to minimize the chances they will fall out of place. The nursing staff will then take measurements from the leads to make sure the pacing leads will work well when needed. The doctor will then tie the lead down and plugged the other end into the generator. The generator is placed in the pocket and the incision sewn up. The sutures used will dissolve on their own and will not need to be removed. A clear dressing is placed over the wound to protect it while it is healing and will need to stay in place for about one week. The procedure is now finished. You will be helped off the table and taken to a recovery area for a brief rest or taken directly to the X-ray department to have a chest X-ray. Finally, an ECG will be taken to check the working of the pacemaker. If those tests are fine, you will be given a return appointment within 7-10 days to attend the pacemaker clinic for a check of the device. You are then ready to be taken home. Like dental freezing, the numbness over the area where the pacemaker was implanted will gradually wear off after 4-5 hours. Nursing staff will instruct you as to what you make take for the pain before you leave the hospital and instructions regarding medications you may have been taking before your operation.

What can I do now that I have a pacemaker?

1. For the first several days, do not do anything strenuous with your arms and allow the wound to heal. Avoid lifting your arm over your head for several days and try not to allow anything to hit the wound area.

2. You may resume normal daily activities as much as you like within limits of pain from the operation site. Ask your doctors about whether you can resume driving because there are usually restrictions about when you may resume driving.

3. You may take a bath as soon as you return home but try not to get the dressing wet or rub the area. Taking a shower is possible but keep your back to the shower spray so that the water does not spray onto the dressing directly.

4. Take your usual medications as directed by your doctor. If you normally take blood thinner drugs (anticoagulants), please ask for instructions from the hospital doctors and follow those instructions. If there is uncertainty or you have forgotten what was said, please speak to your family or local doctor for advice. If necessary, you may call the Device Clinic (519-685-8500 ext. 35866) as a last resort.

FAQ’s

1. How long does a pacemaker last before it needs to be replaced?

A pacemaker generator lasts, on average, 6-8 years but it all depends on how much your body needs the pacemaker to pace the heart. It also depends upon how much electricity is needed to make the heart beat each time The more you use it and the more electricity required for each spark, the shorter time the device will last.

2. Why do I need to be seen in the Arrhythmia Device or Pacemaker Clinic?

Every person who receives a pacemaker should have a regular checkup at least once a year in Pacemaker Clinic. In the Clinic, the amount of battery power remaining is measured and the functioning of the pacemaker is assessed to make sure that the settings are correct, have not accidentally been changed and that there are no signs of trouble with the generator or leads. It also allows the staff to ask how you are feeling in order to determine whether the pacemaker settings need to be changed to better meet your needs.

3. How often should I been checked in the Device Clinic?

All patients should be seen in the Clinic 7-10 days after the pacemaker implantation to check the device and to assess the wound and pocket. The next routine visit is usually at 3 months from the date you received the pacemaker. After that, most patients only need to be seen once per year. If there are any concerns, you may be asked to return to the Clinic sooner or more frequently. If you received a research pacemaker, you may be asked to return more frequently for follow-up checks. Finally, as the battery power starts to get low and time to replacing the generator draws closer, more frequent checks may be needed.

4. Must my pacemaker follow-up checks all be done in London?

Except for the first pacemaker check 7-10 days after the pacemaker is put in, your pacemaker checks can be done at the Device Clinic closest or most convenient to where you live. Our staff may initiate the transfer of files to the alternative clinic for you but you can certainly mention to the staff at any time if you have a preference.

Implantable Defibrillators

An "implantable defibrillator" is more correctly called an "implantable cardioverter defibrillator" or ICD for short. ICD’s are intended for patients who have had or are at high risk for developing life-threatening rapid heart racing attacks called ventricular tachycardia (VT) or ventricular fibrillation (VF) that can lead to death. An ICD is larger in size than a regular pacemaker and many ICD models include all the features of a regular pacemaker. What makes an ICD different from a pacemaker is that, if and when a bout of VT or VF occurs in a patient, the ICD will either rapidly pace the heart or deliver a shock to restore a normal rhythm. It is important to remember that an ICD does not prevent VT or VF attacks; they only stop them once they have occurred.

What are the parts of an ICD?

When a person receives an ICD, two basic parts are inserted: the ICD generator and one or more ICD leads (often called wires). The generator is often called the “battery”. In reality, a generator contains not only the battery but all the important wiring and circuitry that makes the ICD work properly. In fact, generators are like miniature computers. ICD generators send out pacing pulses or shocks and are delivered to the heart by the ICD leads. ICD leads are inserted through the veins and the tips of the leads are attached to the heart. The other end is then hooked into the generator so that the electrical sparks can be sent down the lead and cause the heart to beat.

What is done in preparation for ICD implantation?

The first step in implanting an ICD is for doctors to establish that a pacemaker is needed. Once this decision is made and the operation date booked, you will be notified of the date and time. The ICD implantation operation is performed at the hospital (London Health Sciences Center-University Campus) and only a brief stay in hospital afterwards (1-2 days) is usually all that is required.

In preparation for the operation, you will be given basic instruction by hospital staff. Usually, you will be asked not to eat or drink anything the morning of the operation. Someone else should drive you to the hospital and take you home afterwards. If you are taking medications, please ask the hospital staff contacting you if it is alright to take your pills the morning of the operation. Oral anticoagulants (also called blood thinners pills) must be stopped several days before the operation. If you are taking them, please speak to a nurse at the hospital regarding your situation and to obtain further instructions.

On the day of the operation when you arrive at the hospital, first check in at the Admitting Department. After completing the paperwork, you will be directed to the Heart Unit on the second floor. You will be met by a nurse who will help you change into a hospital gown, place your valuables in a safe place and place you on a hospital stretcher. Everything will be checked in preparation for the operation. The staff will put an intravenous needle into a hand vein. A doctor will explain the procedure to you once again, including the risks of the operation (see below). If you are comfortable and with the explanation provided and your remaining questions have been answered, you will be given the consent form to sign that gives permission for the doctor(s) to implant the ICD.

How is the ICD system implanted?

The doctor will then inject anesthetic drugs to “numb” or “freeze” the skin where the ICD will be implanted. Just like dental freezing, the anesthetic stings or burns as it is injected but works quickly to numb the whole area so that you should feel minimal pain during the rest of the operation.

Once the skin area is numb, the doctor will make a 2-3 inch incision in the skin and make a pocket under the skin for the generator. The doctor will also use a needle to find the vein under the collarbone. One or more ICD leads will be inserted down the vein and guided by X-rays into the right place(s) in the heart. These leads will be hooked or screwed into the muscle to minimize the chances they will fall out of place. The nursing staff will then take measurements from the leads to make sure the pacing leads will work well when needed. The doctor will then tie the lead down under the skin and the other end plugged into the generator. The generator will be placed in the pocket.

Next comes testing of the ICD to make sure that it will be able to stop VF if it should happen after you go home. You will be given more drugs to make you sleep. Your heart will be made to race very rapidly and the ICD will deliver a shock to bring the heart back to normal rhythm. This will be repeated several more times and measurements taken. Once the testing is complete, the incision will be sewn closed. The sutures used will dissolve on their own and will not need to be removed. A clear dressing is placed over the wound to protect it while it is healing and will need to stay in place for about one week. The procedure is now finished. You will be helped off the table and taken to a recovery area for a brief rest or taken directly to the X-ray department to have a chest x-ray. Finally, an ECG will be taken to check the working of the pacemaker. If those tests are fine, you will be given a return appointment within 7-10 days to attend the pacemaker clinic for a check of the device. Like dental freezing, the numbness over the area where the pacemaker was implanted will gradually wear off after 4-5 hours. Nursing staff will instruct you as to what you make take for the pain before you leave the hospital and instructions regarding medications you may have been taking before your operation.

Q: I have never had an attack of VT or VF but I do have heart disease. Would I be eligible for an ICD?

A: Recent clinical studies have shown that some patients who have severely damaged hearts have about a 20% chance of dying from VT or VF over a 2 year period.