Pacemakers: Purpose, Implantation, and Aftercare

When your heart rhythm becomes irregular or beats too slowly, this condition can significantly impact your daily life. A pacemaker is a small electronic device used to maintain heartbeats at a normal rate, thereby ensuring adequate blood flow to vital organs. If symptoms like fainting, dizziness, or weakness recur, or if your heart occasionally pauses, a pacemaker might be a suitable treatment option for you.

Patients at high risk of developing arrhythmias due to advanced heart block (AV block), severe bradycardia, certain dangerous rhythm disorders, or structural heart changes (such as heart failure or cardiomyopathy) may require a pacemaker.

What is a Pacemaker?

A pacemaker is a small, battery-powered electronic device implanted under the skin near your collarbone to regulate your heart’s electrical impulses and ensure a normal heart rhythm. This device corrects problems in the heart’s natural electrical system, allowing your heart to beat as it should. It is typically used for individuals with slow heartbeats (bradycardia) or irregular heart rhythms.

Beyond merely addressing slow heart rhythms, special types of pacemakers with different functions can also be used in specific situations. For instance, ICDs (Implantable Cardioverter Defibrillators) automatically deliver a shock to correct dangerously fast heart rhythms, while CRT (Cardiac Resynchronization Therapy) devices help the heart beat more synchronously in cases of heart failure. The appropriate type of device is determined by the underlying heart condition and the specific type of arrhythmia.

What are the Types of Pacemakers?

Pacemakers are produced in different types based on their usage duration and your clinical needs. Each type of pacemaker is specifically designed for certain arrhythmias and patient groups. Your cardiologist will determine the most suitable pacemaker type for you after a detailed examination and diagnostic tests.

Temporary Pacemakers

Temporary pacemakers are typically used in emergency situations or during short transition periods before a permanent pacemaker is implanted. These devices are located outside your body and are connected to your heart via a lead. Their main advantages include rapid applicability and easy removal when no longer needed.

Permanent Pacemakers

Permanent pacemakers are designed for long-term or lifelong use and are surgically implanted into your body. There are various types of permanent pacemakers with different operating principles.

Single-Chamber Pacemakers

Single-chamber pacemakers are devices that sense and, when necessary, deliver impulses to a single chamber of your heart. They can be implemented in two different ways:

• VVI (Ventricular Pacing): Monitors the activity of your heart’s lower chambers (ventricles) and delivers an impulse when it beats too slowly.

• AAI (Atrial Pacing): Monitors the rhythm of your heart’s upper chambers (atria) and provides support when needed.

Dual-Chamber Pacemakers

Dual-chamber pacemakers (DDD) control both your heart’s atria and ventricles, allowing the heart to beat more synchronously and physiologically. These devices are frequently preferred for atrioventricular conduction problems, complete heart block, and sick sinus syndrome. They can automatically increase your heart rate during exercise, making you feel more comfortable during daily activities.

Biventricular pacemakers (CRT)

Biventricular pacemakers (Cardiac Resynchronization Therapy or CRT) are implanted in patients with heart failure. In this device, one lead is placed in your heart’s right atrium, one in the right ventricle, and the third lead is placed in the venous branches on the back of the left ventricle.

Biventricular pacemakers work not just when you need them, but with every heartbeat of your heart, making contractions more balanced. This strengthens your heart function, reduces heart failure symptoms like shortness of breath and weakness, and improves your quality of life. They are particularly preferred in patients with advanced heart failure, left bundle branch block, and low ejection fraction (the heart’s pumping power).

Implantable Cardioverter-Defibrillators (ICD, CRT-D)

Implantable cardioverter-defibrillators are advanced devices that, in addition to normal pacemaker functions, can detect dangerous arrhythmias that develop suddenly and deliver an electrical shock. Single-lead ICD, dual-lead ICD, or triple-lead (CRT-D) options are available.

• ICD (Implantable Cardioverter Defibrillator): Continuously monitors your heart’s rhythm, delivers a shock when it detects dangerous arrhythmias, and records this information. It is preferred for individuals at risk after a heart attack, those with a high risk of sudden cardiac death, or certain genetic arrhythmias.

• CRT-D: Provides resynchronization in heart failure while also offering shock therapy. This ensures both more harmonious heart function and protection against life-threatening arrhythmias.

Leadless Pacemakers

Leadless pacemakers, unlike classic pacemakers, are small devices implanted directly inside your heart that do not require leads. They weigh approximately 3-4 grams and have no external components. They detect your heartbeats and activate when needed. They do not have a shock-delivery feature but eliminate the risk of lead complications and offer a significant advantage for certain patient groups.

What Does a Pacemaker Consist Of?

A classic pacemaker system comprises two main components: the generator (pacemaker box) and the leads (wires).

The generator consists of a microcomputer and battery system housed within a metal case, responsible for producing the electrical signals sent to your heart. It is typically placed just beneath your collarbone, under the skin. The device is invisible externally and does not restrict your movements.

The leads are thin, flexible wires extending from the generator. These wires are advanced through a vein into specific areas inside your heart, where they are then secured. Through the leads, the electrical impulses generated by the pacemaker are directly transmitted to the heart muscle.

Some new-generation pacemakers are designed to be leadless. These devices integrate both the lead and generator into a single unit, which is directly implanted into a heart chamber. Being leadless, they carry a lower risk of infection and can be preferred, especially for patients requiring a single-chamber pacemaker.

How Does a Pacemaker Work?

A pacemaker continuously monitors your heart’s own natural electrical activity. If your heart does not beat fast enough or its beats become irregular, the pacemaker activates, sending weak electrical impulses. These impulses stimulate your heart, causing it to contract with a regular rhythm. Your pacemaker operates only when necessary, efficiently conserving energy and supporting your heart in line with its natural rhythm.

Why Is a Pacemaker Needed?

A pacemaker is typically needed when your heart’s natural rhythm becomes too slow or irregular. These conditions usually stem from electrical conduction problems developing due to aging, certain heart diseases, or after heart attacks. If you experience symptoms such as fainting, dizziness, chronic fatigue, and shortness of breath, your physician will assess whether a pacemaker is suitable for you.

The main reasons a pacemaker may be needed include:

• Bradycardia (Slow Heart Rate): Your heart beating slower than 60 beats per minute, causing symptoms, is a primary reason for pacemaker need. This often occurs due to the heart’s natural pacemaker, the sinus node, not functioning properly (sinus node dysfunction) or a blockage in the transmission of electrical signals from the heart’s upper chambers to the lower chambers (atrioventricular block).
• Sinus Node Dysfunction: The heart’s natural pacemaker (sinus node) failing to generate electrical impulses fast or regularly enough due to aging, certain medications, or heart conditions. This can lead to dizziness, fainting, extreme fatigue, or shortness of breath.
• Heart Block (AV Block): A blockage or damage in the pathway that carries electrical signals from the heart’s upper chambers to its lower chambers. These blocks cause the heart’s lower chambers (ventricles) to beat very slowly. Not all heart blocks require a pacemaker; the degree of the block is crucial.
• Control of Tachycardia (Fast Heart Rate) or Irregular Rhythms: Sometimes, pacemakers can also be used to slow down or control certain fast and irregular arrhythmias (e.g., to reduce the heart rate to a regular speed in a patient whose heart is beating too fast). Furthermore, certain specialized pacemakers (cardioverter-defibrillators – ICDs) are used to stop life-threatening fast rhythms.
• Syncope (Fainting) or Dizziness: Frequent fainting or dizziness due to the brain not receiving enough blood flow as a result of a slow heart rate.
• Chronic Fatigue and Shortness of Breath: The heart’s slow beat can lead to the body not getting enough oxygen, causing persistent fatigue and shortness of breath that worsens with exertion.
• After Certain Heart Surgeries: Damage to the heart’s electrical conduction system during some heart surgeries can create a temporary or permanent need for a pacemaker.
• Medication Side Effects: Some heart medications (e.g., beta-blockers or calcium channel blockers) can slow the heart rate too much, necessitating a pacemaker.

Your cardiologist will decide whether you need a pacemaker after evaluating your symptoms and test results, such as ECG and Holter monitoring.

How is a Pacemaker Implanted?

Pacemaker implantation is typically a simple surgical procedure performed under local anesthesia, lasting approximately one hour. Your doctor will make a small incision under your collarbone and place the pacemaker generator beneath the skin. Then, thin wires (leads) are advanced through a vein into your heart and secured in the correct positions. A short hospital stay may be required after the procedure.

The pacemaker implantation procedure generally includes the following steps:

• Preparation: You are usually asked to fast before the procedure. Your doctor will administer a mild sedative or local anesthesia (to numb only the implantation area) to help you relax. General anesthesia is rarely used.
• Incision and Device Placement: A small incision (about 5-8 cm) is typically made under the left shoulder, just below the collarbone, on the skin. Beneath this incision, a small pocket is created where the pacemaker generator will be placed.
• Lead Placement: The doctor enters a large vein in the same area (usually the subclavian vein) with a special needle. Through this venous access, thin and flexible pacemaker leads are carefully advanced into the heart. Under live X-ray (fluoroscopy) guidance, the leads are guided to the heart’s right atrium and/or right ventricle and secured to the heart muscle with special hooks or screws.
• Testing and Adjustment: Once the leads are correctly positioned, they are connected to the pacemaker generator. The doctor performs various tests to ensure that the electrical signals sent by the pacemaker effectively stimulate the heart and that the heart’s own signals are correctly sensed. Necessary adjustments are made.
• Device Connection and Closure: The ends of the leads are securely connected to the pacemaker generator. The generator is placed into the pocket created under the skin, and the incision is closed with sutures.
• Post-Procedure: You may need to stay in the hospital for a few hours or overnight after the procedure. An ECG and chest X-ray may be taken to ensure the pacemaker is functioning correctly and no complications have occurred. Mild pain is managed with pain relievers.

The procedure is generally safe, and the risk of complications is low. Most patients can return to their daily activities quickly. You will be given a pacemaker ID card, which you should always carry with you. Follow-up appointments will be scheduled.

What Happens if a Pacemaker is Not Implanted?

If you do not receive treatment when a pacemaker is needed, you may experience serious health problems due to your heart beating too slowly or irregularly. Symptoms like dizziness, fainting, chronic fatigue, and shortness of breath will continue or worsen. The most serious risks include the progression of heart failure or sudden cardiac arrest due to a dangerously slow heart rate.

What Should You Pay Attention to After Pacemaker Implantation?

After pacemaker implantation, you can usually return to your daily life quickly, but there are some important points to consider. These precautions include wound care, avoiding heavy lifting and sudden arm movements, regular device check-ups, and protection from electromagnetic fields. Following your doctor’s instructions and always carrying your pacemaker ID card are crucial.

Here’s what you need to pay attention to for a healthy recovery process and to extend the life of your device after pacemaker implantation:

Wound Care: Keep your wound site clean and dry as instructed by your doctor. If you notice any signs of infection (redness, swelling, discharge, fever), contact your doctor immediately. Stitches are usually removed after 10-14 days or absorbable sutures are used.

Arm Movements and Heavy Lifting: For the first 4-6 weeks, avoid sudden upward movements, heavy lifting, and strenuous physical activities with the arm on the side where the pacemaker was implanted. This is to prevent the leads from dislodging from where they are secured in the heart.

Regular Check-ups: You should have regular follow-up appointments with your cardiologist to ensure your pacemaker is functioning properly and its battery life is sufficient. Checks are typically done within the first month, then every 6 months or annually. If your pacemaker has remote monitoring (telemonitoring) capability, your checks might be more frequent and done remotely.

Pacemaker ID Card: Always carry your pacemaker ID card with you. This card is useful in emergencies or at airport security checks.

Electromagnetic Fields and Devices:

• Everyday Devices: Household appliances like microwave ovens, televisions, computers, and radios are generally safe.
• Mobile Phones: Avoid placing your mobile phone directly over your pacemaker (close to your chest). You can use it with the other ear or on the opposite side of your body.
• Security Alarm Systems and Metal Detectors: Pass quickly through metal detectors at airports or store entrances and do not linger. Inform security personnel about your pacemaker. Do not allow hand-held detectors to be held close to your pacemaker.
• Strong Electromagnetic Fields: Stay away from strong electromagnetic fields such as large motors, high-voltage lines, welding machines, and powerful magnets.
• Medical Procedures: MRI (Magnetic Resonance Imaging) is generally not safe for most pacemakers (however, new generation MRI-compatible pacemakers are available). Always inform your doctor that you have a pacemaker before undergoing an MRI or any other medical imaging test.

Physical Activities: You can gradually return to normal physical activities with your doctor’s approval. Avoiding contact sports (football, basketball) that carry a risk of impact is generally recommended.

Recognizing Symptoms: If you experience any new symptoms such as palpitations, dizziness, fainting, shortness of breath, or pain, swelling, redness at the pacemaker site, contact your doctor immediately.

These precautions will help you live a long and healthy life with your pacemaker.

What are the Risks of Pacemaker Implantation?

Pacemaker implantation is generally a safe procedure, but like any surgical procedure, it carries some risks. The most common risks include infection at the incision site, bleeding, or bruising. Rarely, more serious complications such as lead displacement, pneumothorax, or pericarditis can occur. Your cardiologist will assess your specific situation to explain how relevant these risks are to you and what precautions will be taken. Generally, the benefits of a pacemaker far outweigh its risks.