Overview

If you need to have a pacemaker fitted, a small electrical device called a pacemaker will be surgically implanted in your chest.

The pacemaker sends electrical pulses to your heart to keep it beating regularly and not too slowly.

Having a pacemaker can significantly improve your quality of life if you have problems with a slow heart rate. The device can be lifesaving for some people.

In the UK, pacemaker implantation is one of the most common types of heart surgery carried out, with many thousands of pacemakers fitted each year.

How a pacemaker works

A pacemaker is a small device about the size of a matchbox or smaller that weighs 20 to 50g. 

It consists of a pulse generator, which has a battery and a tiny computer circuit, and 1 or more wires known as pacing leads, which attach to your heart.

The pulse generator emits electrical impulses through the wires to your heart. The rate at which the electrical impulses are sent out is called the pacing rate.

Almost all modern pacemakers work on demand. This means they can be programmed to adjust the discharge rate in response to your body's needs.

If the pacemaker senses that your heart has missed a beat or is beating too slowly, it sends signals at a steady rate. 

If it senses that your heart is beating normally by itself, it doesn't send out any signals.

Most pacemakers have a special sensor that recognises body movement or your breathing rate.

This allows them to speed up the discharge rate when you're active. Doctors describe this as rate responsive.

Implantable cardioverter defibrillators (ICDs)

An implantable cardioverter defibrillator (ICD) is a device similar to a pacemaker.

It sends a larger electrical shock to the heart that essentially "reboots" it to get it pumping again.

Some devices contain both a pacemaker and an ICD.

ICDs are often used as a preventative treatment for people thought to be at risk of cardiac arrest at some point in the future.

If the ICD senses the heart is beating at a potentially dangerous abnormal rate, it'll deliver an electrical shock to the heart. 

This often helps return the heart to a normal rhythm.

A conventional ICD has a pacing lead that's implanted along a vein (transvenously).

There's also a newer type of ICD where the pacing lead is implanted under the skin (subcutaneously).

Why do I need a pacemaker?

The heart is essentially a pump made of muscle, which is controlled by electrical signals.

These signals can become disrupted for several reasons, which can lead to a number of potentially dangerous heart conditions, such as:

• an abnormally slow heartbeat (bradycardia)
• an abnormally fast heartbeat (tachycardia)
• heart block (where your heart beats irregularly because the electrical signals that control your heartbeat aren't transmitted properly)
• cardiac arrest (when a problem with the heart's electrical signals cause the heart to stop beating altogether)

How is a pacemaker fitted?

Having a pacemaker implanted is a relatively straightforward process.

It's usually carried out under local anaesthetic, which means you'll be awake during the procedure.

The generator is usually placed under the skin near the collarbone on the left side of the chest.

The generator is attached to a wire that's guided through a blood vessel to the heart.

The procedure usually takes about an hour, and most people are able to leave hospital on the same day or a day after surgery.

After pacemaker surgery

You should be able to return to normal physical activities soon after surgery. 

As a precaution, it's usually recommended that strenuous activities are avoided for around 4 to 6 weeks after having a pacemaker fitted.

After this, you should be able to do most activities and sports.

You'll be able to feel the pacemaker, but you'll soon get used to it. It may seem a bit heavy at first, and may feel uncomfortable when you lie in certain positions.

You'll need to attend regular check-ups to make sure your pacemaker is working properly. Most pacemakers store information about your natural heart rhythms.

When you have follow-up appointments, your doctor can retrieve this information and use it to check how well your heart and the pacemaker are working.

Using electrical equipment

Anything that produces a strong electromagnetic field, like an induction hob, can interfere with a pacemaker.

But most common household electrical equipment, such as hairdryers and microwave ovens, won't be a problem as long as you use them at least 15cm (6 inches) away from your pacemaker.

If you have an induction hob, keep a distance of at least 60cm (2ft) between the stove top and your pacemaker.

If this is a problem, you may want to consider replacing the appliance with something more suitable.

If you feel dizzy or feel your heart beating faster while using an electrical appliance, simply move away from it to allow your heart beat to return to normal.

Safety

Having a pacemaker implanted is usually a very safe procedure with a low risk of complications.

The biggest concern is the pacemaker losing its ability to control the heartbeat, either because it malfunctions or the wire moves out of the correct position.

It's sometimes possible to reprogramme the pacemaker using wireless signals.

But further surgery may be needed if the pacemaker moves out of position.

Alternatives to a pacemaker

In some cases, it may be possible to control an abnormal heartbeat (arrhythmia) without having a pacemaker fitted.

For example, atrial fibrillation can sometimes be treated with medication or a non-surgical procedure called catheter ablation.

But not all people with an arrhythmia can be treated in this way, and in many cases a pacemaker is considered to be the most effective option.

If your cardiologist recommends having a pacemaker fitted, ask them why they think it's the best option and discuss any possible alternative treatments you could have.

Why is it necessary?

Pacemakers are sometimes recommended for people with conditions that cause the heart to beat abnormally.

Each time the heart beats, the heart muscle contracts (pulls inwards) in preparation for pumping blood around the body.

The contractions are triggered by electrical pulses. These are generated by a group of specialised cells known as the sinoatrial node (SA node).

The SA node is often referred to as a natural pacemaker because it generates a series of electrical pulses at regular intervals.

The pulse is then sent to a group of cells known as the atrioventricular node (AV node). The AV node relays the pulse to the 2 lower chambers of the heart (the ventricles).

A pacemaker or implantable cardioverter defibrillator (ICD) is needed when something disrupts this process and causes an abnormal heartbeat.

An abnormal heartbeat is called an arrhythmia. Here are some of the most common causes of arrhythmias:

Sick sinus syndrome

In sick sinus syndrome, the SA node doesn't work as it should. This can lead to an abnormally slow heartbeat (bradycardia), an abnormally fast heartbeat (tachycardia), or a combination of both.

Symptoms of sick sinus syndrome can include:

• a slower pulse than normal (bradycardia)
• extreme tiredness (fatigue)
• fainting (or nearly fainting)
• dizziness or light-headedness
• shortness of breath
• chest pain
• irregular or fluttering heartbeats (palpitations)

Most cases of sick sinus syndrome are thought to be related to age.

Over time, the SA node tissue can become hardened and scarred. This can disrupt the normal pattern of electrical pulses released by the SA node.

Some types of medication can also trigger sick sinus syndrome as a side effect. These include calcium channel blockers and beta-blockers.

Atrial fibrillation

Atrial fibrillation is a condition that causes the heart to beat abnormally fast.

This is usually considerably higher than 100 beats a minute (often 140 beats a minute or more).

Atrial fibrillation can usually be treated with medication, but some people don't respond to treatment, so a pacemaker may be recommended.

Sometimes people with atrial fibrillation can have a much slower pulse rate than normal, which can also be intermittent (not continuous).

In these cases, a pacemaker will usually be recommended.

Heart block

In people with heart block, the pulse that needs to be sent from the SA node to the AV node is either delayed or absent.

Heart block can be caused when the heart is damaged (acquired heart block), or it can occur if a baby is born with 1 or more defects that affect their heart (congenital heart block).

If you have heart block and it's causing troublesome symptoms, a pacemaker will usually be recommended.

Cardiac arrest

An implantable cardioverter defibrillator (ICD), which is a device similar to a pacemaker, is mainly used to prevent cardiac arrest.

A cardiac arrest is a potentially fatal condition where the electrical activity that controls the heart becomes so disrupted that the heart stops beating.

Unless it's treated quickly, a cardiac arrest will be fatal. 

An ICD can detect abnormal electrical signals that could indicate that a cardiac arrest is about to happen.

If the ICD detects these type of signals, it sends a powerful electrical shock to the heart. 

This basically "reboots" the heart. After the shock, the heart should start beating normally again.

An ICD implantation may be recommended if you have had a cardiac arrest in the past or it's thought you have a significant risk of having one in the future.

Factors that increase the risk of a cardiac arrest occurring include:

• coronary heart disease (where the main vessels that supply the heart become narrowed and hardened, reducing the blood supply)
• having a heart attack
• congenital heart disease (where a person is born with one or more defects affecting their heart)
• cardiomyopathy (abnormalities of the heart muscle, which leads to poor heart function)

How is it performed?

Before having a pacemaker fitted, you'll have a preoperative assessment.

The team looking after you will check you're fit for surgery. You can discuss the operation and ask any questions at the assessment.

Some tests may be performed, including blood tests and an electrocardiogram (ECG).

You'll be asked about your general health and heart problems, and how they affect you.

You'll also be asked about any additional medical problems and previous operations you have had, as well as any problems or reactions you or your family have had with anaesthetics.

Taking steps to improve your health and fitness, such as stopping smoking if you smoke, eating a healthy diet and exercising regularly, should help speed up your recovery time and reduce the risk of complications.

You'll usually be told when you have to stop eating or drinking before surgery during the preoperative assessment.

Your specialist

The pacemaker implantation will be carried out by a heart specialist, known as a cardiologist, who will probably have a special interest in pacemakers.

If you're being treated in a large heart hospital, the operation will often be carried out by an electrophysiologist. This is a cardiologist who specialises in heart rhythm disorders.

Fitting the pacemaker

Transvenous implantation

Transvenous implantation is the most common method of fitting a pacemaker or an implantable cardioverter defibrillator (ICD).

Before the procedure, a thin tube called an intravenous (IV) line will be attached to one of your veins.

Medication to make you drowsy will be given through the IV line to keep you relaxed during the procedure.

The cardiologist will make a 5 to 6cm (about 2 inch) cut just below your collarbone, usually on the left side of the chest, and insert the wires of the pacemaker (pacing leads) into a vein.

The pacing leads are guided along the vein into the correct chamber of your heart using X-ray scans. They then become lodged in the tissue of your heart.

The other ends of the leads are connected to the pacemaker, which is fitted into a small pocket created by the cardiologist between the skin of your upper chest and your chest muscle.

Transvenous implantation is carried out under local anaesthetic, which is given as an injection.

This means the area where the cuts are made is numbed, but you remain awake during the procedure.

You'll feel an initial burning or pricking sensation when the cardiologist injects the local anaesthetic.

The area will soon become numb, but you may feel a pulling sensation during the operation.

Before the procedure, a thin tube called an intravenous (IV) line will be attached to one of your veins.

Medication to make you drowsy will be given through the IV line to keep you relaxed during the procedure.

The procedure usually takes about an hour, but it may take longer if you're having a biventricular pacemaker with 3 leads fitted or other heart surgery at the same time.

You'll usually need to stay in hospital overnight and have a day's rest after the procedure.

Epicardial implantation

Epicardial implantation is an alternative and less widely used method of fitting a pacemaker.

In this method, the pacing lead or leads are attached to the outer surface of your heart (epicardium) through a cut in your abdomen, below the chest.

Epicardial implantation is often used in children and people who have heart surgery at the same time as a pacemaker implantation.

It's carried out under general anaesthetic, which means you'll be asleep throughout the procedure. 

The surgeon will attach the tip of the pacing lead to your heart and the other end of the lead is attached to the pacemaker box. This is usually placed in a pocket created under the skin in your abdomen.

The procedure usually takes between 1 and 2 hours, but it can take longer if you're having other heart surgery at the same time.

Recovery after epicardial implantation usually takes longer than after transvenous implantation.

Implantable cardioverter defibrillators (ICDs)

In most cases, implantable cardioverter defibrillators (ICDs) are fitted transvenously, along a vein. But they can also be fitted under the skin (subcutaneously).

Subcutaneous implantation is either carried out using general anaesthesia, or with local anaesthesia and sedation.

During the procedure, a pocket will be created in the left side of the chest where the ICD will be positioned.

The pacing lead and electrodes are also placed under the skin along the breast bone and are connected to the device.

After the cuts have been closed, the sensing, pacing and recording functions of the ICD will be tested and adjusted.

Fitting an ICD can take 1 to 3 hours depending on the type of device you're having fitted.

An overnight stay in hospital is often, although not always, required.

Testing and setting the pacemaker

Once the leads are in place, but before they're connected to the pacemaker or ICD, the cardiologist will test them to make sure they work properly and can increase your heart rate. This is called pacing.

Small amounts of energy are delivered through the leads into the heart, which cause it to contract and pull inwards.

When the leads are being tested, you may feel your heart beat faster. Tell the medical team about any symptoms you feel.

Your doctor will adjust the settings of your pacemaker after deciding how much electrical energy is needed to stimulate your heartbeat.

Q&A

How will I be monitored?

You'll be attached to a special monitor so the medical team can keep an eye on your heart rhythm.

The monitor consists of a small box connected by wires to your chest with sticky electrode patches.

The box displays your heart rhythm on several monitors in the nursing unit. The nurses will be able to observe your heart rate and rhythm.

A chest X-ray will be carried out to check your lungs, as well as the position of the pacemaker and leads.

Will I be in pain after the procedure? 

You may feel some pain or discomfort during the first 48 hours after having a pacemaker fitted, and you'll be given pain-relieving medication.

There may also be some bruising where the pacemaker was inserted. This usually passes within a few days. Tell the staff if your symptoms are persistent or severe.

When can I leave hospital? 

Most people are able to go home on the day they have the procedure or the day after.

You'll need to arrange for someone to pick you up from hospital and take you home.

Before going home, you'll be given a pacemaker registration card, which has the details of the make and model of your pacemaker. Always carry the card with you in case of an emergency.

You may also want to wear a MedicAlert bracelet or necklace engraved with important information, such as the type of pacemaker you have, a personal identity number and a 24-hour emergency phone number.

Find out more about medical ID jewellery on the MedicAlert website

How soon can I drive? 

If you have an ordinary driving licence, you can start driving again after 1 week as long as:

• you don't have any symptoms, such as dizziness or fainting, that would affect your driving
• you have regular check-ups at the pacemaker clinic
• you haven't recently had a heart attack or heart surgery

You must also tell the Driver & Vehicle Licensing Agency (DVLA) and your insurance company that you have a pacemaker.

If you drive a large or passenger-carrying vehicle, you'll have to wait 6 weeks after your pacemaker is fitted before driving again.

Contact the DVLA to tell them about your pacemaker

Will I be able to feel or see the pacemaker? 

You may be able to feel the pacemaker and it may feel uncomfortable when you lie in certain positions, but you'll soon get used to it.

Modern pacemakers are now so small they're almost completely hidden by the chest tissue and are barely noticeable.

How soon will I be back to normal?

You should feel back to your usual self, or even better, very quickly.

It's best to avoid reaching up on the side you had your operation for 4 to 6 weeks. That means not hanging out washing or lifting anything from a high shelf, for example.

But it's important to keep your arm mobile by gently moving it to avoid getting a frozen shoulder. A physiotherapist can show you how to do this.

You'll usually be able to do all the things you want to do after around 4 weeks.

The time you need off work will depend on your job. Your cardiologist will usually be able to advise you about this.

Typically, people who have had a pacemaker fitted are advised to take about a week off work.

People who drive for a living, such as bus and lorry drivers, won't be allowed to drive these types of vehicles for at least 6 weeks after the pacemaker is fitted.

When can I exercise or play sports again? 

You should avoid strenuous activities for around 4 to 6 weeks after having your pacemaker fitted. After this, you should be able to do most activities and sports.

But if you play contact sports such as football or rugby, it's important to avoid collisions. You may want to wear a protective pad.

Avoid very energetic activities, such as squash.

The British Heart Foundation has more information and advice about how to start exercising again after having heart surgery

How can I care for my wound? 

Don't get your wound wet until your stitches have been taken out. After that, avoid wearing anything that rubs against the area of your wound, such as braces.

Women may need a new bra with wider straps. Avoid exposing your wound to sunlight in the first year as this can cause a darker scar.

Will I have to have my stitches removed? 

It depends on the kind of stitches used. Many doctors use soluble stitches that dissolve on their own. Before you go home, you'll be told what type of stitches you have.

If you need to have your stitches removed, it'll usually be after about 7 to 10 days.

What check-ups will I need? 

You'll usually have your pacemaker checked after 4 to 6 weeks at the hospital where it was fitted.

After this, you'll have it checked every 3 to 12 months, depending on the type of pacemaker you have and how well it's been working.

If after having the pacemaker fitted and leaving hospital you feel you're not getting as much benefit as you imagined, your pacemaker may need some small adjustments. 

The cardiologist or cardiac technician will be able to do this.

What problems should I look out for?

Signs that your pacemaker is not working as it should or you have developed an infection or blood clot include:

• breathlessness 
• dizziness
• fainting
• prolonged weakness
• a swollen arm on the side of the pacemaker
• chest pains 
• prolonged hiccups
• a high temperature
• pain, swelling and redness at the site of the pacemaker

Contact your GP or cardiologist as soon as possible for advice if you experience any of these problems after having a pacemaker fitted.

If this is not possible, call NHS 111 Wales.

Will my pacemaker be affected by electrical equipment? 

Anything that produces a strong electromagnetic field, like an induction hob, can interfere with a pacemaker.

Most common household electrical equipment, such as hairdryers and microwave ovens, will not be a problem, as long as you use them at least 15cm (6 inches) away from your pacemaker.

If you have an induction hob, keep a distance of at least 60cm (2ft) between the stove top and your pacemaker.

If this is a problem, you may want to consider replacing the appliance with something more suitable.

If you feel dizzy or feel your heart beating faster while using an electrical appliance, simply move away from it to allow your heart beat to return to normal.

Mobile phones

It's safe to use a mobile phone, but make sure you keep it more than 15cm (6 inches) from your pacemaker. Use a headset or the ear on the opposite side to the pacemaker.

Shop security systems

Walking steadily through an anti-theft detector in a shop doorway should not affect your pacemaker, but do not stand too close to this type of security device for long.

Airport security systems

Airport security systems do not usually cause problems with pacemakers, but carry your pacemaker identification card with you and tell security staff you have a pacemaker.

Security staff in some countries may insist you pass through the scanner. Move quickly through it and do not linger nearby.

Handheld metal detectors shouldn't be placed directly over your pacemaker.

MRI scans

MRI scans are not usually recommended for people with pacemakers because they produce strong magnetic fields.

MRI-safe pacemakers and implantable cardioverter defibrillators (ICDs) are becoming more common.

Other types of medical tests are safe, but always tell the person treating you that you have a pacemaker.

TENS machines

TENS machines should not be used without first consulting your pacemaker clinic or manufacturer. They produce small electrical impulses that could interfere with your pacemaker.

Lithotripsy

Lithotripsy, a treatment for kidney stones, must be avoided if you have a pacemaker fitted.

General advice

If your job brings you into contact with strong electrical fields, such as arc welding, diathermy or working with high-power radio or TV transmitters, or you have direct contact with car ignition systems, check with your cardiologist or pacemaker technician before returning to work.

Avoid wearing magnetic bracelets and magnets near your chest.

Will I need to have another pacemaker? 

Most pacemaker batteries last for 6 to 10 years. After this, you may need to have the batteries changed.

Ask your doctor how you'll know when the battery needs to be replaced or recharged.

Changing the batteries involves replacing the pacemaker box with a new unit. This is a simple procedure that may or may not require an overnight stay in hospital.

The original lead or leads can usually be left in place, although occasionally they'll also need to be replaced.

How often will I need follow-up appointments? 

You'll need follow-up appointments for the rest of your life after having a pacemaker fitted.

These may be every 3 to 12 months, depending on the type of pacemaker you have and how well it works.

At your follow-up appointment, the technician or doctor will analyse the discharge rate of your pacemaker, measure the strength of the electrical impulse, and record the effects of the impulse on your heart.

Most modern pacemakers can store information about the state of the battery and the performance of the pulse generator.

Your pacemaker can then be reprogrammed to the best settings for you, if necessary.

Will my sex life be affected? 

There's no reason you cannot continue to have a good sex life after having a pacemaker implanted and you're feeling better.

But you should avoid positions that place pressure on the arms and chest for the first 4 weeks of your recovery.

The risk of sex triggering a heart attack is low (around 1 in 1 million).

Who should I tell about my pacemaker? 

You should tell your doctor, nurse and dentist about your pacemaker, as you may need to avoid some medical tests and treatments, such as MRI scans and the use of TENS machines.

You should also tell your family and close friends that you have a pacemaker fitted. Tell them what to do if you lose consciousness or collapse.

Will the pacemaker improve my quality of life?

Most people who have a pacemaker fitted feel it has a tremendously positive impact on their life.

Having a pacemaker can help you be more active. It may also help you stay out of hospital and live longer.

Above all, you should feel better. Previous symptoms, such as breathlessness or dizziness, should disappear.

Risks

As with any medical or surgical procedure, pacemaker implantation has risks as well as benefits.

Blood clots

A blood clot can develop in one of the veins in the arm on the side of the body where the pacemaker was fitted.

This may cause some swelling in the affected arm, but it usually settles in a few days and is rarely a serious problem.

In some cases, you may be given anticoagulant medication, which stops the clot getting bigger.

Pacemaker infection

Some people with a pacemaker can develop a pacemaker infection. This usually happens within the first 12 months of having the device fitted.

Symptoms of a pacemaker infection include a high temperature and pain, swelling and redness at the site of the pacemaker.

Call your GP or cardiologist as soon as possible for advice if you're worried you have developed an infection. 

If this isn't possible, call NHS 111 Wales.

A pacemaker infection is usually treated using a combination of antibiotics and surgery to remove and then replace the pacemaker.

If an infection is not treated, it could spread into your lungs (pneumonia), the lining of your heart (endocarditis), or your blood (sepsis).

Air leak

As the vein the pacemaker wires are inserted into lies very close to 1 of the lungs, there's a risk of the lung being accidentally punctured during the procedure.

This means air can leak from the affected lung into the chest area. This problem is known as pneumothorax.

In most cases, the leak is very small and gets better on its own without treatment.

If a lot of air leaks into the chest, this may need to be sucked out using a needle and placing a special drain into the chest area.

If a drain is required, you may need to stay in hospital for an extra day or 2.

Problems with the pacemaker

As with any electronic device, there's a small chance your pacemaker could stop working properly. This is known as a pacemaker malfunction. 

A pacemaker can go wrong if:

• the lead gets pulled out of position
• the battery of the pulse generator fails
• the circuits that control the pacemaker are damaged after being exposed to strong magnetic fields
• the pacemaker hasn't been properly programmed

Signs your pacemaker may have failed include:

• your heart begins beating more slowly or quickly
• dizziness
• hiccups 
• fainting or nearly fainting

Seek immediate medical advice if you're concerned your pacemaker has failed.

In some cases, it may be possible to correct a pacemaker remotely using wireless signals.

Otherwise, the pacemaker will need to be removed and replaced.

Twiddler's syndrome

Twiddler's syndrome is when the pacemaker generator is pulled out of its normal position because a person is moving it back and forth or round and round under the skin ("twiddling" with it), often without realising.

One possible treatment option is to stitch the generator more firmly to the surrounding tissue so it cannot be moved.