Pacemaker Surgery Explained – The Heart Pacemaker Procedure

Image of a fictional pacemaker implant
Don’t worry this isn’t to Scale!
Any needles are tiny and just feels
like a small scratch!

Pacemaker Surgery Explained – The Heart Pacemaker Procedure

(Don’t read if squeamish)

This is not intended to replace implant training! Proper surgical procedures and techniques are the responsibility of the healthcare professional.

I am going to give a quick explanation of a pre-pectoral (on top of your pectoral muscle, chest) Cardiac pacemaker implant. Most are done under local anaesthetic and take from 30-60 Minutes. The patient is usually well enough to go home that day or the day after.
Now you don’t have to be a doctor to figure out that poking a lead into the heart any old how is going to seriously impact some ones life expectancy… to a few minutes. So cleverly we use your internal plumbing to gain access and this means we can do so with very minimal trauma.
Once a patient has consented to the procedure and all blood tests have shown all the important makers and levels to be in acceptable ranges, they are prepared for the pacemaker implant.
The patient will lay on the operating table and be covered in sterile drapes with the skin around the area of the body to be operated on also sterilised. At the same time the patient will also be hooked up to an ECG, sats probe and blood pressure cuff to monitor their progress through the procedure.. In the more risky cases a defibrillator is often attached to the patient but this is a simply a precautionary measure as we would hate it to not be in place if we required it!
Leads of the cardiac pacemaker entering the heart
A Dual Chamber Pacemaker and Leads
that run from the device down into the Heart!

Once the patient is comfortable and suitably relaxed (a medication that mimics a few Gin and Tonics may have been administered by now) local anaesthetic is used to numb the area and  a small incision is made just under the collar bone on the patients left hand side. If the patient is left handed occasionally pacemakers are inserted on their right hand side. 

Now all veins in your body (nearly all! no-one likes a smart arse) run to the right side of your heart and that is particularly useful in pacemaker implants. At this point, the cardiologist will locate either the Cephalic or Subclavian Vein. They are some of the larger veins in your body and will use them to guide the pacemaker leads down into the desired parts of the heart

With any kind of surgery we want to minimise the trauma that the body will then have to recover from. This is no different when using a vein to gain access to the heart so we use an introducer kit in many cases that allows easy access to the vein. In this order… a needle is inserted into the vein of choice and a guide wire fed through it into the vein. The needle is removed, leaving the guide wire in place and the introducer is slipped over the top of the guide wire securely into the vein. The guide wire is then removed, leaving the cardiologist with a tube (introducer) in the vein that is perfect to slide the leads down without too much difficulty.
The cardiologist is now ready to start feeding the pacemaker lead down into the heart. If the pacemaker is a single chamber pacemaker then the first lead to be put into the heart chooses itself as it is the only lead going into the heart!
If their are 2 or more leads going down the vein into the heart a decision is made on which lead is most appropriate to position first. 99/100 times the Ventricular lead is the first to be positioned for two main reasons; 
1) The ventricle is the most important part of your heart when supplying your body and brain with blood and 2) because if you positioned the top lead (Atrial Lead) first, you would need to pass this lead when positioning the ventricular lead. With that order of play would come an increased risk of dislodging the Atrial lead on the way through.
To assist in the navigation of the lead down into the heart a live x-ray is used and displayed on a monitor infront of the doctor. This gives real time footage of the progress of the lead down the vein into the heart. The ventricular lead is passed down the vein into the atrium (top of the heart) and then pushed into the lower chamber of the heart (The ventricle). Between the top and bottom chambers is the Tricuspid Valve which occasionally makes life a little difficult when feeding the lead into the desired location.
Whilst the lead is being positioned it is very common (nearly 100%) of cases for the heart to get ectopics or a run of ectopics which can feel like thumps in the patients chest and with a touch of light-headedness. These are heart beats that are coming from a separate part of the heart and occur because the lead is tickling the walls of the heart on it way through. Much like somebody sticking a feather up your nose, is going to make you sneeze!
The location of choice for a ventricular lead is usually the Right Ventricular Apex. The reason being the angle of the lead and the amount of nooks and crannies in this part to get the lead into. This isn’t always the case though, the ‘PREVENT’ study showed that pacing in this area can lead to heart failure and atrial fibrillation so in younger patients and older ones too now! A septal lead position is required. This is where the lead goes into the hearts ventricular septum and means a ‘paced’ beat takes a more natural pathway.
A chest x-ray showing a Cardiac Pacemaker in the heart
A Single Chamber Pacemaker Under X-Ray

So the Cardiologist has the lead where they wants it so it is time to be secured. Now this occurs in two ways with Right Ventricular Leads, in Passive fix leads the lead anchors itself in place. It has prongs along the tip of the lead and these not into the tuberculated (rough, nobbly and bobbly) tissue in the heart, much like an anchor catching on the rough sea bed.  The other method used by ‘Active Fix’ Leads is a small corkscrew that comes out the end of the lead and bores its way into the heart. This is more of your using a corkscrew to open a bottle of wine method… but we don’t pull the cork out!!!

Is the lead ok? Time for it to be tested! Now the pacemaker leads are attached to a ‘programmer’ this is the same computer that a technician uses when doing a pacemaker follow up and the Cardiac Technician essentially does a pacing check, looking at threshold, impedance and amplitude. We also do a test for stability, we get the patient to cough, take deep breaths and pant like a dog! We aren’t getting mild entertainment from your dog impressions, we are seeing if common everyday stresses will dislodge the lead! Finally we send a large Voltage down the lead and see if its making anything else beat.
Sometimes pacemaker leads can irritate the diaphragm and give the patient hiccups, so we check that this won’t happen under a high voltage!
If we are all happy with the readings we are getting from this lead we leave it in place and the healing process around the lead will start to occur. The healing is what really secures the lead in place, with the lead tip eventually being engulfed with cardiac tissue.
In a dual chamber device (one with two leads), the Atrial lead is then positioned. Much in the same way the lead is fed through a 2nd introducer and down into the heart, this time stopping in the top chamber (Atrium) and positioned in the right Atrial Appendage which has characteristics making it the site of choice for Atrial Lead deployment. This lead is then tested in the same manor as the ventricular lead.
Now for the easy bit, the pre-programmed pacemaker is given to the Cardiologist who plugs in the Pacemaker leads being careful not to pull them at all as they still aren’t fully secure in the heart. At this point the pacemaker starts to work and all that is left is for a pocket to be made under the skin to house the device. The patient will feel some pulling and tugging at this point but no pain. Once the pocket is made the pacemaker fits in it nice and snuggly before finally the pocket is stitched up!.
The patient is then monitored for a couple of hours and often an X-Ray is requested to check for any Pneuomo/Haemothorax (A leak of air or blood as a result of all the surgery) When given the all clear the patient is free to go home and get on with their life as a proud new pacemaker patient who is now a lot less likely to faint!

No we understand all of this here is an animation of a right sided pacemaker implant.

A complete explanation of these topics and more is available in the book Pacemakers Made Easy by Carl Robinson.

THE PAD would like to thank The Sorin Group (Pacemaker Specialists) for this helpful animation on Cardiac Pacemaker Implant.

Thank you for reading…

About time I did some of my research project…
Cardiac Technician

Image courtesy of jscreationzs /

Comments 1

  1. Had one fitted last week in France, just worried about dislodging the wire. Your description and especially the delivery is brilliant.

    Thank you

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