A pacemaker is a small implantable device which assists the heart in maintaining its natural rhythm. A defibrillator is a pacemaker which also has the ability to shock the heart back into rhythm in rare life-threatening circumstances.
Who needs this procedure?
The heart’s internal electrical system controls the rate and rhythm of the patient’s heartbeat. When this system is faulty, it can cause arrhythmias which can result in the heart beating too slowly or too fast.
A pacemaker is a small electronic device which is used to increase the heart rate when required. Modern pacemakers are externally programmable and allow the doctor to select the optimum pacing modes for individual patients. An implantable defibrillator can assess whether the heart’s rhythm has become too fast and could result in a cardiac arrest. The defibrillator can automatically provide a timely shock to restore the normal rhythm and save the patient’s life.
What is involved?
The patient will be admitted to the hospital on the morning of the procedure and go home the next day, following a pacemaker check. The surgeon needs to be informed of the patient’s medications especially blood thinners such as aspirin, clopidogrel, warfarin, Xarelto, Eliquis or Pradaxa. Some of these must be ceased a few days prior to surgery depending on other medical conditions.
For most patients, pacemakers or defibrillators are inserted under general anaesthetic with the procedure taking approximately 45 minutes.
A pacemaker is a small device – only a little larger than a 50c piece, and about 5mm in thickness. A defibrillator is only marginally larger to account for the larger battery requirement. Typically, the device is inserted just under the collarbone on the left hand side of the chest but can also be implanted on the right side when required. The electrodes are threaded into the heart via a large vein underneath the collarbone (the subclavian vein). The electrodes are inserted using x-ray guidance to ensure optimal positioning. Before completing the surgery, the pacemaker is tested and the incision is closed using completely dissolvable stitches that are buried beneath the skin.
Inserting a pacemaker or defibrillator is a very safe procedure, however there are some risks involved. These include bleeding, infection and potential damage to the lung and heart. Because the electrodes are constantly exposed to the bloodstream there is also a long-term risk of the leads becoming infected. If this is the case the electrodes must be removed by a specialist.
A defibrillator is very similar to a pacemaker in both its technology and surgical technique. Defibrillators are inserted if a patient has suffered life threatening arrhythmias (ventricular tachycardia or ventricular fibrillation). They are also inserted for patients who have enlarged or failing hearts and are at risk of suffering such an arrhythmia.
At the time of surgery, the surgeon may choose to test the defibrillation function by artificially causing the heart to enter ventricular fibrillation for a few seconds before the new defibrillator shocks the heart back to a normal rhythm.
Defibrillators are very common and can give patients the peace of mind that if they were to suffer a potentially deadly heart rhythm, having an internal defibrillator gives them the best chance of survival.
Cardiac Resynchronisation Therapy
Cardiac Resynchronisation Therapy (CRT) involves placing a specialised pacemaker that has an additional lead inside a vein on the left side of the heart (left ventricle). This pacemaker may also have an additional defibrillator function if necessary.
Patients who are suffering from heart failure often have abnormal electrical pathways in the heart that result in the right ventricle contracting before the left ventricle. This is inefficient and can result in debilitating shortness of breath.
If the patient is a candidate for CRT, electrodes are placed in both the right and left sides of the heart to co-ordinate or ‘resynchronise’ the pumping chambers of the heart. Most patients will notice an improvement in their shortness of breath and exercise capacity. The procedure is almost identical to insertion of a pacemaker; however, the device is slightly larger and the procedure can last up to a few hours due to the positioning of the electrodes in the heart.
What is the recovery like?
An overnight stay in the hospital ensures that the medical team can check the full functionality of your pacemaker and ensure that your heart rhythm is appropriate. Mild swelling, pain and site tenderness may occur and can be relieved with over-the-counter medication.
Typically, you can expect to return to normal activities within a few days post-surgery. The arm on the side of the pacemaker shouldn’t be raised above 90 degrees for two weeks to prevent dislodgment of the electrodes. Vigorous activities and heavy lifting must be avoided for about one month. A follow up appointment at Dr Bassin’s rooms will be booked 2 to 4 weeks post surgery to assess your recovery and retest the function of the device.
Pacemakers must be regularly checked by a Pacemaker Technician – something that is scheduled every 6 – 12 months to help with early detection of any issues. These checks and any adjustments necessary are done from outside your body by using a radio wave programmer, without invasive procedures. The battery life of the device is approximately 10 years depending on how much usage the pacemaker has required. When the battery is close to running out the entire device is changed requiring a small day-only surgical procedure.
When can I drive?
Roads and Maritime requires a period of 2 weeks without driving following insertion or change of a pacemaker or a defibrillator for a private license. If you have suffered a cardiac arrest prior to insertion of a defibrillator the driving restriction is 6 months.
For a commercial licence the restriction is 4 weeks following insertion of a pacemaker. Anyone with an implantable defibrillator cannot hold a commercial driving licence.