What Is a Permanent Pacemaker?

The most common use of pacemakers is the treatment of abnormal heart rhythms (arrhythmias).

A pacemaker is a tiny device (not more than the size of a small matchbox), placed in the chest or abdomen, that sends small electrical impulses to the heart muscles for maintaining a suitable heart rate. It may also be used to treat heart failure, fainting spells (syncope), and certain diseases of the heart muscles (hypertrophic cardiomyopathy).

The commonest use of pacemakers, however, is the treatment of abnormal heart rhythms (arrhythmias). The heart has its internal electrical system to control the rate and rhythm of the heartbeat. During a heartbeat, the different parts of the heart receive electrical impulses from the heart’s natural pacemaker (the sinoatrial or SA node) that causes phasic contraction and relaxation of different parts of the heart. The normal heartbeat allows the heart to pump blood regularly and adequately to meet the body’s requirement.

Pacemakers can be classified as:

• Temporary pacemakers: These are used to treat short-term heart problems, such as a slow heartbeat caused by a medicine overdose, heart attack, or heart surgery. 
• Permanent pacemakers: These are used to regulate long-term (chronic) heart rhythm problems. 

Faulty electrical signals in the heart lead to arrhythmias. This may cause the heart to beat too fast (tachycardia), too slow (bradycardia), or with an irregular rhythm. An arrhythmia may hamper the ability of the heart to pump blood effectively leading to the following symptoms:

• Fatigue
• Fainting
• Breathlessness
• Uneasiness
• Chest pain
• Sweating

A permanent pacemaker may relieve the symptoms by sending low energy electrical pulses to overcome the faulty electrical signals in an arrhythmia. This regularizes the heartbeat and enables the heart to pump blood effectively to the body.

• A permanent pacemaker implantation procedure is a minor surgery that can be done in a hospital or a special heart treatment lab.
• The surgery site is cleaned with antiseptics.
• The anesthesiologist gives intravenous antibiotics to prevent infections and sedation to keep you calm during the surgery.
• Local anesthesia is administered to numb the area where the doctor will put the pacemaker so that you do not feel any pain.
• The doctor inserts a needle into a large vein near the neck or shoulder of your non-dominant hand. 
• The doctor then uses the needle to thread the pacemaker wires into the vein and correctly place it in your heart. To ensure proper placement, the procedure is done under X-ray image guidance.
• The doctor will make a small cut into the skin of your chest or abdomen to create a small pocket under your skin where they place the pacemaker's small metal box containing the pacemaker’s battery and generator. 
• They will then connect the metal box to the wires that lead to your heart. 
• The doctor then tests for the proper functioning of the pacemaker.
• Once the pacemaker functioning is ensured, the doctor will apply sutures to close the cut. 
• A sterile dressing is applied. 
• An arm restraint or immobilizer is applied to the arm on the side of the surgery for 12-24 hours to limit movement.
• Pain levels are typically low after the procedure. You may be given pain medication to manage any pain associated with the incision site.

The common complications after a permanent pacemaker surgery include:

• Early complications   
  • Bleeding
  • Swelling
  • Bruising/pain
  • Phlebitis/thrombophlebitis (inflammation of the veins)
  • Lead dislodgement or displacement
  • Local infection
  • Blood vessel injury
  • Pneumothorax (presence of air in the space between the lungs and the chest wall)
  • Hemothorax (presence of blood in the space between the lungs and the chest wall)
  • Myocardial (heart muscle) perforation
  • Anaphylaxis (severe and potentially fatal allergies)
  • Air embolism (entry of air bubbles in the blood vessels)
  • Pacemaker infection
  • Pacemaker malfunction
  • Dysrhythmia (abnormal heart rhythm)
  • Chylothorax (lymph fluid leaks in the space between the lungs and the chest wall)
  • Pacemaker syndrome (a phenomenon in which a patient feels symptomatically worse after pacemaker placement and presents with progressively worsening symptoms of congestive heart failure)

• Late complications
  • Pocket erosion (damage to the skin pocket that contains pacemaker’s metal box)
  • Lead dislodgement  
  • Hematoma (a localized collection of blood)
  • Phlebitis/deep vein thrombosis (inflammation/clotting inside a vein)
  • Infection   
  • Hemothorax (collection of blood in the space between the lungs and the chest wall)  
  • Atrioventricular fistula (abnormal communication between an atrium and a ventricle)  
  • Infection of pacer lead/generator  
  • Myocardial perforation   
  • Pacer malfunction   
  • Pacemaker syndrome   
  • Allergy or sensitivity to the device  
  • Lead fracture   
  • Endocarditis