Pacemaker implantation

A pacemaker is a device that helps maintain a normal heart rate when the heart beats too slowly or the electrical signal is not transmitted correctly. The decision to implant one is based on the type of condition, the symptoms and the likelihood of there being a reversible cause.

What is a pacemaker and how does it work?

The heart has its own electrical system that initiates and coordinates each heartbeat. The signal usually originates in the sinus node, located in the right atrium, and is then transmitted to the ventricles so that the various chambers contract in an orderly manner.

When this signal is generated too slowly, pauses occur or the transmission to the ventricles is interrupted, the heart rate may be insufficient to maintain adequate circulation. This can lead to tiredness, dizziness, shortness of breath, fainting or reduced exercise tolerance, although some abnormalities are detected before symptoms develop.

A conventional pacemaker consists of a generator, which contains the battery and electronic components, and one or more electrodes – thin wires that reach the heart via a vein. The system detects the heart’s own electrical activity and delivers pulses only when the heart rate or conduction requires it.

When might a pacemaker be recommended?

Implantation may be considered when there is a significant abnormality in heart rhythm or electrical conduction, and it is thought that pacing may prevent symptoms or complications.

One of the most common situations is symptomatic bradycardia, in which the heart beats too slowly, leading to tiredness, dizziness, fainting or difficulty with physical exertion. It may also be indicated when the sinus node is not functioning properly or causes prolonged pauses.

Another important indication is atrioventricular block, in which the electrical signal does not pass correctly from the atria to the ventricles. The need for a pacemaker depends on the type and degree of the block, its persistence and its clinical impact.

Before making a decision, the team investigates whether the condition may be due to medication, metabolic disorders, endocrine problems or other potentially reversible causes. In certain advanced cases of block, the device may be recommended even in the absence of clear symptoms, due to the risk associated with the conduction disturbance.

How is it decided which type of pacemaker each person needs?

The choice of device depends on which part of the electrical system is affected, what the heart’s natural rhythm is, and which chambers require stimulation. Not all pacemakers perform exactly the same function.

Single-chamber devices stimulate a single chamber, usually the right ventricle. Dual-chamber devices can stimulate both the right atrium and right ventricle and, in selected patients, help maintain a coordination pattern more similar to the heart’s natural function.

Some people with heart failure and specific abnormalities in ventricular activation may require cardiac resynchronisation therapy, which stimulates both ventricles to improve their coordination. This is a different indication from that of a conventional pacemaker.

There are also leadless pacemakers, which are inserted via a catheter and fixed directly inside the heart, without a subcutaneous pocket or conventional venous electrodes. In other cases, techniques for stimulating the cardiac conduction system may be used, aimed at utilising the heart’s own electrical pathways in a more physiological manner.

The choice is based on the electrical abnormality, the anatomy, any associated conditions and the most appropriate pacing strategy for each situation.

Pre-implantation assessment and preparation

The pre-implant assessment combines symptoms with the electrical recordings that have enabled the condition to be identified. An electrocardiogram, Holter monitor or other monitoring systems can show when pauses, bradycardia or conduction disorders occur and help to link them to the symptoms.

Blood tests and other investigations may also be requested depending on the clinical context. The team pays particular attention to identifying any reversible causes and assesses any cardiovascular or general medical conditions that may affect the procedure.

Before implantation, checks are carried out to ensure there is no active infection, and preventive measures are taken to reduce the risk of infection of the system. Patients must also disclose any allergies, coagulation disorders, previous chest procedures, known difficulties with venous access and the presence of other implanted devices.

Regular medication is reviewed on a case-by-case basis. Anticoagulants, antiplatelet agents and other treatments must not be discontinued without medical advice, as their management depends on the risk of bleeding and the reason for which they are prescribed.

How a pacemaker is implanted

The procedure is carried out in a room equipped for cardiological procedures, with continuous heart rhythm monitoring and X-ray imaging support.

Local anaesthesia is usually administered to the area where the device is to be implanted and, where necessary, sedation is used to ensure patient comfort. The level of sedation is adjusted according to the type of procedure and the patient’s clinical condition.

One or more electrodes are inserted via a vein near the collarbone and advanced to the relevant heart chambers under radiological guidance. Once in place, the team checks that they are correctly detecting electrical activity and that they are able to stimulate the heart using appropriate settings.

A small space is then created under the skin of the upper chest to house the generator. The electrodes are connected to the device, the initial settings are adjusted, and the device’s function is checked again before the wound is closed.

Implantation of a wireless pacemaker

Wireless pacemakers use a different technique. The device is inserted via a catheter, usually through a vein in the groin, and is fixed directly inside the heart.

As they do not require a pocket under the skin of the chest or conventional venous electrodes, they do away with some elements of the traditional system. Their suitability, however, depends on the patient’s pacing requirements and individual characteristics.

Recovery following implantation

During the first few hours, your heart rate, the device’s functioning and the area around the surgical site are monitored. You may experience tenderness, tightness or bruising around the wound, particularly if you are taking anticoagulants or antiplatelet medication.

The length of observation depends on the type of pacemaker, the immediate post-operative course and any associated medical conditions. Some patients may be discharged after a short period, whilst others may need to remain in hospital to complete the monitoring process.

During the first few days, you should follow the instructions for caring for the wound and the dressing. You should avoid knocks, sudden jerks, heavy lifting and certain extreme movements of the arm on the side of the implant for the specified period.

It is not usually necessary to keep the arm immobile. Mobility is regained gradually, as excessive restriction can lead to pain and stiffness in the shoulder.

A return to work, driving and exercise depends on the reason for the device’s implantation, how the wound is healing, any previous history of syncope and the type of activity usually undertaken.

Risks and potential complications depending on the type of implant and the patient’s clinical condition

Pacemaker implantation is a cardiological procedure and may be associated with complications. The type and likelihood of these occurring depend on the patient’s individual characteristics, antithrombotic treatment, venous access, the number of electrodes and the type of device implanted.

Possible problems related to the wound and venous access include bleeding, haematoma or infection. An electrode may become dislodged after placement and, with certain types of venous access, a pneumothorax may occur, i.e. the entry of air around the lung.

Vascular injuries, perforation of the heart wall, fluid build-up around the heart or malfunctions of the system may also occur. The impact of these complications varies: some require only monitoring or adjustments, whilst others may need specific treatment or a further procedure.

Infections affecting the generator or the electrodes require particularly careful assessment and, in certain cases, may necessitate removal of the system.

The extent of the risk cannot be expressed by a single estimate applicable to everyone. The implantation of a simple device and a procedure requiring several electrodes or a more complex pacing strategy represent different scenarios.

Pacemaker check-ups and monitoring

Monitoring forms part of the treatment throughout the device’s lifetime. Check-ups enable the functioning of the generator and the leads to be checked, the programme settings to be adjusted, and to determine how long and in what situations the heart is being paced.

The pacemaker stores information on heart rhythm, which can provide relevant data for monitoring. The settings are adjusted according to the patient’s clinical progress, their activity levels and their pacing requirements.

Many modern devices allow for remote monitoring, sending technical information to the healthcare team from the patient’s home. This tool facilitates more continuous monitoring and can help detect certain abnormalities between face-to-face check-ups.

Remote monitoring does not completely replace face-to-face consultations, nor does it function as an emergency care system. The onset of significant symptoms requires medical assessment even if no alert has been received from the device.

Battery and generator replacement

Battery life depends on the model, the programming, the number of electrodes and the amount of stimulation each person requires. Regular check-ups enable us to estimate in advance when the battery is nearing the end of its useful life.

When that time comes, it is not a single battery that is replaced, but the entire generator. The new device is usually connected to the existing electrodes if they are still functioning correctly.

The replacement procedure usually takes place in the same area as the original generator, and where the electrodes can be retained, it is a different and generally less complex procedure than the initial implantation.

Pacemakers, electronic devices and MRI scans

Most household appliances and commonly used electronic devices can be used as normal after an implant.

Mobile phones are usually compatible with pacemakers, although it is recommended that you avoid placing them directly on the generator. It is also advisable to keep certain objects containing strong magnets away from the implant site.

Security scanners may detect the device. Carrying your pacemaker identification card allows you to inform staff of the implanted system when necessary.

Magnetic resonance imaging (MRI) requires specific assessment. Many current systems allow MRI scans to be carried out under certain conditions, but it is necessary to know the model of the generator and the electrodes and to follow a programming and monitoring protocol.

For this reason, the presence of a pacemaker should not lead to an MRI scan being automatically ruled out, nor should it be scheduled without first checking the characteristics of the implanted system.

Situations requiring specific assessment

Anticoagulant or antiplatelet therapy

These medicines may increase the risk of haematoma or bleeding around the implant site. Their management is tailored to the clinical indication and individual risk, whilst avoiding unplanned discontinuation.

Active infection

The presence of an infection may affect the timing of implantation, as infection of the device is a significant complication and may subsequently require removal of the system.

Complex venous access or previous procedures

Previous procedures, catheters, devices or venous abnormalities may alter the access route and implantation technique.

Heart failure

Some people with heart failure require a specific pacing strategy, such as cardiac resynchronisation therapy or certain forms of physiological pacing, rather than a conventional pacemaker.

Future need for MRI scans

Where it is anticipated that a person may require MRI scans during their lifetime, the system’s compatibility may form part of the device planning process.

Symptoms requiring medical assessment

Following implantation, you should contact the team if you experience increased pain, redness, warmth, discharge or progressive changes to the skin over the generator. A fever with no clear cause also requires assessment.

You should also seek advice if dizziness, fainting or symptoms similar to those experienced before the implant return, or if you experience persistent palpitations, repeated hiccups or muscle twitching near the device.

Loss of consciousness, severe breathing difficulties, persistent chest pain, significant bleeding, a rapidly enlarging bruise or a sudden deterioration in your general condition require urgent medical attention.

Specialists involved

The care pathway begins by accurately identifying the specific rhythm or electrical conduction disorder present and determining whether the patient would benefit from permanent cardiac pacing.

At the Publio Cordón Memorial Hospital, the Electrophysiology and Arrhythmia Unit is the specialist unit responsible for the assessment and implantation of pacemakers. It treats bradycardia and conduction disorders and has expertise in pacemakers, implantable cardioverter-defibrillators and cardiac resynchronisation devices, as well as follow-up through in-person check-ups and remote monitoring.

The unit forms part of the Cardiology Department, whose structure enables the coordination of clinical assessment, electrical diagnosis and device selection within a single cardiovascular pathway. The department also comprises Clinical Cardiology, Haemodynamics and Advanced Cardiac Imaging for situations requiring further assessment.

In cases of heart failure, structural heart disease or other cardiovascular conditions, these units can collaborate in selecting the pacing strategy and in subsequent follow-up.

Specialist nursing staff are involved in preparation, wound care, patient education regarding the device and subsequent monitoring. Where the procedure or clinical situation requires it, Anaesthetology and other support departments may also be involved.

Not everyone requires the involvement of all these units. The care pathway is tailored to the type of electrical abnormality, the selected device, any associated conditions and long-term follow-up requirements.

Preguntas frecuentes

Does the pacemaker run continuously?

Answer: Not always. Many pacemakers continuously monitor the heart rate and only deliver pulses when they detect that the rate has fallen below the programmed threshold or that electrical conduction is not occurring correctly. Other people require pacing for a greater proportion of their heartbeats, depending on their heart condition and the device’s settings.

Does a pacemaker implant cause pain?

Answer: Local anaesthetic is usually used, so during the procedure you may feel pressure, tugging or a sensation of manipulation rather than pain. After the implant, it is common to experience tenderness, tightness or discomfort around the wound for the first few days.

How long do you have to stay in hospital after the implant?

Answer: The length of observation depends on the type of device, the immediate clinical course and any associated conditions. Some people may be discharged after a short period, whilst others need to remain in hospital to complete their follow-up.

Can you move the arm on the side with the pacemaker?

Answer: It is not usually necessary to keep the arm still. During the period recommended by the medical team, you should avoid heavy lifting, sudden jerks and abrupt or extreme movements, whilst gradually regaining comfortable mobility in the shoulder.

Can you use a mobile phone with a pacemaker?

Answer: Mobile phones can generally be used as normal. It is recommended that you avoid placing them directly on top of the generator and keep any accessories or devices containing strong magnets away from it.

Can security checks affect a pacemaker?

Answer: Security systems may detect the presence of the device. Passing through a security gate as normal does not usually cause any problems, but it is advisable to carry your pacemaker ID card and to inform security of its presence where necessary. Hand-held detectors should not be held against the generator for any prolonged period.

What happens when the pacemaker’s battery runs out?

Answer: The battery forms part of the generator and cannot be replaced separately. Servicing allows us to anticipate when the end of its service life is approaching and, when that time comes, the entire generator is replaced. The electrodes can be retained if they continue to function correctly and there is no other reason to inspect or remove them.

Does remote monitoring replace face-to-face check-ups?

Answer: Not entirely. Remote monitoring allows technical information from the pacemaker to be transmitted and can help detect certain abnormalities between check-ups, but it is still necessary to attend the check-ups as advised by the medical team. Nor does it function as an emergency service should significant symptoms arise.

Medical information for general guidance

This information sheet aims to help you understand what a pacemaker is, in which situations it may be recommended, how the type of device is selected, how the implant is carried out and what follow-up checks are required afterwards. It also explains generator replacement, remote monitoring and the main precautions relating to the device.

At Publio Cordón Memorial Hospital, we believe it is important for medical information to be accurate, understandable and useful in guiding each individual through their care journey. Our specialists devote part of their work to explaining conditions, tests and treatment options in an accessible way, helping patients and their families to better understand each stage and participate with greater confidence in decisions about their health. This commitment to knowledge and public outreach is also part of our dedication to research and medical progress.

The information contained in this factsheet describes the general principles of pacemaker implantation. The indication and type of device must be tailored to each individual, taking into account the specific arrhythmia or conduction disorder, symptoms, possible reversible causes, associated conditions, and each person’s stimulation and monitoring requirements.