Heart Failure and the Biventricular Pacemaker
What Happens During the Pacemaker Implantation?
Pacemakers can be implanted two ways:
Inside the Heart (Endocardial, Transvenous approach): This is the most common technique used. A lead is placed into a vein (usually under your collarbone), and then guided to your heart. The tip of the lead attaches to your heart muscle. The other end of the lead is attached to the pulse generator, which is placed under the skin in your upper chest. This technique is done under local anesthesia (you will not be asleep).
Outside the Heart (Epicardial approach): Your chest will be opened and the lead tip is attached to the outside of the heart. The other end of the lead is attached to the pulse generator, which is placed under the skin in your abdomen. This technique is done under general anesthesia (you will be asleep) by a surgeon. This is typically performed in conjunction with open heart surgery being performed for another reason.
Your doctor will decide which approach is best for you, although almost all patients receive the transvenous approach.
A Closer Look at What Happens During the Endocardial Approach
- Your procedure will take place in the electrophysiology (EP) lab, catheterization lab, or operating room. You will lie on a bed and the nurse will start an IV (intravenous) line to deliver medications and fluids during the procedure. An antibiotic will be given through your IV at the beginning of the procedure to help prevent infection. You will receive a medication through your IV to make you drowsy. The medication will not put you to sleep. If you are uncomfortable or need anything during the procedure, please let the nurse know.
- The nurse will connect you to several monitors. The monitors allow the doctor and nurse to monitor your condition at all times during the procedure.
- Because it is very important to keep the area of insertion sterile to prevent infection, your chest will be shaved (if necessary) and cleansed with a special soap. Sterile drapes will be used to cover you from your neck to your feet. A soft strap will be placed across your waist and arms to prevent your hands from coming in contact with the sterile field.
- The doctor will numb your skin by injecting a local numbing medication. You will feel a pinching or burning feeling at first. Then the area will become numb. Once this occurs, an incision will be made to insert the pacemaker and leads. You may feel a pulling as the doctor makes a pocket in the tissue under your skin for the pacemaker. You should not feel pain. If you do, tell your nurse.
- After the pocket is made, the doctor will insert the leads into a vein and guide them into position using a fluoroscopy machine.
- After the leads are in place, the doctor tests the leads to make sure lead placement is correct, the leads are sensing and pacing appropriately and the right and left ventricle are synchronized. This is called "pacing" and involves delivering small amounts of energy through the leads into the heart muscle. This causes the heart to contract. When your heart rate increases, you may feel your heart is racing or beating faster. It is very important to tell your doctor or nurse any symptoms you feel. Any pain should be reported immediately.
- After the leads are tested, the doctor will connect them to your pacemaker. Your doctor will determine the rate of your pacemaker and other settings. The final pacemaker settings are done after the implant using a special device called a "programmer."
- The pacemaker implant procedure lasts one to two hours. A biventricular pacemaker may take longer.