Dr Oliver Segal

Once you’ve been diagnosed with a bradycardia, Dr Segal will discuss pacemaker implantation with you. This is a simple procedure performed using a local anaesthetic and mild sedation. The latter means you are given drugs intravenously to make you sleepy, but you continue to breathe without support and can be woken if necessary.

Pacemakers are sited under the left collarbone. Local anaesthetic is injected into the skin under the left collarbone to make it numb. A small incision is made at this site, usually about 4cm long. The tissues underneath are dissected to create a small pocket under the skin for the pacemaker battery.

The axillary vein is a large vein that carries blood back from the arm to the heart and is used for inserting pacemaker leads into the heart. Dr Segal uses ultrasound to visualise the axillary vein, allowing a fine needle to be safely inserted, through which a fine wire is advanced. The needle is then removed, and a plastic sheath advanced over the wire that allows the pacing lead to be directed to the heart.

This has changed over the years. Traditionally, once the vein has been accessed, the pacing lead is pushed down through it into the heart guided by an X-ray camera. Fine metal wires called stylets are inserted into the lead to help change its shape, allowing it to be pushed into different positions. The wires can be bent and curled before they’re inserted into the lead to help with this.

More recently, much thinner pacing leads are used that don't have stylets and are advanced through long plastic sheaths. These newer pacing leads are designed to sit within the middle wall of the heart (the septum) so that they connect directly to the ‘wires of the heart’ – the conduction system. This allows ‘conduction system pacing’ (CSP), which has potential benefits for heart function. Sometimes both types of lead are used.

Leads are secured to the heart by a small metal screw at the tip of the lead, called a helix. The helix is designed to screw into the heart tissue itself, thereby anchoring it. Over time scar tissue forms over the tip of the lead, holding it permanently in place. This type of lead is called an active fixation lead. Previously, passive pacing leads were used, which have simple silicone anchors at the end rather than a helix.

The lead is then tested for its ability to record heart signals, called sensing, and its ability to pace the heart, called threshold. If these values are satisfactory, the top of the lead is sewn into the pocket under the collarbone, so the lead is then anchored at both ends. If the values aren’t satisfactory, the lead is retracted and re-positioned.

A second lead may then be added so that both the atrium and the ventricle can be paced although this is not always necessary. For example, patients who have permanent atrial fibrillation cannot have the atrium paced as this rhythm prevents it.

Once the lead, or leads, is in the right position with acceptable values, the other end is inserted into the pacemaker battery, or generator. It’s secured by tightening a screw. The pacemaker is then placed in the pocket under the skin and the leads wrapped around it, placing them beneath the generator.

The leads and generator are placed within an anti-bacterial envelope called a TYRX™. This is made of a flexible mesh which is impregnated with antibiotics and dissolves over several weeks. This reduces the risk of infection by 50%. This is then placed into the pacemaker pocket. Once secured, the pocket and wound are closed with stitches. Dr Segal uses stitches that are slowly absorbed over the next 6 weeks, so you don’t need to go back to your doctor to have them removed.

If you’re very thin, it’s often better to place the pacemaker generator under the chest muscle rather than just the skin itself. This protects the generator and prevents it slowly eroding through the skin, which is a major complication. As it’s more painful, Dr Segal chooses to do this with a general, rather than a local, anaesthetic.

Like all operations or procedures, there are several things that can go wrong during or after pacemaker implantation. The accepted overall risk for pacemaker implantation is 3-5%. In other words, 3 to 5 in every 100 people will experience a complication. Dr Segal’s complication rate for pacemaker procedure is much lower at 1%. 

The following is a list of complications that can occur with pacemaker implantation.

1. Infection

Risk of it happening: <1%

Pacemakers are a foreign body. Bacteria in the air or from other sources can attach themselves to metal or silicone and can cause infection. As antibiotics cannot penetrate metal or silicone, infection can be difficult to treat, and it is sometimes necessary to extract the pacemaker and leads. This is a straightforward procedure if the pacemaker leads are less than a year old. Leads that have been in place for many years can be difficult to extract and can require laser or other techniques to perform. Use of the TYRX pouch substantially reduces this risk.

2. Pneumothorax

Risk of it happening: <1%

A pneumothorax is collapse of the lung due to injury to the lining of the lung. This can occur when trying to gain access to a vein with a needle. The needle can inadvertently injure the lining of the lung causing it to collapse. It can cause breathlessness and is usually easily diagnosed on chest x-ray. The treatment depends on how much the lung collapses. Small collapses can simply be monitored and will heal on their own. Larger collapses require insertion of a fine drain between the ribs to allow the lung to expand. This can usually be removed after a day or two. Rarely it is necessary to perform surgery to repair the hole in the lung lining. As Dr Segal uses ultrasound guidance to visualise the axillary vein, this risk is now extremely small indeed.

3. Cardiac perforation & tamponade

Risk of it happening: <1%

This is when the pacemaker lead inadvertently goes through the wall of the heart causing blood to leak out into the sack around the heart, called the pericardium. If the perforation is small, this can be left. If it’s larger, it requires insertion of a drain into the pericardium using a needle inserted under the ribs. Rarely this can require surgical correction.

4. Lead displacement

A pacemaker lead can move after it has been positioned. Often this means it will not pace properly. This is usually easily detected by the post-operative pacing check or chest x-ray. If the lead has moved and is not pacing properly or appears unstable it will require a repeat procedure to re-position it.

5. Bleeding/haematoma

Risk of it happening: <1%

Bleeding can occur after any surgical procedure. This risk is higher if you take blood thinners. Many cardiac patients take different blood-thinning drugs for conditions like atrial fibrillation or after a previous stent. Previously, we would stop these drugs before pacemaker insertion, but nowadays we continue these drugs to reduce the risk of stroke and heart attack. Dr Segal is highly experienced at performing pacemaker insertion in people taking blood thinners and bleeding occurs very rarely.

Your wound
Dr Segal uses a medical adhesive (glue) called Dermabond over the wound to keep it waterproof. This rubs off over several weeks. The wound is also covered with a special waterproof dressing called Aquacel for 7 days. It is important to keep the wound clean and dry to allow it to heal during this time. Dr Segal always uses stitches which are dissolvable and gradually dissolve over the next few weeks.

Your left arm
You need to be careful with the use of your left arm for the first 4 weeks after your pacemaker implant. This is to prevent the pacemaker leads from moving before they have fully ‘bedded in’ to the veins and heart. You should avoid lifting your left arm above shoulder height during this time – this is most relevant when putting on t-shirts or jumpers. You should also avoid reaching across your body and heavy lifting. 

Driving
You’ll be unable to drive for at least a week after pacemaker implantation. If you’ve blacked out before the pacemaker, you may already have surrendered your license to the DVLA. If you haven’t lost consciousness, then you’re not required to inform the DVLA of your pacemaker implant for a Group 1 driving license (Cars and Motorcycles). If you hold a Group 2 driving license (Lorries and Buses) you will be unable to drive for 6 weeks.

We will tell you if you need to inform the DVLA. Please note there are different rules depending on different conditions and different rules for driving if you have an ICD (a defibrillator) which are outlined in the final FAQ below.

Device follow–up
The cardiac physiologist and Dr Segal will program your pacemaker to work in the best way for your heart condition. You will see Dr Segal and a cardiac physiologist again in the pacemaker clinic 4 weeks after the implant where they’ll test your pacemaker function, make any programming changes that may be necessary, ensure your well-being and monitor the battery.  After this check, you’ll need further physical checks at least once a year for the rest of your life. Sometimes, we need to see you more frequently than this and Dr Segal will inform you of the reasons for this at the time.

We also offer all pacemaker and ICD patients the option of remote monitoring. This means pacemakers and ICDs transmit information to the clinic from home or wherever you are based, most often now through your mobile phone. Please see the section on Remote Monitoring.

Battery life

Transvenous pacemaker batteries usually last 7-10 years. Leadless pacemaker batteries may last 10-15 years, or longer, but they haven’t been available that long, so we don’t know for sure. A variety of factors affect how long the battery lasts. When you come for a pacemaker check, the battery life on the device will be monitored. As the battery life on your device decreases, the frequency of pacemaker follow-up needs to be increased. This will be discussed with you during your appointment. Before the battery runs out, we’ll arrange a pacemaker battery replacement procedure.

Exercise

You can gradually return to your normal level of exercise usually very soon after the implant, and to strenuous exercise after your first pacemaker check, which is 4 weeks after the implant. Certain actions which involve big rotations of the left shoulder e.g. swimming, golf, rowing, mountain climbing or specific aerobic exercise involving large arm swings are best avoided after a transvenous pacemaker implant, at least for the first 4-6 weeks. This allows the leads to ‘bed in’ properly. Resting the leg for a week after a leadless pacemaker is all that’s necessary.

The leads of a transvenous pacemaker are the vulnerable part of the system as they are exposed to repetitive movement both at the shoulder and chest, and within the beating heart, meaning they can fracture after many years. In general, it’s best to avoid exposing the lead to high levels of repetitive movement at the shoulder if that’s possible, to help promote their longevity. This doesn’t mean people should avoid all types of strenuous exercise involving large arm movement, but it’s best to bear it in mind.

Travel

Most people with implanted heart devices can travel freely unless they are restricted by their underlying medical condition. We provide device ID cards after implants which you can use at airport security. Pacemakers can be checked remotely if there’s a phone signal and it’s connected to your mobile phone, but they can also be checked in more than 120 countries around the world if problems arise – contact details are available on the manufacturers’ websites.

Driving

You’ll be unable to drive for a week after routine pacemaker implantation, or possibly longer if you have had to surrender your license beforehand. You’re required by law to inform the DVLA of your pacemaker implant if you are a Group 1 or Group 2 driving license holder. You must also inform your driving and travel insurance companies. It’s very important you do not drive until you have discussed this with Dr Segal first.

Airport security

Modern airport security scanners, known as mm-wave body scanners, do not affect pacemaker function at all and it’s safe to be scanned in them. It’s always best to let security staff know you have a device though, as it will show up on the scan.

It’s unlikely that the old-style metal detector screening devices at airports or courts will interfere with your device function or data collection but it’s important you let security personnel know you have a pacemaker and show your identification card before walking through them. Security staff will usually use an electronic wand to scan you instead of using the detector but if not, you can walk through the archway at a normal pace and move away from the system if you feel any dizziness or rapid heartbeats. Please ask the security attendant to avoid placing or waving the wand back and forth over your device to prevent any malfunction. Metal detectors will sound an alert when they detect the metal case of your pacemaker.

Mobile phones and other communication devices

Communication equipment such as mobile phones, pagers and other Bluetooth-enabled devices often have powerful magnets, and these may temporarily interact with your pacemaker and affect its function.

Device interaction can be minimised by:

• Maintaining a distance of at least 6 inches between the equipment and the pacemaker implant site
• Hold your mobile phone to the ear on the opposite side of your implant site
• Not carrying your phone or other transmitting device in a breast pocket on the same side as your pacemaker device site or in a shoulder bag near it – some phones emit signals even when they’re not in use
• Avoiding lingering near electronic anti-theft systems if possible

Many retail stores and libraries are equipped with electronic surveillance gates to prevent theft. To reduce the chances of these systems affecting your device’s function or data collection, avoid prolonged exposure while passing through the gates. Simply walk through these systems at a normal pace.

Your home environment

Your pacemaker is not affected by most household electrical equipment such as household appliances, microwave ovens, electrical items for personal care and cleaning, power tools and home electronics. If you use an induction hob, you should keep your pacemaker at least 30cm away from the heating zone when the induction cooktop is on. Conventional heating elements (gas/electric) do not affect your device.

Industrial equipment

Working with or near certain industrial equipment such as arc welding tools, power plants, transmission lines, and other sources of high electrical current can interfere with pacemaker function. Please let Dr Segal know if you’re likely to be exposed to any of these potential sources of strong electromagnetic radiation as this has major implications.

Medical and dental procedures

Always tell medical and dental personnel you have a pacemaker. Having a pacemaker device does not prevent you from undergoing medical and dental procedures. With proper precautions, most procedures are unlikely to interfere with its function. However, some medical procedures may temporarily affect the device’s ability to function properly.

Some procedures require your doctor or cardiac physiologist to retrieve information from your pacemaker and change the programming prior to and following the procedure. These may include:

• Radiotherapy
• Electrocautery or diathermy (all types)
• Catheter ablation
• Transcutaneous Electrical Nerve Stimulation (TENS)
• Transurethral needle ablation
• Magnetic resonance imaging (MRI) scans
• Radiofrequency treatments (e.g. dermatology)
• Certain ultrasonic dental equipment

It’s very important to let Dr Segal know if you are offered treatment with a deep brain or sacral nerve stimulator (neuro-stimulator) as these can potentially interact with a pacemaker and significantly affect its function.

CT scanning is generally safe, although there have been rare reports of very high dose CT scans causing pacemaker malfunction and inducing dizzy spells. Therefore, you should ask that radiation exposure to the pacemaker area is minimised. This is also important if you’re receiving radiotherapy.

Almost all currently available, modern pacemakers and leads in the UK have now been tested for compatibility with MRI scanning, if appropriate precautions are taken. What these precautions are will depend on the pacemaker and MRI type and reason for its use.

Patients must usually wait at least 6 weeks after a device has been inserted before having an MRI, to allow sufficient time for leads to stabilise. It’s very important you let MRI clinic staff know you have a pacemaker device and present your device identification card to them. Many MRI units will be unable to scan patients with pacemakers or ICDs, but we have the right expertise and training to do this at HCA UK. Please contact Dr Segal before finalising any plans to have an MRI.

MRI scans can only be performed safely if the device is checked and temporarily re-programmed by an appropriately trained cardiac physiologist or cardiologist before and after the MRI scan and cardiac monitoring equipment is available in the MRI unit.

Older pacemakers and leads haven’t usually been tested in MRI scanners and the safety of undergoing an MRI scan with an older device cannot always be determined beforehand. It’s very important this is only arranged once appropriate planning and precautions have been taken, if the scan is thought to be appropriate. This is also important if you have old, redundant leads no longer connected to the pacemaker, and especially if you are ‘pacemaker dependent’.

If you suspect your pacemaker is no longer functioning correctly, you should let Dr Segal know. Your symptoms may include:

• Fainting
• Severe dizziness/near fainting
• Unexplained falls

If you have a concern about your device site or wound, for example it’s inflamed, red or discoloured, or if it’s starting to come through the skin – call Dr Segal immediately. Managing pacemaker wounds requires specialist care, so please let Dr Segal know if you have any concerns.

In general, the same advice applies for living with an ICD as for pacemakers, detailed above. One of the key differences with an ICD is that exposure to anything which can potentially cause malfunction could either lead to it delivering a shock (causing pain and more rarely a change in heart rhythm) or preventing it from delivering a shock (leading to failure to treat a serious arrhythmia, which could potentially be life-threatening).

Modern ICDs have also been extensively tested in MRI scanners and are ‘MRI-conditional’. It’s more challenging to perform MRI scans in patients with ICDs, but it’s still possible if the right precautions are taken and there’s a need to go ahead.

It’s critical that patients with ICDs contact their cardiologist before undergoing medical procedures or potentially exposing themselves to any of the risks outlined above.

Driving

You’ll be unable to drive for at least a month after ICD implantation, although this might be 6 months or more if you’ve suffered a cardiac arrest. You’re required by law to inform the DVLA of your ICD implant if you’re a Group 1 or Group 2 driving license holder. It’s very important you do not drive until you have discussed this with Dr Segal first and are clear about the rules.

A biventricular device is one that has leads in both ventricles. This type of device is used to help improve heart function in people with heart failure and who have a specific problem with the heart’s conduction system called left bundle branch block. This causes the uncoordinated contraction of the left ventricle.

This is somewhat analogous to a problem with the timing of a car engine. The car will still drive but not very efficiently. By correcting the timing, the function of the heart can improve and, in some people, it can even go back to normal.

Conduction system pacemakers (CSPs) are the latest type of transvenous pacemaker, in which the ventricular lead is deliberately inserted into the heart’s conduction system, or wiring system. These were developed to simulate normal electrical conduction in the heart and avoid the risk of developing heart failure, which occasionally occurred when leads were placed elsewhere in the ventricle. This is now the new standard of care for pacemakers implanted by Dr Segal.

The key benefits include keeping both sides of the heart pumping in perfect sync, mimicking a natural heartbeat. It avoids the gradual weakening of the heart muscle that can sometimes be caused by long-term traditional pacing positions, and they offer an effective, less complex alternative for patients who need Cardiac Resynchronisation Therapy (CRT) or for whom traditional CRT lead placement is impossible, although further data is awaited from trials to fully support this.