Insertion of the device can be performed as minor surgery, or it can take place during an open heart surgery.

If it is performed as minor surgery, it is an inpatient procedure in a hospital. The night before the procedure, patients will be asked to sign a consent form and stop eating or drinking after midnight. Certain medications may need to be reduced or stopped temporarily, so patients should discuss their medication schedules with their cardiologist before surgery. Patients may be asked to remove dentures, jewelry, nail polish and/or glasses.

The insertion site will be cleaned and shaved, and the patient will be given a local anesthetic to numb the area. Heart rate and blood pressure will be monitored during the procedure.

Once the incision area has been numbed, a small incision is made in the chest wall just below the collarbone. A pocket is formed under the skin. The patient may feel pulling, but there should be no pain.

Wires can be placed through the subclavian vein and/or cephalic vein, which can be easily accessed from the pocket under the skin. The first wire is threaded through the vein to the right ventricle, and a second wire is threaded to and attached to the right atrium. A third wire is implanted into the left ventricle, a somewhat more complicated procedure. This wire passes through the right atrium into a vein called the coronary sinus, which drains the heart of oxygen–poor blood, and then placed into a lateral branch to pace the left ventricle.

The most common complication during transplantation is the inability to successfully place the left ventricular pacing lead. In about 10 percent of patients, implantation is unsuccessful.

The procedure generally lasts two to five hours. After it is over, patients are usually admitted to the hospital overnight. During this time, a Holter monitor may be worn to monitor the heart’s rhythm. After release from the hospital, regular checkups are necessary to evaluate the function of the pacemaker.

Alternative surgical implantation procedures are available, including endoscopic and even a robotically assisted approach. Both approaches are currently being explored.