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Temporary pacemaker insertions are usually performed while the patient is in the hospital for a related heart condition (e.g., following a heart attack). The procedure may take place in the patient’s hospital room or in a minor surgery room. After a local anesthetic and a sedative (if necessary) have been administered, a small tube (catheter) is inserted, usually in the neck or groin area. Wires from the external pacemaker are then threaded through this tube and into the heart. The external pacemaker is either hung on an I.V. (intravenous) pole by the bedside, or pinned to the bed sheets. Patients should not touch the unit and should limit their activity while the temporary pacemaker is in use. Alternatively, the pacemaker may be connected to the heart through a needle placed through the patient’s chest, or more rarely, through the esophagus.
Permanent pacemaker insertion is more invasive and is considered minor surgery. It can be performed either as an inpatient or an outpatient procedure. Permanent pacemaker insertion takes places in a cardiac catheterization lab, electrophysiology lab, hospital operating room or outpatient surgical facility.
The patient is given a local anesthetic, at which time the patient’s heart rate and blood pressure are monitored for the duration of the procedure. The insertion site will be cleaned and shaved. Then one of two methods will be used, depending on where the pacemaker is to be inserted:
- If the pacemaker is to be inserted into the chest (an endocardial implantation), then a small cut (incision) is made in the chest wall just below the collarbone to create a small surgical pocket. The wires (leads) from the pacemaker are then passed through a vein in the upper chest and placed in the right atrium or right ventricle, with the visual guidance of x-rays. The tip of the lead is then attached to the inner surface of the heart chamber using small screws or tines. If there is more than one lead, the process is repeated. The main body of the pacemaker is then inserted into the surgical pocket created under the collarbone. Following insertion, the skin is closed with stitches (sutures). The entire procedure takes about an hour.
- Occasionally, leads are placed on the outer surface of the heart in a process known as epicardial implantation (outside the heart). When this procedure is used, the surgeon opens the chest wall, the leads are placed onto the heart’s surface and the pacemaker is inserted under the skin of the upper abdomen. This alternative is only used when the veins are unsuitable for passing the wires through in order to reach the inner heart (due to, for example, some types of congenital heart disease or if the patient is a child).
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