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How does a Pacemaker Implant work?

Pacemaker implantation is a common surgery and it significantly improves the quality of life led by the patient.  The blood-pumping organ, heart, is essentially made of a few groups of muscles. These muscles are controlled by electrical signals to ensure that the heart beats naturally and effectively to circulate blood to all parts of the body. When this electrical signal gets disrupted due to some reason, then an individual may experience tachycardia (where hear beats abnormally slow), heart block, arrhythmia (irregular heartbeat), or a cardiac arrest (abrupt and sudden stopping of the heartbeat).

The contractions happen as a result of triggered electrical pulses generated by sinoatrial node or the SA node. It acts like a pacemaker of the heart. This electrical pulse is then sent to the atrioventricular node or the AV node for relaying the pulse to the ventricles. Pacemaker implantation is suggested when this electrical signaling network is disrupted.The faulty functioning of the natural pacemaker of the heart may lead to the following:

Sick sinus syndrome: It is characterized by a slow heartbeat (bradycardia) or fast heartbeat (tachycardia) or a combination of both. It can happen due to age, a previous history heart attack, and thyroid problem, too much of potassium accumulation in blood, heart surgery, or sleep apnea.

Heart Block

In this case, the impulse is either delayed or absent.

Cardiac arrest

The heart can stop beating. It may result because of the presence of coronary artery disease and muscle problems in the heart, which can happen after the age of 35.


Some of the symptoms observed in patients requiring pacemaker implantation are:

  • Bradycardia
  • Tachycardia
  • Uncontrollable fatigue
  • Dizziness experienced throughout the day
  • Shortness of breath
  • Acute chest pain
  • Palpitation and fluttering of the heart (arrhythmia)

What is a pacemaker implant?

A pacemaker implant is a small device that weighs around 20 g to 50 g and is the size of a matchbox. It has a pulse generator with a battery, a tiny computer circuit and a few wires called pacing leads. This system is attached to the heart and it emits signals through the wires. The pacing rate or the rate of electrical impulses can be adjusted as per the requirement of the body and be accordingly programmed. It can sense if a heartbeat is missed or if the heart is beating too slow. Accordingly, it starts sending a steady signal to normalize the beating of the heart. If the beats are normal, then it simply does not send any signal.

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Before the Treatment

Several tests conducted before pacemaker implantation to check whether the patient is suitable for it or not. These include the following: 

: Electrodes, which are basically sensor pads, are attached to the chest or limbs at times to measure the heart impulses.

Holter monitoring:
Ambulatory or Holter monitor records the rhythm of heart for a period of 24 hours. Wires go from the chest to a battery-operated recording device, which is carried in the pocket or worn as a belt or a shoulder strap. A diary is kept with the patient. The doctor compares the diary with the recordings to figure out the cause.

Harmless sound waves are employed to allow the doctor to see the heart functioning. Without incision, a transducer is placed in the chest to collect the waves from the heart and it transmits it to a machine. The sound wave patterns are interpreted to compose an image of the beating heart on a placed monitor.

Stress test:
An electrocardiogram is taken before and after a patient walks on a treadmill and then nuclear imaging is done.

How it is Performed

Insertion of a permanent pacemaker is a minimally invasive procedure. Access to heart chambers takes place as transvenous access to local anaesthesia.  The most common method is via the subclavian vein or the cephalic vein. In rare cases, it is through femoral vein or the internal jugular vein.  Either in an operating room or in a cardiac catheterization laboratory, the pacemaker implant procedure is performed.

In the infraclavicular region, the pacing generator is placed subcutaneously. Via thoracotomy, the pacemaker leads are implanted surgically. The pacing generator is then placed in the abdominal area. Either via left or right pectoral sites, single chamber and dual chamber insertion can be accomplished. The chest is then prepared. Sterile drapes are applied to the incision area to keep it as sterile as possible. Antibiotic prophylaxis is nowadays employed for the implantation. Preoperative antibiotic can reduce the chances of any infection by almost 80 percent. Cefazolin 1g is administered intravenously one hour prior to the procedure. Other antibiotics can be administered if the patient is allergic to cephalosporins, vancomycin, or penicillins.

The central vein is accessed percutaneously. Due to skeletal landmarks being deviated in some patients, there will be a need of fluoroscopic examination to reduce the time and complications in access. At the junction of first rib and the clavicle, the subclavian vein is typically accessed. For the confirmation of deep vein thrombosis, a phlebography is required for visualization of the vein.

Now a guide wire is advanced through the access needle and tip of the guide wire in placed in the right atrium or venacaval area under fluoroscopy. The guide wire is kept in place after the needle is withdrawn.  If required, a second guide wire is also placed. Double wire technique may be employed through a sheath which is then withdrawn. Two separate sheaths can be manoeuvred over the two guide wires. During the lead advancement, some friction can be felt.

An incision of one to two inches is made in the area of the infraclavicle, which is parallel to the middle third of the clavicle and a subcutaneous pocket is made with both sharp and blunt dissection. This is for the implantation of the pacemaker generator. In many cases, surgeons prefer the access later and pocket first.

A peel-like special sheath and dilator are advanced over the guide wire. The guide wire and dilator are withdrawn keeping the sheath in place. A stylet is then inserted in the center channel of the pacemaker lead making it more rigid.  This lead-stylet combination is then inserted into the sheath and advanced to the concerned heart chamber under fluoroscopy.  In order to prevent dislodgement, the ventricular lead is positioned before the atrial lead. For the positioning in the tricuspid valve, a small curve at the tip of the stylet make it more mobile to reach the right ventricular apex. The introducing sheath is peeled once the lead is secured. With a pacing system analyser, the lead impedances are measured after the pacing lead stylet is removed. To prevent diaphragmatic stimulation, the pacing is performed at 10V. 

After the confirmation of thresholds and lead position, the proximal end of the lead is secured to the pectoralis tissue with the help of a non-absorbable suture. This suture is sewn to a sleeve which is located on the lead. This is placed in the right atrium is a second lead is required.  For patients who have already had a cardiac surgery, the lead tip is positioned medially or in the free lateral wall of right atrium. Same process of stylet withdrawal is followed after this. After positioning and testing of leads, the pacemaker pocket is fed with antimicrobial solution and the pulse generator is connected to the leads. To prevent migration or twiddler syndrome, many surgeons secure the generator to the underlying tissue with non-absorbable suture.

Before final confirmation of lead positioning, a look is taken under the fluoroscope. With the help of adhesive strips and absorbable sutures, the incision is closed. A sterile dressing is then applied on the surface. To limit movement for 12 to 24 hours, an immobilizer or arm restraint is applied. The chances of pneumothorax are ruled out with the help of a postoperative chest radiograph.


Recovery post a successful Pacemaker Implantation

Usually, a patient is kept under observation for more than a day after the pacemaker implantation surgery. It takes around six weeks before the patient to get used to the implanted device. Heavy works must be avoided initially. One should ensure that the concerned arm is not rendered immobile during this time to prevent a frozen shoulder. A physiotherapist can exactly show the movements that you need to perform to keep your arm healthy. Carry the duly filled pacemaker implant card for emergency to avoid any unwanted situation.

Cost Comparison

Pacemaker Implantation Cost 

Pacemaker implantation is a common procedure, which is performed across the globe. However, there is a drastic variation in the cost of pacemaker surgery in India and abroad despite the fact that the same technology, equipment, and technique are used to conduct it. This is because of the difference in the  hospital charged and the pacemaker cost in India and abroad. The price of pacemaker in India is just a fraction of what it costs in other regions, including the Western countries. This has a huge impact on the total pacemaker surgery cost in India.

Some of the other factors that dictate the pacemaker implantation cost in India and abroad include the following:

  • The quality of pacemaker used
  • The number of chambers in which the lead is placed
  • Duration of hospitalization
  • Hospital charges
  • Surgeon’s fees

Treatment cost in India: 4500
Treatment cost in Turkey: 9000
Treatment cost in United Arab Emirates: 6000
Treatment cost in Spain: n/a
Treatment cost in Israel: 12500
Treatment cost in Singapore: 24000
Treatment cost in Thailand: 14500
Treatment cost in Greece: 22000
Treatment cost in South Africa: 12500
Treatment cost in Tunisia: 7000
Treatment cost in Lebanon: n/a
Treatment cost in Lithuania: 11500
Treatment cost in Poland: 5000
Treatment cost in Saudi Arabia: n/a
Treatment cost in Switzerland: n/a
Treatment cost in Czechia: 6000
Treatment cost in Hungary: n/a
Treatment cost in Malaysia: 7500
Treatment cost in Morocco: n/a
Treatment cost in South Korea: 21500

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Q: What is the cost of pacemaker implant?

A: The cost of pacemaker implant varies from one country to the other. There are a variety of implants available and the cost may vary among different manufacturers.

Q: Do I feel heavy with a pacemaker Implant?

A: Initially yes, but slowly you get use to it.

Q: Is a pacemaker cost covered under insurance?

A: Usually insurances do cover pacemaker cost.

Q: What are the risks of pacemaker implantation?

A: Patients rarely experience complications during or after pacemaker implantation. Infection, perforation in the cardiac muscle, leakage of air around the lungs, and problems with the pacing leads are some of the complications associated with this procedure.

Q: How soon can I drive after pacemaker surgery?

A: You can start driving within a week as long as you do not experience any discomfort such as dizziness and fainting. You should start driving only after consulting your doctor.

Q: How long does a pacemaker battery last?

A: A pacemaker battery may last anywhere between 6 to 10 years. Another surgery to replace the battery is required after that.

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