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Pacemaker Implantation

Paying for the pacemaker

A pacemaker is a “prosthesis” and so is covered by all levels of health insurance.

The health fund will usually pay the hospital or the pacemaker company directly. Veterans Affairs patients and public patients will not receive any account for the pacemaker.  If you are in a private hospital the account for my fees goes directly to your insurance fund so you will not be out of pocket.  If you are a public patient in a public hospital there are no fees. 

Possible Problems

You may get significant bleeding or bruising at the pacemaker site.

This is more common if you are on drugs to stop blood clotting.  Let me know if this occurs.  At no time should a needle be inserted into a bruise to drain it.  This is usually unsuccessful and can lead to infection.

Infection of the pacemaker site is rare.  If you ever notice pain, redness or marked swelling over the pacemaker notify my office immediately, in case there is an infection.  
Skin infections of the incision may be treated with a course of antibiotics.  Rarely, an infection may be so serious as to require removal of the pacemaker.

The pacemaker wires may move from their original position.  This occurs in about 1% of patients and nearly always in the first few hours after the procedure, so will be picked up on the ECG monitor.  Another operation to reposition the wires will then be necessary.  Occasionally, later testing of the pacemaker shows that the leads need to be repositioned weeks after the original procedure.  Occasionally, the lung will partly collapse (pneumothorax) during the insertion of the pacemaker wires.  This is usually treated by inserting a small tube into the chest to re-inflate the lung.

After the pacemaker implantation

You will return to the ward and should stay sitting up until you want to go to sleep that night.

You can eat and drink immediately.  You should stay in bed for at least 4 hours after the procedure.  You will be on an ECG monitor.  You will be given several doses of antibiotics through the intravenous cannula.  If you have any pain at the pacemaker site, notify the nursing staff.  Usually, paracetamol (Panadol) is enough to relieve the pain.  If you notice bleeding or bruising at the pacemaker site, notify the nursing staff   You can use your arm normally.  Some staff will tell you to restrict your arm use, but I do not advise this.  It is not necessary and runs the risk of causing shoulder problems.  

You will have a chest x-ray to check the pacemaker position.  A technician will check the pacemaker. You will usually be able to go home the day after the pacemaker implantation. You should continue your usual medications, unless I have notified you of changes.  You can resume normal activities as soon as you feel comfortable.  There will be a plastic dressing over the pacemaker incision.  This is watertight so you can wash normally.  After 10 days pull the dressing off from side to side (not top to bottom which would disrupt the incision).  You will be given an appointment for a pacemaker check either in my office or with the Royal Melbourne Hospital clinic (including country sites).  If you do not receive any appointments notify my office.

The pacemaker implantation

The pacemaker implantation will be performed in the Cardiac Catheterisation Laboratory (the Cath Lab) which is very similar to an operating theatre but with a special x-ray machine.

The staff in the Cath Lab are nurses and technologists.  There may also be a doctor who will assist me with the procedure.  If you have any questions or are concerned in any way please ask me or one of the staff.  Specific questions about why you are having the pacemaker implanted or about the details of the procedure should be directed to me.

You may be given some sedating medicine through the intravenous cannula.  This will make you feel more relaxed.  It may make you sleepy and if you feel like going off to sleep then do so.  We will wake you up when we are finished!   If you feel very anxious then tell us.  The procedure will be done under local anaesthesia.  It is a bit painful when the anaesthesia goes in and at times during the procedure but the pain should not last long.  If it is really hurting, then let me know and we can fix that.

There will be a cut in the skin, about 3 centimetres long (a little longer than one inch).  One, two or three wires will be passed along a vein and placed in the heart.  An x-ray will be used to guide the wires to the right place in the heart.  You may wish to watch the TV monitor screen, but most people don’t.  The wires will be tested to make sure they are in the right place and then connected to the pacemaker.  The pacemaker is about 3 or 4 centimetres across and about 5 millimetres (1/4 inch) thick. It will be placed in the fatty tissue just under the skin.  The skin incision will be sewn up with dissolvable stitches.  You will not be able to see the stitches and they will not need to be removed.

Before the pacemaker implantation

Your should not eat or drink for 4 hours before the procedure but you should take all your usual medicines at the usual times with a small glass of water.

A blood test will be taken to check your blood count (haemoglobin), potassium level and kidney function.  An intravenous cannula will be inserted in a vein in your arm.  You will be given antibiotics through the cannula.  If you are allergic to any antibiotics (in particular penicillin, flucloxacillin or gentamicin), please notify me.

Admission to hospital

You will be admitted to hospital either the night before or on the morning of your procedure. 

My secretary will give you the details if you are to be admitted to a private hospital.  The booking officer of the Royal Melbourne Hospital will send you the details if you are to be admitted to RMH.   If you take WARFARIN (Coumadin or Marevan), or  CLOPIDIGREL (Iscover or Plavix), drugs to stop blood clotting, you must notify my secretary or me as soon as possible.  You may need to stop these drugs several days before the procedure and resume them afterwards.  We will tell you the exact details.  You can continue to take ASPIRIN (including Cardiprin, Astrix, Cartia, Solprin).

What happens if I have to have surgery for some other problem?

If you are to have surgery, inform the surgeon that you have a pacemaker.

The surgeon will usually contact me to check that the surgery will not interfere with the pacemaker.  
There is usually no problem regarding this.

Is there anything I can’t do?

Pacemakers are not affected by X-rays.  

Most recently implanted pacemakers will not be damaged by an MRI scan.  You need to check with your doctor whether with your pacemaker it is safe to have an MRI.

Will electrical items affect my pacemaker?

Most electrical goods in your environment do not affect pacemakers. 

You can use power tools, microwave ovens, electric appliances and electric razors without a problem.  These items should be kept in good condition.  Chain saws and electric arc welders can usually be used without a problem, but you should ask me about this.

How reliable are pacemakers?

Pacemakers are very reliable.

 They undergo extensive testing by the manufacturer and are registered by the Therapeutic Goods Administration of the Australian Government Department of Health and Aged Care.  However, problems may occur rarely in a tiny number of pacemakers relative to the total number implanted each year.  Obviously, I do not use pacemakers that are known to be faulty!  If I am notified of a problem (“safety alert”) that affects your pacemaker, I will let you know promptly.  Sometimes pacemaker replacement will be required.

How long will the pacemaker last?

The pacemaker battery usually lasts between 7 and 10 years. 

Regular testing will detect that the battery is running down but you will not feel any different.  The pacemaker will then need to be changed at a minor operation, usually without an overnight stay in hospital.  The wires (“leads”) stay in place.

How is a pacemaker checked?

Your pacemaker should be checked regularly

I usually schedule a test 1 to 2 months after the implant, then at 6 and 12 months after the implant.  The pacemaker will be tested every 6 or 12 months after that.  Testing involves an ECG and a check with a programmer.  No needles or other painful procedures are necessary.  You don’t even have to undress.  Most tests will be done in my offices but if you live in the country, I will arrange for you to be tested at a country pacemaker clinic at a town nearby.  If you have not been tested for a year or more please let me know.  If you move, please send your new address to my office.  If you move interstate or overseas, we can arrange for pacemaker testing near your new home.

What is a pacemaker?

A pacemaker consists of a battery, electronic circuits and wires (leads) connected to the heart.

It prevents the heart rate from going too slow.  For example if the pacemaker is set at 60 per minute, then it will not allow the heart rate to fall below this level.  The pacemaker will usually increase the heart rate when you start moving around or exercising.  The pacemaker is enclosed in a sealed metal case.  It is about 3 to 4 centimetres (1 to 2 inches) across and about 5 millimetres (1/4 inch) thick.  It sits under the skin.  You will be able to feel a lump and in some cases (especially if you are thin) there will be a visible bump.

Why am I having a pacemaker implanted?

There are several reasons why a pacemaker is implanted. 

It is usually because the heart rate is too slow.  In some patients the heart rate is fast at some times and slow at others.  Sometimes drugs or “ablation” are required to control a fast heart rate and a pacemaker is also required because these treatments make the heart rate too slow.  Sometimes, when patients have blackouts or dizzy turns we don’t know for sure that a slow heart rate is the problem, but a pacemaker is the safest option to treat them.  We also implant pacemakers to help with heart muscle weakness (“heart failure”).

The normal heart rate (or pulse rate) is 60-80 per minute at rest, rising to 150 or more on exercise and sometimes falling to 40 during sleep.