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Pacemakers

A pacemaker, or cardiac stimulator, is an implantable medical device designed to regulate the heart rate when it becomes too slow or irregular. Used primarily in the treatment of bradycardia and cardiac conduction disorders, it is a safe and effective solution for many patients.
Understanding how pacemakers work

Pacemakers, also known as cardiac stimulators, represent a major advance in modern cardiovascular medicine. These small but proven effective implantable devices compensate for failures in the cardiac conduction system by providing appropriate electrical stimulation to the heart muscle (myocardium). It is mainly indicated for patients with symptomatic bradyarrhythmias, i.e., an excessive slowing of the heart rate that can cause symptoms such as discomfort, syncope, dizziness, or fatigue.

In general, it consists of a device implanted under the skin in the upper chest area and connected to one or more electrical wires that run through a vein and are then implanted in the heart. In practical terms, the pacemaker continuously monitors the heart's electrical activity. In the event of an abnormal drop in heart rate, it emits an electrical impulse designed to trigger a contraction of the myocardium. As a result, it can prevent the clinical consequences of bradycardia: syncope, heart failure, or even cardiac arrest. Thanks to technological advances and progressive miniaturization, today's pacemakers offer greater autonomy and personalized programming.

Clinical indications for pacemaker implantation

Pacemaker implantation is based on specific criteria, relying on both electrocardiographic data and clinical manifestations. A slow heart rate (bradycardia) is the most common indication. This slowdown may result from a dysfunction of the sinus node (the physiological center of the heart's electrical activity) or a conduction block between the atria and ventricles, known as atrioventricular block.

Sinus dysfunction is often observed in elderly individuals. It manifests as prolonged pauses in the rhythm, an abnormally low heart rate at rest, or an inability to increase the heart rate during exercise. These situations can cause symptoms such as unexplained fatigue, dizziness, or even loss of consciousness.

Atrioventricular block, on the other hand, prevents the normal transmission of electrical impulses between the upper and lower chambers of the heart. When it is complete (third-degree block) or accompanied by symptoms, a pacemaker is formally indicated in order to restore effective conduction and prevent complications.

The evaluation of a patient with symptoms that may require pacemaker implantation is based on a series of tests including an electrocardiogram, ambulatory rhythm recording (Holter type), cardiac ultrasound, and sometimes stress tests. These tests aim to document conduction abnormalities, their frequency, their correlation with symptoms, and to assess the overall function of the heart.

Types of implantable pacemakers

There are several types of pacemakers. The choice depends on the characteristics of the heart rhythm disorder and the medical profile of the person concerned. All have the main function of triggering, if necessary, an electrical signal that stimulates the heart muscle to maintain an adequate heart rhythm. However, their complexity and mode of operation may vary.

typologies pacemakers

The single-chamber pacemaker

The single-chamber or monocameral pacemaker is the simplest model. It stimulates a single chamber of the heart, most often the right ventricle, which is the lower right chamber of the heart. This type of pacemaker may be suitable for patients who do not need stimulation in the upper part of the heart, the right atrium, most often because they already have a permanent arrhythmia in this area, called atrial fibrillation.


The dual-chamber pacemaker

The dual-chamber pacemaker, which is the most common type, coordinates the electrical activity of the two chambers of the right side of the heart: the atrium and the right ventricle. It can monitor electrical activity and stimulate the heart in these two areas, allowing it to reproduce the natural sequence of heartbeats. In a healthy heart, the atrium contracts first to fill the ventricle, which then contracts to propel the blood.

The biventricular pacemaker

In some more complex cases, a specific type of pacemaker is used: the biventricular pacemaker, also known as a cardiac resynchronization device. It is mainly intended for patients suffering from heart failure, i.e., weakness of the heart muscle that makes pumping blood less efficient. In these patients, the two ventricles do not always contract at the same time, which aggravates the symptoms. The biventricular pacemaker, which stimulates the left ventricle via one of its veins, in addition to stimulating the right ventricle, allows the two sides of the heart to be “resynchronized,” which improves contraction strength and can reduce the signs of heart failure.


Leadless pacemaker

Finally, certain devices called leadless pacemakers have been developed recently. Unlike other types, they consist of one or two capsules that are implanted directly into the heart, without any electrical wires or a box under the skin. This miniaturized technology reduces certain risks associated with wires (such as infections or vein thrombosis) but is still reserved for specific indications.

Physiological pacing: stimulation closer to the natural rhythm

More recently, pacemaker implantation has aimed not only to correct a slow heart rhythm, but also to reproduce the “normal” functioning of the heart by placing the electrical wires as close as possible to the natural electrical fibers running through the myocardium. This is the principle of physiological pacing, which reproduces the heart's normal electrical pathway instead of artificially replacing it. The implantation procedure is no more risky and the devices implanted are the same, but it is a more meticulous task that requires more sophisticated equipment and a suitable operating room with modern tools. However, it offers a real advantage for the patient, especially in the medium and long term. Physiological pacing eliminates the risk of medium-term cardiac function deterioration, which can occur in around 25% of patients with a pacemaker with traditional lead placement in the heart.


Care at Hôpital de La Tour

At Hôpital de la Tour, all three of our cardiac operating rooms are equipped for physiological pacing and, since 2021, all patients who can benefit from this technology are implanted in this way, which corresponds to >70% of procedures.

The procedure: what to expect?

Pacemaker implantation is a surgical procedure that is generally well tolerated. It is performed in a specialized rhythmology operating room, often under local anesthesia combined with light sedation. The goal is to ensure optimal comfort for the patient while allowing the practitioner to perform the procedure with precision.
 
The most common access point is under the collarbone, on the left side in most cases. The doctor then inserts one or more leads into a vein and guides them to the heart chambers using real-time X-rays and an electrocardiogram. Once the probes are in place and tested, they are connected to a small box containing the battery and electronic circuits (the pulse generator), which is implanted under the skin in a pocket created for this purpose.

The procedure lasts between 45 minutes and 1.5 hours on average, depending on the type of pacemaker implanted and the complexity of the procedure. Leadless models are inserted through the femoral vein, usually in the groin, and attached directly inside the right ventricle.

At the end of the procedure, a chest X-ray is taken to check that the leads are correctly positioned. The initial adjustment of the device is performed before the patient leaves the operating room. These settings will be refined during follow-up consultations. The procedure can be performed on an outpatient basis, but for elderly people with comorbidities or those taking anticoagulants, an overnight stay may be preferable.

Like any invasive procedure, the procedure carries risks, but these are rare and in most cases not life-threatening. Possible complications include hematoma at the implantation site, probe displacement, or pericardial irritation, both of which sometimes require reoperation to reposition the probe, and much more rarely, infection or pneumothorax (air around the lung). These events are well known to medical teams, who take all necessary precautions to avoid or treat them quickly.

Pacemakers and daily life

After a pacemaker is implanted, patients can quickly resume their normal lives. During the first few weeks, it is recommended to avoid sudden movements or intense exertion with the arm on the implanted side, while the leads stabilize. During the first month, bathing, swimming, and sports activities should be avoided, except for gentle exercise or walking. After one month, the patient is considered to be fully recovered and can resume their life without any major restrictions. 
Everyday objects such as cell phones, tablets, computers, and all household appliances, including microwaves and induction hobs, can be used without risk.
 
Security gates at airports can detect the device, but do not damage it. Passing quickly through the detector therefore poses no major risk. However, if you stand under the gate for a longer period of time, the pacemaker may be temporarily affected, with a risk of discomfort for patients who depend on it. For this reason, it is recommended that you show your pacemaker card (issued immediately after the procedure) and walk around the detector.
 
Pacemakers can be affected by certain specific medical equipment and require quick reprogramming before undergoing tests such as MRIs. It is therefore essential to inform any healthcare professional of your pacemaker before undergoing any technical tests or treatment.

Regular medical follow-up is essential. It allows the pacemaker settings to be adjusted, the device's memory to be read, and the battery status to be monitored, which generally lasts about 10 years.

FAQ about pacemakers

Can you live a normal life with a pacemaker?

Yes. Once the recovery period is over, the vast majority of patients lead active, independent lives. Pacemakers do not interfere with daily functions and automatically adapt to the body's activity. They significantly reduce the symptoms associated with bradycardia, such as dizziness and discomfort, and improve quality of life

Can you exercise with a pacemaker?

Physical activity is not only possible, but encouraged, especially after consulting your doctor. The pacemaker adapts to exertion by increasing the heart rate when necessary. Only a few temporary restrictions apply after implantation, particularly regarding movements of the arm on the side of the pacemaker.

How long does a pacemaker last?

The lifespan of a pacemaker generally varies between 8 and 15 years. It depends on the type of stimulation, the frequency of activation, and the technical characteristics of the implanted model. Replacement is a scheduled and relatively simple procedure, which involves replacing only the generator, as the leads are often retained.

Can you feel the pacemaker under the skin? Is it visible?

The pacemaker is inserted under the skin, usually under the collarbone. It may be slightly visible or palpable, especially in very thin people, but it does not cause pain once healing is complete. Its small size and discreet location make it very comfortable to wear on a daily basis.

Who should I see about these symptoms?

We recommend that you see the following health professional(s) :
Dr. med.
Nicolas Dayal
Cardiologist
Hôpital de La Tour

Specialties involved

Cardiology