Patient Information & Consent
Permanent Pacemaker Implantation
A guide to the procedure, its benefits, the risks involved, and how to prepare — to help you make an informed decision about your care.
This page is a patient information resource, not a legal consent form. You will be asked to sign a formal consent form on the day of your procedure. Please read this carefully in advance and bring any questions to your appointment with Dr Nijjer. You can change your mind about having the procedure at any time, including after signing the consent form.
PPM
About the Device
What Is a Cardiac Pacemaker?
A pacemaker is a small, battery-powered electronic device that monitors your heart's rhythm and delivers a tiny electrical impulse when the heart beats too slowly or pauses unexpectedly. It takes over the role of the heart's own natural pacemaker — the sino-atrial node — when that system fails to work reliably.
The device has two main components. The generator is a sealed metal case containing the battery and electronic circuits, roughly the size of a large coin (20–50 g). It sits in a small pocket created just beneath the skin below the left collarbone. The leads are fine, insulated wires that run from the generator through a vein into the heart, delivering electrical impulses directly to the heart muscle and relaying the heart's own signals back to the device.
Modern pacemakers are programmable and adaptive. They can adjust the pacing rate in response to physical activity, and their settings can be checked and fine-tuned non-invasively in the pacemaker clinic using a wireless programmer held over the chest — no needles or incisions are needed.
Pacemakers have been used safely since the early 1960s. Approximately 25,000 are implanted in the United Kingdom each year.
Why You May Need One
When Is a Pacemaker Recommended?
A pacemaker is recommended when the heart's electrical conduction system is not working reliably. The most common reasons are:
Symptomatic bradycardia — an abnormally slow heart rate causing blackouts (syncope), near-fainting (pre-syncope), breathlessness, or fatigue. This may result from sinoatrial node disease ("sick sinus syndrome") or from heart block, where the electrical signal is delayed or blocked between the upper and lower chambers.
Heart block — a failure of the electrical signal to travel reliably from the atria to the ventricles through the AV node. Second- or third-degree heart block can cause the ventricles to beat too slowly or miss beats entirely.
After catheter ablation — some procedures used to treat fast or irregular rhythms may deliberately create a degree of heart block, making a pacemaker necessary to maintain an adequate heart rate.
Heart failure — in selected patients a specialised biventricular pacemaker (cardiac resynchronisation therapy, CRT) can improve heart function by synchronising the contractions of the two lower chambers.
No drug alternatives exist for symptomatic bradycardia. Dr Nijjer will discuss the reasons for your specific recommendation, the type of pacemaker proposed, and what happens if you choose not to proceed — including the risk of continued or worsening blackouts.
Device Selection
Types of Pacemaker
The type of pacemaker recommended depends on the nature of your heart rhythm disorder and, in the case of heart failure, on the degree of chamber dyssynchrony. Dr Nijjer will advise which system is appropriate for you.
VVI
Single-Chamber Pacemaker
1 lead
One lead, placed in the right ventricle (or, less commonly, the right atrium). The generator senses and paces a single chamber only. The simplest and smallest device.
- Atrial fibrillation with slow ventricular response
- Sinoatrial node disease where atrial pacing is not required
- Patients where simplicity and longevity are priorities
DDD
Dual-Chamber Pacemaker
2 leads
Two leads — one in the right atrium, one in the right ventricle — allowing the device to sense and pace both chambers in sequence. Maintains the natural timing between upper and lower chambers (AV synchrony).
- Heart block (second- or third-degree) in sinus rhythm
- Sick sinus syndrome requiring both atrial and ventricular support
- Carotid sinus hypersensitivity
- Most common type implanted
CRT
Biventricular Pacemaker
3 leads
Three leads — right atrium, right ventricle, and left ventricle (via the coronary sinus). Resynchronises the two lower chambers to improve pumping efficiency in heart failure. May be combined with a defibrillator (CRT-D).
- Heart failure with reduced ejection fraction
- Left bundle branch block with QRS > 130 ms
- Dyssynchrony on echocardiography
- Technically more complex — longer procedure time
What to Expect
The Implantation Procedure
Pacemaker implantation is performed in the cardiac catheterisation laboratory under strictly sterile conditions. The procedure is carried out under local anaesthetic, with sedation available if you are anxious or prefer to be more relaxed during the procedure.
The area below your left collarbone (clavicle) is cleaned and numbed with local anaesthetic. A small incision — approximately 4–5 cm — is made in the skin. The pacing lead or leads are introduced through a vein just beneath the incision and guided carefully into position within the heart under continuous X-ray (fluoroscopy). Electrical measurements are taken to confirm each lead is well-positioned and sensing and pacing reliably.
Once the leads are secured, the generator is connected and placed into a small pocket created beneath the skin and above the chest muscle. The skin is closed with sutures. The whole procedure typically takes 60–90 minutes for a single- or dual-chamber device, and up to 2–3 hours for a biventricular system.
Sedation. A small dose of sedative medication can be given to help you relax — either as a tablet before the procedure or as an injection at the time. You remain conscious throughout. Because sedation affects reactions and coordination, you will need someone to accompany you home and you should not drive until the following day.
After the Procedure
Recovery & Hospital Stay
After the procedure you will be transferred to the ward and connected to a cardiac monitor so that the nursing team can confirm the pacemaker is working correctly. Your heart rate, blood pressure, and wound will be checked regularly.
A chest X-ray is taken to verify the position of the leads and to confirm that no air entered the space around the lung (pneumothorax) during the procedure. Most patients stay in hospital overnight.
Before you go home you will have a formal pacemaker check — a non-invasive test using a wireless programmer that verifies the device settings, battery status, and lead measurements. If everything is satisfactory, you will be discharged with a pacemaker identification card that you should carry at all times and present to any healthcare professional who treats you.
You will be enrolled in a pacemaker follow-up clinic where the device is checked at regular intervals, usually every three to twelve months depending on the device type and how dependent you are on pacing. As the battery approaches its end of life, the generator alone is replaced under local anaesthetic; the existing leads are reused where possible.
1
Admission & Preparation
Fasting confirmed, chest shaved, IV access placed, consent form signed, antibiotic dose given
2
Local Anaesthetic & Incision
Left subclavian area numbed; small skin incision; vein identified for lead delivery
3
Lead Placement
Lead(s) advanced through vein under X-ray guidance; electrical measurements confirm correct position
4
Generator Implanted
Generator connected to leads and placed in subcutaneous pocket; wound closed with sutures
5
Monitoring & Discharge
Overnight monitoring; chest X-ray; pacemaker check next morning; ID card issued on discharge
Understanding the Risks
Overall Procedure Risk
All medical procedures carry some risk. For pacemaker implantation the risks are well-characterised and low in absolute terms. The team is equipped and trained to manage any complication immediately.
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1,000
Risk of serious complication overall
What Risks Are Involved?
The overall risk of a serious complication from pacemaker implantation is less than one in a thousand. This figure encompasses life-threatening events. The more frequent complications listed below — such as bruising and haematoma — are minor in the majority of cases and do not threaten life or require re-operation.
Your individual risk depends on your age, body habitus, kidney function, whether you are on anticoagulation, the type of device being implanted, and the complexity of your coronary and chest anatomy. Dr Nijjer will discuss your personal risk profile before the procedure.
Bruising / haematoma at wound site
Common — up to 1 in 5
Lead displacement requiring repositioning
Uncommon — 1–3 in 100
Pneumothorax (air around lung)
Uncommon — approx. 1 in 100
Pericardial effusion (fluid around heart)
Rare — 5 in 1,000
Device infection requiring system removal
Rare — <1 in 100
Death
Very rare — <1 in 1,000
These figures represent population averages for elective procedures. Your individual risk may be higher or lower depending on your medical history, the complexity of your anatomy, and the type of device being implanted. Dr Nijjer will discuss your personal risk profile with you before any procedure and will document any specific additional risk factors on your consent form. Preventive antibiotics are given routinely at the time of implant to reduce infection risk.
Risks Explained
Individual Risks in Detail
"Common" means it occurs in more than 1 in 100 patients; "uncommon" in 1–10 per 1,000; "rare" in fewer than 1 per 1,000. All risk estimates are for elective procedures in patients with no major co-morbidities.
Bruising & Haematoma
Discolouration and swelling at the wound site below the collarbone affects around one in five patients to some degree. A haematoma — a collection of blood that forms a firm, tender lump — occurs in approximately 5 in 100 cases. In most cases it resolves without any treatment. Significant haematoma that delays discharge or requires surgical drainage occurs in roughly 1 in 100 cases. The risk is higher in patients on anticoagulant therapy.
Lead Displacement
A pacing lead may shift position in the days after implantation before it becomes firmly anchored in the heart muscle. This occurs in approximately 3 in 100 upper-chamber leads and 1 in 100 lower-chamber leads. Rates are higher for the coronary sinus lead in biventricular devices (up to 10 in 100). Displacement causes the pacemaker to function poorly and is detectable at the follow-up pacing check.
Pneumothorax — Air Around the Lung
When the needle or sheath is introduced into the vein below the collarbone, there is a small risk of puncturing the lining of the lung (pleura) and allowing air to enter the space around the lung. Small pneumothoraces are often detected only on the post-procedure chest X-ray and resolve by themselves within a few days. A larger pneumothorax may cause breathlessness and require treatment.
Pericardial Effusion — Fluid Around the Heart
A pacing lead can occasionally perforate the thin wall of the heart (cardiac perforation), allowing blood to collect in the pericardial sac surrounding the heart. This is detected on echocardiography. Small effusions are common and usually require no treatment. A large effusion can compress the heart (cardiac tamponade), which is a medical emergency requiring urgent drainage.
Device Infection
Infection of the pacemaker pocket or leads is a serious complication that may not become apparent for weeks or months after the procedure. Superficial wound infection can often be treated with antibiotics. Deep infection involving the device or lead surfaces usually requires complete removal of the entire pacing system — generator and leads — followed by reimplantation after a course of intravenous antibiotics. Preventive antibiotics are given routinely at the time of implantation.
Lead Fracture & Long-Term Lead Failure
Over years of use, the insulation or conductor within a pacing lead can develop a fault. This may cause the battery to drain early, deliver inappropriate pulses, or fail to pace the heart reliably. Current data suggest lead failure requiring intervention occurs in approximately 4 in 1,000 cases per year. Most cases are detected at routine pacemaker clinic follow-up before symptoms develop. A new lead is added alongside the old one; in most cases the original lead is left in place rather than removed.
Skin Erosion & Wound Breakdown
In a small number of patients — approximately 5 in 1,000 — the skin overlying the pacemaker pocket thins progressively and the device begins to protrude or the wound reopens. This often indicates a low-grade infection. Prompt attention is important as exposed hardware increases the risk of deep infection. It is more common in very lean patients or those who have had previous chest surgery.
Stroke, Heart Attack & Death
Life-threatening cardiovascular complications — including stroke, myocardial infarction (heart attack), and death — are very rare in elective pacemaker implantation and are substantially less frequent than in coronary intervention procedures. They arise from the stress of the procedure, sedation, or in rare cases from manipulation of catheters and leads in a heart with significant underlying disease.
Before Your Procedure
How to Prepare
Your admission letter will contain personalised instructions. The following guidance applies to most patients — please contact Dr Nijjer's team if you are unsure about anything.
Medications & Medical History
- 1 Warfarin — if you are taking warfarin, you will usually be advised to stop it five days before the procedure. Some patients require a "bridging" plan using low-molecular-weight heparin injections; Dr Nijjer's team will advise you individually. Do not stop warfarin without specific guidance.
- 2 DOACs (rivaroxaban, apixaban, dabigatran, edoxaban) — these are usually withheld for 24–48 hours before the procedure. Your team will advise the exact timing based on your kidney function and the specific drug.
- 3 Insulin and diabetes medications — do not take insulin or oral diabetes drugs on the morning of the procedure. Blood glucose will be monitored during your admission. Bring your medications to hospital with you.
- 4 All other regular medications — take these as usual with a small sip of water unless told otherwise. Bring a complete list of your medications to hospital.
- 5 Pregnancy — if you think you may be pregnant, please contact the team before your admission. X-rays used during the procedure could harm an unborn baby. A pregnancy test may be required if your last period was more than 10 days ago.
On the Day of Admission
- 1 Fasting — follow the fasting instructions in your admission letter (typically nothing to eat or drink except water for 4–6 hours before). Clear water may be taken up to 2 hours before.
- 2 Shave your chest — please shave the left side of your chest and the area around and below your left collarbone the evening before or morning of your admission. A disposable razor is preferable to an electric shaver.
- 3 Shower — bathe or shower on the morning of your admission. Do not apply deodorant, talcum powder, or body lotion to the chest or upper body on the day of the procedure.
- 4 Plan your stay — bring an overnight bag; most patients stay one night in hospital. Arrange for a friend or family member to collect you the following day. You should not drive yourself home.
- 5 Valuables — leave jewellery and valuables at home if possible. Remove any piercings before admission. You will be asked to remove hearing aids, dentures, and glasses before the procedure.
Life After Implantation
Living with Your Pacemaker
Modern pacemakers are reliable devices that support a full and active life for the vast majority of patients. The practical restrictions below are modest and are explained in detail in the pacemaker information leaflet you will receive on discharge.
DVLA
Driving
You must not drive for one week after pacemaker implantation. You must notify the DVLA and your motor insurance company. Standard (Group 1) licence holders may usually resume driving after one week if there are no complications. Different rules apply for Group 2 (HGV/bus) licence holders — the DVLA must be consulted individually.
MRI
MRI Scans
Standard MRI scanning is not compatible with all pacemakers. If you have an MRI-conditional device (increasingly the standard), MRI can be performed under specific conditions at a centre experienced in pacemaker-compatible scanning. You must inform any treating team or radiographer that you have a pacemaker before any scan. CT and X-ray scans are safe.
ID
Pacemaker ID Card
You will be issued a pacemaker identification card on discharge. Carry it in your wallet at all times. It contains your device model, implant date, Dr Nijjer's contact details, and the pacemaker clinic number. Present it to any doctor, dentist, or other healthcare professional who treats you, and show it at airport security.
Rx
Surgical & Dental Procedures
Always tell any surgeon, anaesthetist, or dentist that you have a pacemaker. Electrosurgery (diathermy) used in operations can interfere with some devices and may need to be used with caution. Specialist programming may be required before certain procedures. Dental treatment and most outpatient procedures are generally safe.
⚡
Electromagnetic Interference
Everyday household electrical equipment — including mobile phones, microwaves, televisions, and computers — is safe. However, avoid close or prolonged contact with arc welding equipment, high-tension power sources, and car ignition systems (for those who work on engines). Metal detectors at airports will detect the device; show your ID card and ask for a hand search if needed.
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Battery Replacement
Pacemaker batteries last approximately 8–13 years depending on how much the device is used. When the battery approaches its end of life, the generator is replaced in a straightforward procedure under local anaesthetic — similar to the original implant but shorter, as the existing leads do not need to be replaced in most cases. The old generator is returned to hospital for specialist disposal.
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Physical Activity & Sport
Most patients can return to normal activities within one to two weeks. Swimming, cycling, walking, and gym exercise are generally all permitted once the wound has healed. Contact sports (rugby, martial arts, boxing) are not usually advised due to the risk of direct impact to the device. Racquet sports and golf are generally acceptable; discuss any specific activity with Dr Nijjer.
✓
Follow-up & Remote Monitoring
You will attend the pacemaker follow-up clinic at regular intervals (typically every 3–12 months). Many modern devices also support remote monitoring via a home transmitter that sends device data to the clinic automatically — reducing the frequency of in-person visits for stable patients. If you feel unwell or notice any changes, contact the pacemaker clinic directly.
Rx
Medications
In some cases, having a pacemaker fitted may allow your doctor to reduce or stop certain medications — particularly drugs that had been kept at a low dose to avoid worsening bradycardia. Any changes to your medication will be discussed at your follow-up appointment once the pacemaker has been assessed in situ.
Before You Consent
Questions to Ask Dr Nijjer
You have the right to ask any questions before signing a consent form. The following may be a useful starting point:
- Why do I need a pacemaker, and what happens if I choose not to have one?
- Which type of pacemaker do you recommend for me, and why?
- Will you be performing the procedure yourself, or a colleague?
- Are there any specific risks that are higher for me based on my medical history?
- Will my pacemaker be MRI-conditional, and will I be able to have MRI scans in future?
- How will my anticoagulation or diabetes medications be managed around the procedure?
- What symptoms should prompt me to contact the pacemaker clinic urgently after discharge?
- Will I need to change or stop any of my regular medications after the pacemaker is fitted?
- Can I have a copy of the consent form to read at home before my admission?
Your Right to Withdraw Consent
You may change your mind about having the procedure at any time — including after signing the consent form, and including after arriving in the catheterisation laboratory. Your consent is voluntary and can be withdrawn without any effect on your future care.
If you have questions before or after your procedure, or wish to discuss the risks and benefits further, please contact Dr Nijjer's team:
Phone: 0203 983 8001
Email: jessica@oneheartclinic.com
Address: One Heart Clinic, 68 Harley Street, London W1G 7HE
We aim to respond to all enquiries within one working day. For urgent clinical concerns after your procedure — such as chest pain, breathlessness, dizziness, or concerns about the wound — please call 999 or attend your nearest A&E department.
Speak to Dr Nijjer Before Your Procedure
Dr Nijjer's team is available to answer any questions about your upcoming procedure, discuss your individual risk profile, or arrange a pre-procedure consultation at Harley Street.