A pacemaker is installed through a relatively straightforward surgical procedure that typically takes 2 to 5 hours. You’re usually awake for it. The device is implanted just below your collarbone, with thin wires threaded through a vein into your heart. Here’s what the process looks like from start to finish.
Before the Procedure
You’ll be asked to stop eating solid food at least 6 to 8 hours before surgery. Clear liquids like water, black coffee, or juice without pulp are typically allowed up to 2 hours beforehand. Your doctor will give you specific instructions about any medications you’re taking, particularly blood thinners, which may need to be paused or adjusted in the days leading up to the procedure.
On the day of surgery, you’ll change into a hospital gown, remove any jewelry, and have an IV line placed in your hand or arm. If there’s hair around the incision site near your collarbone, the surgical team will shave it. You’ll then lie on your back on the procedure table.
How the Surgery Works
The standard approach, called the endocardial method, uses local anesthesia. The area around your collarbone is numbed, and you’ll receive sedation through your IV to make you drowsy, but you won’t be fully asleep. A less common approach, called the epicardial method, requires general anesthesia and is used in specific situations where the standard route isn’t possible.
The surgeon makes a small incision just below your collarbone and inserts a thin plastic tube called an introducer into a vein. Through this tube, the surgeon threads one, two, or three thin wires (called leads) through the vein and advances them into the heart. A live X-ray displayed on a screen, called fluoroscopy, lets the surgeon see exactly where the leads are going in real time.
Once the leads reach the correct chambers of the heart, the surgical team tests them to confirm they’re positioned properly and can communicate with the heart muscle. This involves sending small electrical signals through the leads to verify the heart responds as expected. If the readings aren’t right, the leads get repositioned and tested again.
After the leads are confirmed to be working, the surgeon creates a small pocket under the skin near the collarbone and tucks the pulse generator (the small battery-powered device) into it. The leads are connected to the generator, and the incision is closed. The result is a small bump under your skin where the device sits.
Leadless Pacemakers: A Different Approach
Some patients receive a leadless pacemaker, which is a self-contained device about the size of a large vitamin capsule. Instead of being placed under the skin near your collarbone, the entire device is delivered through a vein in your leg and implanted directly inside the heart. There’s no chest incision, no wires, and no visible bump or scar on your chest. The procedure is also shorter than a traditional implant. Leadless pacemakers aren’t suitable for everyone, since they currently work as single-chamber devices, but they’re a growing option for patients who qualify.
Complication Rates
Pacemaker implantation is considered low-risk, but no surgery is without complications. A large registry study tracking over 20,000 patients and 39,000 leads over a decade provides a clear picture of how often problems occur. Infection was the most common issue at about 1.1% of patients. Lead dislodgement, where a wire shifts out of its intended position, happened in roughly 1.7% of patients. Hematoma (a collection of blood at the surgical site) occurred in about 0.5% of cases. More serious but rare complications included a collapsed lung (pneumothorax) at 0.11% and cardiac perforation, where a lead pokes through the heart wall, also at 0.11%.
When lead dislodgement does happen, it raises the risk of needing a second procedure to reposition the wire. It also slightly increases the chance of infection compared to patients whose leads stay in place (2.0% vs. 1.1%).
Recovery and Activity Restrictions
Most people go home the same day or the day after surgery. The incision site will be sore, and you can expect some bruising and swelling around the area for the first week or two. The key restriction in the weeks that follow involves your arm on the side where the pacemaker was placed. You should not raise that arm above shoulder level until your doctor clears you. For at least 3 to 4 weeks, avoid activities that strain your chest or upper arm muscles. This means no heavy lifting, no golf swings, no reaching overhead for items, and no vigorous upper-body exercise.
These restrictions exist because the leads need time to anchor securely into the heart tissue. Moving your arm too aggressively too soon can pull a lead out of position, which would require another procedure to fix. After the initial healing period, most people return to normal activity without significant limitations.
Ongoing Monitoring After Implantation
A pacemaker requires regular check-ups to make sure the device is functioning correctly and the battery has adequate charge. In the first month after implantation, monitoring typically happens every 2 weeks. After that initial period, the schedule stretches out considerably.
For a single-chamber pacemaker, remote monitoring (where the device transmits data from your home to your doctor’s office) generally drops to every 8 to 12 weeks for the first few years, then increases to every 4 weeks as the battery ages. Dual-chamber pacemakers follow a similar pattern, with slightly more frequent checks in the first 6 months before settling into a longer interval. In-person clinic visits are recommended twice in the first 6 months, then once or twice a year depending on your device type.
Pacemaker batteries last roughly 5 to 15 years depending on how often the device needs to fire. When the battery eventually runs low, the monitoring system catches it well in advance, and the pulse generator is replaced in a procedure that’s simpler than the original implant since the leads are already in place.