Permanent Pacemaker
Implantation for the treatment of slow heart rhythm (bradycardia).
Areas of Expertise
Pacemaker, ICD and Arrhythmia Treatment in İzmir
Advanced heart failure management and device-based treatment of arrhythmias are among Prof. Dr. İstemihan Tengiz's fields of work. He was a study group member of the international VICTORIA trial investigating vericiguat in heart failure (N Engl J Med, 2020), and contributed to the ARNi-TR real-world registry study. This area covers permanent pacemaker implantation, ICD implantation, cardiac resynchronisation therapy (CRT) and atrial fibrillation management.
What is heart failure?
Heart failure means the heart cannot pump enough blood to meet the body's needs, or can do so only at high filling pressures. It does not mean the heart has stopped. The most common symptoms are breathlessness on exertion, waking at night short of breath when lying flat, swelling of the legs, fatigue and weight gain.
Classification is based on ejection fraction (EF), which reflects the contractile strength of the left ventricle: reduced, mildly reduced and preserved EF. This distinction matters because proven drug therapies differ between the groups. How much symptoms limit daily life is graded with the NYHA classification.
Which tests are performed?
Assessment starts with a detailed history and examination. ECG, chest X-ray and blood BNP or NT-proBNP are first-line tests; normal levels of these markers make heart failure very unlikely. Echocardiography is the key investigation that establishes the diagnosis and defines the type.
To identify the cause, coronary assessment (CT or invasive angiography), cardiac MRI where indicated, thyroid function, iron stores, kidney function and Holter monitoring in suspected arrhythmia are used. Establishing the cause changes treatment directly — for instance, in ischaemic heart failure, opening the artery can improve cardiac function.
Contemporary drug therapy
In heart failure with reduced ejection fraction, four drug classes now form the foundation of treatment: an angiotensin receptor-neprilysin inhibitor (ARNI) or ACE inhibitor, a beta blocker, a mineralocorticoid receptor antagonist and an SGLT2 inhibitor. Using all four together and uptitrating to target doses substantially reduces hospitalisation and mortality. Diuretics for congestion and correction of iron deficiency where present are added to this.
Prof. Dr. İstemihan Tengiz was a study group member of the international VICTORIA trial investigating vericiguat in heart failure, published in the New England Journal of Medicine. He also contributed to the ARNi-TR registry examining real-world outcomes of ARNI therapy in Turkey.
Permanent pacemaker
A pacemaker stimulates the heart to beat at an adequate rate when the heart rhythm becomes dangerously slow. The main indications are advanced atrioventricular block and symptomatic sick sinus syndrome. Typical complaints are dizziness, fainting, persistent fatigue and a marked fall in exercise capacity.
The device is implanted under local anaesthesia into a pocket beneath the skin below the collarbone, with leads advanced to the heart through a vein. The procedure usually takes under an hour and patients are generally discharged the next day. For the first few weeks it is advised not to raise the arm above shoulder level or lift heavy objects.
ICD and cardiac resynchronisation therapy (CRT)
An implantable cardioverter defibrillator (ICD) recognises life-threatening fast arrhythmias and terminates them with a shock. It is recommended in patients at high risk of sudden cardiac death — for example those whose ejection fraction remains low after at least three months of optimal drug therapy, and those who have already had a serious arrhythmia.
Cardiac resynchronisation therapy (CRT) paces both ventricles simultaneously in patients whose right and left ventricles contract out of step, seen as a wide QRS on the ECG. In suitable patients it reduces symptoms, improves exercise capacity and can improve cardiac function. Where needed, it is combined with defibrillator capability in a single device.
Managing atrial fibrillation
Atrial fibrillation, in which the upper chambers beat irregularly and rapidly, is the most common sustained arrhythmia. It can cause palpitations, breathlessness and fatigue, or run entirely silently. Its main danger is that a clot forming in the atrium travels to the brain and causes a stroke; this risk is calculated with the CHA₂DS₂-VASc score based on age and accompanying conditions.
Treatment has three components: calculating stroke risk and starting anticoagulation in appropriate patients, controlling either heart rate or rhythm, and correcting underlying drivers. High blood pressure, sleep apnoea, excess weight, alcohol and thyroid disorders all trigger atrial fibrillation, and treating them matters at least as much as medication in maintaining rhythm.
Living with a device
Patients with a pacemaker or ICD are seen at regular intervals to check battery status, lead function and recorded rhythm events. Many modern devices offer remote monitoring and transmit data automatically. Battery life varies with device type and how much it is used; when it runs out only the generator is replaced in a short procedure, and the leads usually stay in place.
In daily life mobile phones, microwave ovens and household appliances cause no problems; it is enough not to carry your phone in the pocket on the same side as the device. Show your device card at airport security and stay away from electric welding equipment and strong magnetic fields. MRI can be performed only with MR-conditional devices and an appropriate protocol.
Procedures Performed
ICD Implantation
Defibrillator against the risk of sudden cardiac death.
Cardiac Resynchronisation (CRT)
Restoring pumping coordination in heart failure.
Atrial Fibrillation Management
Rhythm/rate control and anticoagulation planning.
Frequently Asked Questions
My ejection fraction is 35% — what does that mean?
Ejection fraction shows what percentage of the blood in the left ventricle is ejected with each beat; the normal range is roughly 50-70%. A value of 35% means pumping strength is significantly reduced and requires full drug therapy and close follow-up. The good news is that this figure is not fixed; with appropriate treatment it improves in many patients over months.
How long does a pacemaker battery last?
It varies with device type, how often it paces and programming settings, but generally lasts many years. Battery level is measured at every routine check and replacement is planned in advance as the end of life approaches. Only the generator is replaced, and this takes less time than the original implantation.
What should I do if my ICD delivers a shock?
If you receive a single shock and feel well afterwards, contact your physician without panic and arrange a check-up. If you receive more than one shock in a short period, or if you faint, have chest pain or severe breathlessness after a shock, go to an emergency department. The data recorded by the device will show exactly why the shock was delivered.
Can I have an MRI with a pacemaker?
Most devices implanted today are MR-conditional and imaging can be performed under appropriate conditions. This requires documentation that the device is MR-conditional, specific programming before and after the scan, and a suitably equipped centre. Carry your device card and always tell the physician requesting the MRI.
Is anticoagulation always necessary in atrial fibrillation?
Not for everyone. The decision rests on the CHA₂DS₂-VASc score, which estimates stroke risk from age, sex, blood pressure, diabetes, heart failure and previous stroke. In patients at high risk, anticoagulation prevents the great majority of strokes. Aspirin does not provide adequate protection for this purpose.
What should I watch for day to day with heart failure?
Weigh yourself every morning under the same conditions; a gain of more than two kilograms within two or three days indicates fluid retention and should be reported. Limit salt, keep to the fluid allowance set by your physician, never skip your medication and maintain regular light-to-moderate exercise. Influenza and pneumococcal vaccination are particularly important in this group.
Content reviewed by Prof. Dr. İstemihan Tengiz. Last reviewed:
The information on this page is for general information only and is not a substitute for medical advice. Please consult your physician about your symptoms.