Implantable Cardiac Pacemakers

Since implantable artificial cardiac pacemakers were first produced in Sweden and the United States in 1958, there has been continual improve-ment in manufacturing techniques, and reliability ofmodem apparatus has increased to the extent that pacing is generally accepted as the treatment of choice for a high proportion of patients with com-plete heart block. Nevertheless the use of pace-makers is restricted in Britain, so that though there are approximately 12,500 patients with heart block only some 800 are actually being treated in this way. This restriction is particularly noticeable by com-parison with other countries where pacemakers are used more freely, and though the population of Sweden is only one-seventh that of the United Kingdom there are twice as many patients with cardiac pacemakers, while the total number im-planted each year in Spain approaches that in Britain. There appear to be several main reasons account-ing for the slow increase in pacing in Britain. Early experience was accompanied by a high incidence of pacemaker failure, premature battery exhaustion, infection, and broken electrodes, and these compli-cations resulted in a conservative approach to the treatment of heart block so that many patients are not referred for consideration of pacing. In some areas this is combined with a shortage of facilities, so that patients cannot easily be referred locally. The hospital work load associated with pacing can be very large and involves many departnents and personnel, including surgeons, physicians, techni-cians, and radiographers. Many hospitals are unable or unwilling to undertake this load, particularly since a large proportion of the work must be carried out at night or at weekends as emergency procedures. The financial cost of providing a pacing service is considerable and is undoubtedly a factor in limiting the facilities. If the cost of the pacemaker and the time in hospital alone are considered, approximately £12 per month will be needed for every patient; this figure is almost unaffected by the choice ofapparatus unless the more expensive demand pacemakers are