Specialist Cardiac Electrophysiology · Fawkner & Wantirna

If you need a pacemaker, the type matters —
and so does where it paces your heart

This site explains what modern, physiological pacing is and what may be ideal for different situations — in plain language, giving you the information you need to ensure you or a loved one gets the best outcome from a pacemaker implant.

Why it matters

The location of pacing makes a measurable difference

Traditional pacemaker lead placement was chosen for convenience, not physiology. Decades of research now show the difference in outcomes is consistent and substantial.

Ventricular pacing & heart function

Higher rate of heart weakening (PICM) with traditional RV pacing vs conduction system pacing^[25]

69%

Lower risk of heart weakening with conduction system pacing vs traditional RV pacing^[25]

Atrial pacing & atrial fibrillation

57%

Higher risk of new AF with traditional atrial pacing vs Bachmann's Bundle pacing^[12]

71%

Lower risk of recurrent AF with Bachmann's Bundle pacing vs traditional atrial pacing (HR 0.29)^[12]

Physiological pacing has been our focus since 2017

Most pacemaker centres place leads where they are easiest to reach. We place them where they work best — engaging the heart's own electrical wiring rather than bypassing it. This approach, called conduction system pacing (CSP), produces more natural heartbeats and substantially better long-term outcomes for many patients.

We have been performing conduction system pacing since 2017, with thousands of cases across our team. We are one of Melbourne's most experienced centres for Bachmann's Bundle pacing — a specialised technique for the upper chambers not currently performed at many centres.

Our locations

Two convenient clinics across Melbourne

Consulting, diagnostic services, and device follow-up at both sites. Full diagnostic suite including echocardiography, stress testing, Holter monitoring, pacemaker and defibrillator testing.

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Fawkner

Serving Melbourne's northern suburbs.

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Wantirna

Serving Melbourne's eastern suburbs.

Core Education

Understanding
pacemakers

Your heart's electrical system, what a pacemaker does, the different types of pacing, and why the location of the leads matters — explained in plain English.

Your Heart's Natural Wiring

The heart has its own built-in electrical freeway

Think of your heart as a pump with four chambers. The two top rooms (atria) collect blood coming in; the two bottom rooms (ventricles) push it around your body. Every heartbeat starts as a tiny electrical spark in the sinus node — your heart's natural pacemaker — in the top-right of the heart.

From there, the signal travels along a dedicated high-speed pathway called the cardiac conduction system, ensuring the chambers contract in the right order, at the right speed, with perfect coordination. This system is fast — electrical signals move through the heart’s electrical conduction system at roughly ten times the speed it would take to travel through ordinary heart muscle. When everything works as it should, the result is a synchronised, efficient heartbeat every single time.

The conduction system is like a freeway. Conventional pacing forces the signal onto backstreets. Conduction system pacing keeps it on the freeway — fast, direct, and on time.

Sinus Node (SA Node)

Your heart's natural pacemaker. Fires the starting signal and sets the rate based on what your body needs moment to moment.

Bachmann's Bundle

A specialised pathway running across the roof of the heart, carrying the signal to activate both top chambers simultaneously.

AV Node

The gatekeeper between top and bottom chambers. Introduces a brief, controlled pause so the atria finish contracting before the ventricles begin.

Bundle of His & Bundle Branches

The signal enters the ventricular freeway and splits — left and right branches carry it down both sides of the wall between the ventricles.

Purkinje Fibres

The signal fans out at full speed through both ventricles simultaneously. The result: a coordinated, powerful squeeze. This is what normal sinus rhythm looks like on the inside.

Why location matters so much for pacing: When a pacemaker stimulates the heart via its own conduction system, the signal travels the normal route at full speed — producing a heartbeat that's nearly identical to a natural one. When it stimulates ordinary muscle instead (as conventional pacing does), the signal takes a detour. Over many years of daily pacing, that detour takes a measurable toll on the heart.

Types of Pacing — and What's Ideal

Not all pacing is equal: an overview of your options

Conventional pacing (traditional right ventricular pacing)

The ventricular lead is placed on the right side of the heart — the right ventricular septum or apex — because it's easy to reach and stays in place. It remains the most common approach worldwide, and it works. The problem: it bypasses the conduction system. The signal spreads slowly through ordinary muscle. The left ventricle (the main pumping chamber) gets activated late. Over years, this uncoordinated contraction can weaken the heart in approximately 1 in 5 heavily paced patients^[4] — a condition called Pacing-Induced Cardiomyopathy (PICM). Many patients don't know this risk exists until symptoms of breathlessness or fatigue appear.

Conduction System Pacing (CSP) — the modern preferred approach

CSP places the ventricular lead so that it connects directly with the heart's own electrical wiring, specifically the left bundle branch area (LBBAP). Unlike conventional pacing — where the lead tip sits on the surface of the right ventricular wall — the LBBAP lead is gently advanced through the wall between the two ventricles (the septum) until it reaches and captures the left bundle branch on the other side. The signal then immediately enters the fast Purkinje network, activating both ventricles simultaneously. The ECG looks nearly identical to a natural sinus beat. CSP is now formally recommended in the 2023 international pacing guidelines^[8] and is increasingly considered the ideal approach for many people.

Bachmann's Bundle pacing — physiological pacing for the upper chambers

Most pacemakers also have an atrial lead. Atrial leads have historically been placed in the right atrial appendage due to convenience, however this can cause an increased risk of atrial fibrillation and heart failure. Bachmann's Bundle pacing corrects this at source, activating both atria simultaneously. It requires specific expertise and is not offered at all centres — making the choice of where to have your pacemaker implanted important.

Implanter experience matters

Conduction system pacing is a more technically demanding procedure than conventional pacemaker implantation. The results you get depend significantly on the experience of the person performing it — and research confirms that a meaningful number of cases are needed before a practitioner reaches full proficiency.

Published research shows that LBBAP success rates achieve a good level of success after approximately 100–150 procedures. Key procedural measures continue to improve up to around 200–250 cases — meaning that outcomes are meaningfully better in the hands of someone who performs these techniques routinely and at high volume.^[1][24]

What this means for you: When choosing where to have a conduction system pacemaker implanted, it is reasonable to ask how many LBBAP procedures your implanting doctor has performed. Research suggests that outcomes improve substantially with experience, and that the best results are achieved by practitioners who perform these techniques routinely and in high volume.

Leadless pacemakers — tiny, self-contained, no wires

A miniature device implanted entirely inside the heart — no leads threading through veins, no generator under the skin, no visible scar. Best suited for specific patient groups. See the page for full details.

The key question: “Am I a candidate for conduction system pacing?” It isn't right for everyone — but it's always worth asking, and it matters to be treated by someone experienced enough to offer it when it is appropriate. See for the full list of questions to ask your doctor.

Deep Dive

Conduction System Pacing:
why it's the better option for many people

Why CSP Is Considered the Better Option

Coordinated contraction, less long-term strain, closer to how a healthy heart beats

Your heart's conduction system is a biological masterpiece. Electrical signals travel through it at roughly 3–4 metres per second — about ten times faster than through ordinary heart muscle. This speed ensures both ventricles squeeze simultaneously, producing maximum pumping efficiency with minimum effort.

When a traditional pacemaker stimulates the right ventricle from outside this system, the signal has to travel through ordinary muscle. It's slower, it takes a different path, and it arrives at the left ventricle late. On an ECG, this produces a wide, abnormal-looking electrical pattern. Over years, this daily uncoordinated squeezing gradually remodels the heart muscle — causing it to thicken and weaken in a predictable pattern called pacing-induced cardiomyopathy (PICM).

Conduction system pacing works differently. The lead engages the heart's own wiring directly. The signal immediately enters the heart's conduction system and spreads at full speed, activating both ventricles together. The ECG looks nearly identical to a natural sinus beat. The heart works efficiently, without the chronic strain of dyssynchrony.

⚠ Conventional RV Pacing

The pacing lead sits on the right ventricular wall. The signal spreads slowly through ordinary muscle — right ventricle fires first, left ventricle fires late. The two chambers beat out of sync.

✓ Conduction System Pacing (LBBAP)

The lead is advanced through the septum to engage the left bundle branch. Both ventricles activate simultaneously via the heart's own fast-conduction network — just like a natural beat.

Who Benefits from CSP

Common situations where CSP is ideal — with an honest note

CSP is increasingly considered the preferred option for many people who need a pacemaker. Here are the situations where the evidence is strongest:

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AV block with high pacing burden

If the pacemaker will deliver most of your heartbeats (e.g. complete heart block), CSP's physiological advantage matters most — and the risk of PICM with conventional pacing is at its highest.

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Mild-to-moderate heart failure

Patients with reduced pumping function who also need pacing gain significantly from CSP's synchronised contraction — often as a superior alternative to biventricular pacing (CRT).^[5]

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Heart function declining on conventional pacing

Patients who have developed PICM on conventional RV pacing often recover substantially after upgrading to an LBBAP lead.

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Younger patients

Someone paced for decades accumulates far more risk from conventional pacing. The long-term advantage of CSP compounds significantly over time.

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Left bundle branch block (LBBB)

LBBAP can correct the electrical delay of LBBB, offering similar or better resynchronisation than biventricular pacing for selected patients.^[9]

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Patients needing upgrade

Upgrading from conventional RV pacing to LBBAP is an established option with good published evidence of cardiac function recovery.

CSP isn't right for everyone. Certain anatomical or clinical factors can make conduction system pacing technically difficult or less appropriate. Your electrophysiologist is the right person to assess this. What matters is that the question gets asked — and that you're treated by someone with the experience to offer it when appropriate.

What the Evidence Says

A plain-language summary of why the field is moving toward CSP

The clinical evidence for conduction system pacing has grown substantially since 2017. It is now reflected in the 2023 international pacing guidelines^[8] and continues to accumulate. The key findings, in plain terms:

~20%

Patients developing PICM with heavy conventional RV pacing^[4]

Patients developing PICM with LBBAP in a 23-month follow-up study^[3]

10.5%

Heart failure hospitalisations with conventional pacing^[2]

3.7%

Same outcome with LBBAP — a 65% reduction^[2]

Outcome	Conventional RV Pacing	CSP / LBBAP
How the heartbeat spreads	Slow, uncoordinated — right then left	Fast, synchronised — both together^[1]
Risk of heart weakening (PICM)	~20% over 5 years^[4]	2–7% in major studies^[3]
Heart pumping strength over time	Often declines^[4]	Stable or improves^[3]
Heart failure hospitalisations	10.5%^[2]	3.7%^[2]
Atrial fibrillation burden	Increased^[7]	Reduced^[7]
Guideline status	Conventional standard	HRS 2023 recommended^[8]

Bachmann's Bundle pacing — the same principle for the upper chambers

Traditional Right Atrial Appendage pacing produces delayed left atrial activation and, over time, increased AF risk. Bachmann's Bundle pacing corrects this at source, activating both atria simultaneously. A study of 349 patients found that Bachmann's Bundle pacing was associated with a 71% lower risk of AF coming back and an 80% lower risk of developing new AF compared with traditional atrial pacing. In patients with traditional leads, AF became progressively worse over two years — in those with Bachmann's Bundle leads, it did not.^[12] Bachmann's Bundle pacing has also been shown to reduce the workload on the lower chambers and improve how well the left side of the heart fills with blood before each beat.^[12]

The Latest Technology

Leadless pacemakers:
no wires, no scar, inside the heart

What Is a Leadless Pacemaker?

A completely different approach to pacing

Leadless pacemakers contain the entire pacing system in a small bullet shaped device that sits in the heart.

The capsule is delivered through a small puncture in a vein in the groin or neck. A thin tube carries it up through the body and into the heart, where it is attached gently to the inner wall of the right ventricle. The whole procedure typically takes under an hour, and most patients go home the same day or the next morning.

The Advantages

Six reasons a leadless pacemaker may be better for some patients

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No scar near the collarbone

Because there is no generator under the skin and no wound near the shoulder, there is no visible lump and no scar near the collarbone. Recovery is generally faster and more comfortable, with less impact on daily life.

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Lower risk of infection

One of the most serious complications of traditional pacemakers is infection of the skin pocket where the generator sits. Because leadless devices have no pocket, this risk is eliminated — a significant advantage for patients who are already vulnerable to infection.^[19]

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Long battery life

Leadless pacemakers can have a battery life of up to 17 years. For many patients this means only ever needing one device in their lifetime.^[20]

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No arm movement restrictions

With a traditional pacemaker, patients must avoid raising the arm on the pacemaker side above shoulder height for 4 to 6 weeks while the leads settle in place. Leadless pacemakers have no leads to dislodge, so there are no arm movement restrictions during recovery at all.

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No lead-related complications

Traditional pacing leads can fracture, dislodge from their position, or gradually affect the tricuspid heart valve over years of continuous movement. Leadless devices have no leads at all, so none of these risks apply.

Who Are They Best Suited To?

The patients most likely to benefit

Leadless pacemakers are not the right choice for everyone. They work best in specific situations where the absence of leads and a skin pocket offers a clear advantage.

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Permanent atrial fibrillation (AF)

When AF is permanent, the upper chambers of the heart are already beating irregularly and pacing them serves little purpose. Only the lower chamber needs a pacemaker — making a single leadless device the simplest and most elegant solution.

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High risk of infection

Patients on kidney dialysis, those who have had a previous pacemaker infection, or anyone whose skin heals poorly are at higher risk of device pocket infection. With no pocket, leadless pacemakers eliminate this risk entirely.

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Blocked or scarred veins near the collarbone

If the veins near the collarbone are damaged, scarred, or blocked from previous procedures, threading traditional leads through them can be difficult or impossible. A leadless device delivered through a groin vein bypasses this problem entirely.

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Tricuspid valve problems

Traditional leads pass through the tricuspid valve and can gradually cause wear or damage over years of movement. Patients who already have tricuspid valve disease may be better protected by a leadless device, which leaves this valve completely untouched.

Limitations

What to understand before choosing a leadless pacemaker

Leadless pacemakers represent a genuine step forward in technology. However, they are not suitable for every patient, and it is important to understand their current limitations clearly before making a decision.

They still pace from the right ventricle — the same limitation as conventional pacing

The most important limitation is one that is easy to miss: currently available leadless pacemakers pace from the right ventricle — the same location as traditional conventional pacing. This means they carry the same potential for uncoordinated ventricular contraction over time, and do not offer the physiological benefits of Left Bundle Branch Area Pacing (LBBAP).

In other words, a leadless pacemaker is an advance in how the device reaches the heart, but not in where inside the heart it paces. For patients who need the most coordinated, physiological heartbeat — particularly those with a high proportion of paced beats — a traditional lead placed at the left bundle branch area remains the superior option for protecting heart function over time.^[22]

Most devices only pace one chamber

Most leadless pacemakers pace only the lower chamber (right ventricle). If you also need pacing in the upper chamber — for example, because of sick sinus syndrome without permanent AF — a dual-chamber system is required.

A dual-chamber leadless system is available, where two separate leadless capsules — one in each chamber — communicate wirelessly with each other. However, this is newer technology with a shorter clinical track record than single-chamber leadless devices and a significantly shorter battery life.^[21]

Battery replacement works differently and is more complex

With a traditional pacemaker, replacing the battery is straightforward — the old generator is removed and a new one is attached to the existing leads. With a leadless device, this is different: when the battery runs low, the old device is switched off and left permanently inside the heart, and a new capsule is implanted alongside it.

Over time, as the original device embeds itself in heart tissue, removing it becomes progressively more difficult. Retrieval is possible in the early years if needed, but becomes more complex the longer the device has been in place. For most patients this is manageable, but it is worth understanding before committing to a leadless device.^[23]

What to Expect

Getting a pacemaker:
what happens at every stage

A plain-English guide to the entire journey — from your first appointment to going home and beyond.

Before the Procedure

The lead-up to your implant

Before your pacemaker is implanted, you will have a series of appointments and tests. This is also your opportunity to ask about the type of pacing — such as Left Bundle Branch Area Pacing and Bachmann's Bundle pacing — that is most appropriate for you.

Referral from your GP or cardiologist

Your doctor will refer you to a cardiac electrophysiologist — a heart rhythm specialist. They will review your ECG, monitor recordings, and other test results to confirm a pacemaker is needed and plan exactly what type.

Specialist consultation

At your first appointment, the electrophysiologist will explain your condition, the type of pacemaker recommended, and how many leads are needed. This is the right time to ask about physiological pacing options such as LBBAP and Bachmann's Bundle pacing.

Pre-procedure tests

You will likely have blood tests, a chest X-ray, an ECG, and a heart ultrasound (echocardiogram). These help confirm your heart's current state and guide the plan for your procedure.

Instructions for the day before

You will be asked not to eat or drink from midnight the night before. Your doctor will advise which of your regular medications to take or pause — particularly any blood thinners, which often need to be managed carefully around the procedure.

Arriving at hospital

You will be admitted on the morning of the procedure. A nurse will check your blood pressure and heart rate, put a small needle into a vein in your arm (for fluids and medication), and ask you to change into a hospital gown. The team will explain the procedure again and ask you to sign a consent form.

During the Procedure

What actually happens — step by step

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Will I be asleep?

Typically no — pacemaker implants are not done under general anaesthetic. You will be awake but given strong sedation (sometimes called "twilight anaesthesia") that makes you deeply relaxed and drowsy. Most people have little or no memory of the procedure afterwards. If you would prefer to have the procedure done under a general anaesthetic, discuss this with your cardiologist prior to booking the procedure.

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Will it be painful?

The area near your collarbone is numbed with a local anaesthetic injection first. You may feel pressure or pushing during the procedure, but you should not feel sharp pain. If you feel any discomfort, tell the team immediately and they will give you more pain relief.

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How long does it take?

A single-lead device usually takes 45 to 90 minutes. A two-lead (dual-chamber) device takes 1 to 2 hours. Procedures involving physiological pacing techniques such as LBBAP may take a little longer in inexperienced hands, but are routine at specialist centres.

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Where does it happen?

In a specially equipped room called a cardiac catheterisation laboratory (cath lab), which has X-ray equipment used to guide the leads into position. The team includes your electrophysiologist, a cardiac nurse, and a device technician.

The procedure, step by step

Preparation

You lie on a narrow table. The area below your left collarbone is cleaned with antiseptic, covered with sterile drapes, and numbed with local anaesthetic. Your heart rhythm is monitored throughout on a screen.

Accessing the vein

The doctor makes a small puncture — or a very small cut — just below the collarbone to access a vein. A thin plastic tube is inserted into the vein to act as a channel for the lead or leads. There are no large cuts involved.

Placing the leads

The leads are threaded through the vein and guided into the heart using real-time X-ray images on a screen. The doctor steers each lead to its target position.

Testing

Before the leads are finalised, the team tests each one to confirm it is sensing the heart's natural beats and pacing correctly. Measurements are taken to ensure the lead is in the right spot and is working well.

Fitting the generator

A small pocket is created just under the skin below the collarbone. The generator is connected to the leads and tucked gently into this pocket. The wound is then closed with stitches that dissolve on their own — no suture removal needed. The scar is typically 4 to 5 centimetres long.

Final checks and recovery room

A chest X-ray is taken immediately after to confirm the lead positions look correct. You are then moved to a recovery area where nurses monitor your heart rate, blood pressure, and the wound for several hours.

After the Procedure

Recovery — what to expect and how to look after yourself

In hospital

Most people stay in hospital overnight and go home the following morning. Before you leave, a device technician will check and program your pacemaker, and you will receive a pacemaker identification card that you should carry with you at all times. You will be given written instructions to take home, and a phone number to call if you have any concerns.

The first week at home

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Rest, but keep gently moving

Fatigue is normal for the first few days. Short, gentle walks are encouraged from day one — but avoid anything strenuous, heavy lifting, or reaching above your head on the pacemaker side.

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Do not drive

You must not drive for at least two weeks after the procedure. Your doctor will advise the specific timeframe, which may vary depending on the reason for your pacemaker and your particular situation.

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Protect the wound

Keep the wound dry for 5 to 7 days. Do not scrub or rub the area. Watch for signs of infection: increasing redness, warmth, swelling, discharge, or fever above 38°C. If any of these occur, contact your doctor promptly.

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Limit arm movement

Avoid raising your arm on the pacemaker side above shoulder height or making sweeping overhead movements for 4 to 6 weeks. This gives the leads time to anchor firmly into the heart tissue.

Go to the emergency department or call your doctor immediately if you experience: chest pain, severe shortness of breath, fainting or near-fainting, ongoing hiccupping (which can indicate a displaced lead), significant swelling or discharge from the wound, or a temperature above 38°C.

The first 4 to 6 weeks

Most people feel fully back to normal within 2 to 4 weeks. During the first 4 to 6 weeks, continue to avoid heavy lifting (more than 3 to 4 kilograms on the pacemaker side) and vigorous overhead arm movements. Most people can return to office-based work within 1 to 2 weeks. Light physical activity such as walking and gentle cycling is usually fine within 2 to 4 weeks.

Ongoing follow-up and remote monitoring

You will have a check-up at around 4 to 8 weeks after the procedure, then typically once every 6 to 12 months. At each visit, the device is checked using a special wand or reader held over the pacemaker — this takes only a few minutes and is completely painless. The technician checks the battery level, lead performance, and reviews stored heart rhythm data.

Many centres, including ours, also use remote monitoring — a small bedside unit that sends your pacemaker's data to the clinic automatically overnight, usually while you sleep. This allows the team to detect any issues early without you needing to come in.

Living normally with a pacemaker

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Mobile phones

Do not carry it in a breast pocket directly over the device.

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Flying and travel

Flying is completely safe. Always carry your pacemaker ID card when travelling. Inform airport security staff that you have an implanted device — they can use an alternative screening method.

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Sport and exercise

Most people with pacemakers can exercise normally. Your cardiologist may turn on a rate-responsive feature that detects physical activity and speeds up your heart rate automatically if needed. Ask your cardiologist about any sport-specific restrictions.

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Household appliances

Most everyday appliances including microwaves, computers and televisions are safe. Talk to your doctor about precautions when using induction stove tops, electric blankets and some electric scales.

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MRI scans

Most modern pacemakers are MRI-compatible under specific conditions. Always inform the radiology team and your pacemaker clinic well before any planned MRI. The clinic will adjust device settings for the scan if needed.

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Other medical procedures

Always tell any doctor, dentist, or allied health professional about your pacemaker before any procedure — particularly those involving electrosurgery (diathermy), which is commonly used during operations.

Your Questions Answered

Frequently asked
questions

Common questions about pacemakers, the procedure, recovery, and modern pacing techniques — answered in plain English.

Before Your Procedure

Questions to ask your cardiologist before getting a pacemaker

These are the most important questions to ask before any pacemaker procedure.

What is "pacing-induced heart weakening" and should I be worried about it?

Pacing-induced cardiomyopathy (PICM) is a gradual weakening of the heart's pumping strength that can occur when a pacemaker activates the heart in an uncoordinated way over many years. It affects approximately 1 in 5 people who rely heavily on traditional right ventricular pacing. The good news is that it is largely preventable — Left Bundle Branch Area Pacing (LBBAP) dramatically reduces this risk. If you are expected to receive a high proportion of paced beats, asking about LBBAP before your procedure is one of the most important questions you can ask.

I already have a traditional pacemaker. Should I be concerned?

Not necessarily. If your pacemaker only delivers a small proportion of your heartbeats — say, less than 20 to 30% — the risk of heart weakening is much lower. However, if you are heavily dependent on pacing, it is worth asking your cardiologist to check your heart function with an echocardiogram (heart ultrasound) at your next review. If any weakening has occurred, upgrading the ventricular lead to a LBBAP position is an established option that has been shown to help recovery.

Is LBBAP a riskier procedure than traditional pacing?

In experienced hands, the risk profile is very similar. The LBBAP lead does need to be advanced a little deeper through the wall between the two lower chambers, which adds a small amount of technical complexity. However, in centres that perform this regularly, complication rates are comparable to traditional pacing.^[6] The long-term benefit of protecting your heart function far outweighs the modest procedural difference.

Why might my doctor not offer me LBBAP or Bachmann's Bundle pacing?

These techniques require specific training and experience that not every electrophysiologist has yet completed. Not all hospitals stock the specialised lead types required. For a small number of patients, the anatomy of the heart makes these techniques more difficult. None of this means you cannot ask — or seek a second opinion at a centre that does offer them.

What is a leadless pacemaker and am I a candidate?

A leadless pacemaker is a miniature device implanted entirely inside the heart, with no wires and no generator under the skin. It is best suited to patients with permanent atrial fibrillation, high infection risk, or blocked veins near the collarbone. It is not currently suitable for everyone — particularly those who need coordinated physiological ventricular pacing via LBBAP. See the tab for full details.

Can I ask for a second opinion if I am not sure about my options?

Absolutely — and we would encourage it. Seeking a second opinion before a pacemaker implant is entirely normal and reasonable. A pacemaker lead, once placed, typically stays in position for 10 to 15 years. Understanding your options fully before the procedure is far preferable to needing an upgrade later. If you would like to discuss your situation with us, please reach out through the Contact page — there is no obligation in making contact.

About Pacemakers

General questions

Will I feel the pacemaker or know when it is working?

Most people do not feel the pacemaker pacing their heart — the electrical impulses are far too small to cause any sensation. Some people notice that their heart rate feels more regular, or that they have more energy and less breathlessness than before — which are positive changes, not sensations from the device itself. The generator under the skin may be slightly noticeable if you press on it, but it should not cause pain or discomfort.

Will my pacemaker give me electric shocks?

No. Standard pacemakers deliver tiny, painless electrical pulses to keep the heart rate up — you will not feel these. Pacemakers do not deliver shocks. An implantable defibrillator (ICD) is a different device that can deliver a shock to correct a dangerous fast rhythm, but a standard pacemaker is not capable of this. If you have a combined device (pacemaker plus defibrillator), your doctor will explain what to expect from each function.

How long will the battery last?

Most pacemaker batteries last between 10 and 15 years, depending on how often the device needs to pace and the settings used. The battery is checked at every follow-up appointment and the decline is very gradual — there is always plenty of warning. When the battery runs low, the generator (the box) is replaced in a straightforward 30 to 45 minute procedure under local anaesthetic. The leads are usually left in place, and a new generator is simply attached to them.

Can I use my mobile phone, microwave, or induction cooktop?

Yes to all of these, with simple precautions. For mobile phones, keep them at least 15 cm (6 inches) from the pacemaker and avoid carrying one in a breast pocket directly over the device — using the opposite ear or hands-free is the easiest solution. Microwave ovens and induction cooktops are safe to use normally. Bluetooth headphones, tablets, and computers are all fine. Your pacemaker clinic will give you a full list of things to be aware of at discharge.

Can I fly with a pacemaker?

Yes, absolutely. Air travel is completely safe with a pacemaker. The change in cabin pressure and altitude at cruising height has no effect on the device. At airport security, carry your pacemaker ID card and show it to security staff — they will offer an alternative screening method. Walk-through metal detectors are generally safe for a normal brief pass-through, but avoid lingering directly in front of one.

Can I have an MRI scan?

Most modern pacemakers implanted in recent years are described as "MRI-conditional" — meaning MRI scans are safe under specific conditions, usually at 1.5 Tesla strength with the pacemaker temporarily reprogrammed for the scan. Inform both the radiology team and your pacemaker clinic well before any planned MRI. The clinic will adjust your device settings for the scan and restore them afterwards. If you have an older device, check with your clinic first as some earlier models had more restrictions.

Can I exercise and play sport?

Yes, in most cases. Most pacemakers include a "rate-responsive" feature that detects physical activity and automatically increases the pacing rate so your heart can keep up with exertion. After the healing period of 4 to 6 weeks, most people can resume all recreational activities including swimming, cycling, golf, gym work, and team sports. High-impact contact sports such as rugby or boxing require a specific conversation with your cardiologist, as a direct blow over the device is something to consider.

What is the difference between a pacemaker and a defibrillator?

A pacemaker treats hearts that beat too slowly — it delivers gentle, continuous prompts to keep the rate at a safe level. A defibrillator (ICD) treats hearts that go into dangerously fast rhythms — it delivers a shock to reset the heart back to a normal rhythm. Some people have a device that does both. Your cardiologist will recommend the right device based on your specific diagnosis. The pacing lead placement principles discussed on this site apply equally to pacemakers and ICDs.

About the Procedure

Questions about having a pacemaker implanted

Will I be awake during the procedure?

Yes — pacemaker implants are not performed under general anaesthetic. Instead, you receive sedation (sometimes called "twilight" sedation) that makes you feel deeply relaxed and sleepy. The skin and tissue near the collarbone are also numbed with local anaesthetic. Most people feel very little during the procedure and have little or no memory of it afterwards. If you feel any discomfort at any point, you can tell the team and they will give you more medication straight away.

How long does the procedure take?

A single-lead pacemaker typically takes 45 to 90 minutes. A two-lead (dual-chamber) device usually takes 1 to 2 hours. Procedures using physiological pacing techniques such as Left Bundle Branch Area Pacing may take a little longer but are routine at experienced centres. You will then spend several hours in a recovery area being monitored before moving to the ward for an overnight stay.

When can I go home?

Most people go home the day after their procedure, once the device has been checked and programmed and a final chest X-ray has been reviewed. In straightforward cases at experienced centres, same-day discharge is sometimes possible. Your care team will advise based on your individual situation.

Will there be a visible scar?

There will be a small scar below the left collarbone, typically 4 to 5 centimetres long. Stitches are usually dissolvable, so you will not need to come back to have them removed. The scar fades over months and is usually not very noticeable, particularly under clothing. There may also be a small visible lump under the skin where the generator sits — this is normal and most people become accustomed to it quickly.

What should I bring to hospital?

Bring a list of all your current medications and doses, any recent test results or specialist letters, comfortable clothing to wear home (nothing too tight around the chest or shoulders), and toiletries for an overnight stay. Leave valuables at home if possible. Arrange for someone to collect you — you will not be able to drive yourself home.

For Referring Practitioners

For GPs and
referring doctors

Indications, when to consider a CSP referral, the evidence in brief, GP education, and contact details.

Indications

When to consider a conduction system pacing referral

Conduction system pacing is endorsed by the HRS/APHRS/LAHRS 2023 Guideline on Cardiac Physiologic Pacing^[8] and is increasingly considered the preferred approach in the following situations. Consider specifying CSP / LBBAP in the referral letter when referring patients with:

LBBAP / Ventricular conduction system pacing

📋 Complete or high-degree AV block with expected high ventricular pacing burden (>40% VP%)
📋 Existing LV dysfunction (EF 35–50%) requiring pacing — particularly where biventricular CRT is being considered
📋 LBBB with reduced EF — LBBAP as an alternative to biventricular CRT^[9]
📋 Pacing-induced cardiomyopathy on prior conventional RV pacing — for upgrade to LBBAP
📋 Younger patients expected to be paced for decades
📋 Any patient where long-term cardiac function preservation is a clinical priority

Bachmann's Bundle pacing

📋 Paroxysmal or persistent atrial fibrillation with pacing indication
📋 Inter-atrial block on ECG (P-wave ≥120 ms, particularly with biphasic morphology in lead II)
📋 Left atrial dilatation (>40 mm)
📋 History of AF-related stroke or TIA
📋 Post-CABG or valve surgery with atrial pacing indicated

Sample referral wording: “Please consider Left Bundle Branch Area Pacing (LBBAP / conduction system pacing) as the preferred ventricular strategy, and Bachmann's Bundle pacing for the atrial lead, given this patient's expected high pacing burden and history of paroxysmal AF.”

Evidence Summary

The evidence base — in brief

PICM incidence

Conventional RV~20%

LBBAP / CSP ^[3,4]2–7%

HF hospitalisation

Conventional RV10.5%

LBBAP / CSP ^[2]3.7%

LVEF change (mean)

Conventional RV−7%

LBBAP / CSP ^[4]−2%

QRS duration

Conventional RV160–200 ms

LBBAP / CSP ^[1]110–130 ms

Atrial high-rate episodes

Conventional RVIncreased

LBBAP / CSP ^[7]Reduced

HRS guideline endorsement

ConventionalStandard

LBBAP / CSP ^[8]Class 2b (2023)

BB pacing vs RAA: AF recurrence

RAA (reference)Higher risk

Bachmann's Bundle ^[13]HR 0.29 (71% lower)

GP education sessions: Dr Mutha is available for GP education on conduction system pacing, appropriate patient selection, and device management. Contact us via Heart of Melbourne to arrange a session for your practice or CME group.

Common Clinical Questions

Questions from referring practitioners

Does LBBAP take longer and carry more procedural risk than conventional pacing?

In experienced hands, procedural complication rates are comparable. LBBAP requires deeper septal penetration to engage the left bundle branch, typically adding 15–30 minutes. Large published series confirm similar cardiac perforation, lead dislodgement, and vascular complication rates to conventional pacing when performed by operators with significant LBBAP case volume.^[6] The long-term cardiac function benefit substantially outweighs the modest procedural difference.

Which patients should NOT be offered LBBAP?

Contraindications or relative challenges include dense septal fibrosis or calcification, very thin septa, certain complex congenital anatomy, and cases where biventricular pacing is specifically required. We recommend referring with a CSP preference expressed and allowing the implanting electrophysiologist to determine feasibility. Not all apparent “failures” are true anatomical failures — experience in assessing this is part of what a high-volume centre brings.

How do I monitor a paced patient for PICM in general practice?

In patients with high ventricular pacing burden (>20–30% VP%), consider:

Annual or biannual echocardiogram to track LVEF and wall motion
Symptoms of breathlessness, orthopnoea, reduced exercise tolerance, or ankle oedema warrant earlier referral
A drop in LVEF ≥10% or to below 50% from a previously normal baseline in a paced patient should prompt urgent device review and consideration of LBBAP upgrade
Remote monitoring alerts will often flag significant LVEF decline before symptoms develop

Can patients with existing conventional pacemakers be upgraded to LBBAP?

Yes. Patients who develop PICM can be upgraded by adding or replacing the ventricular lead with an LBBAP lead. Published series show LVEF recovery averaging 6–12% following upgrade, with many patients normalising cardiac function. This should be considered before escalating to biventricular CRT in appropriate cases. Refer early — recovery is better when PICM is identified before significant remodelling occurs.

Who should I refer specifically for Bachmann's Bundle pacing?

Patients with: (1) paroxysmal or persistent AF with dual-chamber pacing indication; (2) inter-atrial block (P-wave ≥120 ms, particularly with biphasic P in lead II or notched P in V1); (3) LA diameter >40 mm; (4) prior AF stroke/TIA; (5) post-cardiac surgery with anticipated atrial pacing. Bachmann's Bundle pacing requires specific experience — it is a focus of ours and we welcome referrals.

Get in Touch

Contact us &
clinic locations

Reach out for information or to arrange a consultation — both are welcome. There is no obligation in making contact.

Our Clinics

Two locations across Melbourne

Both clinics offer consulting, diagnostic services, and device follow-up. Full diagnostic suite at each site: echocardiography, stress testing, Holter monitoring, pacemaker and defibrillator testing, and 24-hour blood pressure monitoring.

📍

Fawkner

Melbourne's northern suburbs

Consulting and diagnostic services. Ample parking available on site.

📞 Contact via Heart of Melbourne
🕐 Please contact us for current clinic hours

Heart of Melbourne Website

📍

Wantirna

Melbourne's eastern suburbs

Consulting and diagnostic services. Convenient access from the eastern suburbs and Dandenong Ranges.

📞 Contact via Heart of Melbourne
🕐 Please contact us for current clinic hours

Heart of Melbourne Website

Appointments

Seeing Dr Vivek Mutha

👨‍⚕️

Dr Vivek Mutha

MBBSFRACPFESC

General Cardiologist · Arrhythmia & Device Specialist
Conduction System Pacing · Heart of Melbourne

View Full Profile

Making an Appointment

Appointments are made through the Heart of Melbourne office. A GP or specialist referral is required.

No private health insurance required. Dr Mutha does not routinely bulk bill, however bulk billing is available for pensioners and healthcare card holders on request.

Referral pads and online referral forms are available through the Heart of Melbourne website at hom.com.au.

Book via Heart of Melbourne

For GPs: Online referrals and referral pads are available at hom.com.au. Please include relevant clinical history and, where appropriate, specify your preference for conduction system pacing (LBBAP) and Bachmann's Bundle pacing in the referral letter. Dr Mutha is available for GP education sessions — contact the Heart of Melbourne office to arrange.

Preparing for Your Appointment

What to bring

📄

Referral letter

Your GP's referral with relevant clinical background, including any preference for physiological pacing techniques.

📊

Recent test results

ECGs, Holter reports, echocardiogram results, or blood tests from the last 6–12 months.

💊

Medication list

A current list of all medications, doses, and frequency — including vitamins and supplements.

❓

Your questions

Write them down beforehand. See our page for a ready-made list.

Bring someone with you. A family member or trusted friend can help you remember what was discussed, ask questions you might forget under pressure, and provide support. First cardiology consultations often cover a lot of information quickly — two sets of ears are better than one.

Medical References

Superscript numbers throughout this site correspond to these peer-reviewed publications.

1Jastrzębski M, et al. MELOS multicentre LBBAP study. Eur Heart J. 2022;43:4161–4173. doi link

2Li X, et al. LBBAP vs RVP for AV block. Front Cardiovasc Med. 2021;8:685253. doi link

3Bednarek A, et al. LBBAP prevents PICM. PubMed. 2023. PMID:37154051

4Shimeno K, et al. LBBAP preserves LVEF. Heart Rhythm. 2025. link

5Vijayaraman P, et al. LBBAP vs BiVP for CRT. Heart Rhythm. 2024;21(8):1342–1353.

6Okubo Y, et al. LBBAP mid-term outcomes. J Interv Card Electrophysiol. 2024. doi link

7Yang WY, et al. LBBAP vs RVP & AF risk. Front Cardiovasc Med. 2024. doi link

8Chung MK, et al. HRS/APHRS/LAHRS Guideline on Cardiac Physiologic Pacing. Heart Rhythm. 2023;20:e17–e91.

9Wu S, et al. LBBAP for CRT. Can J Cardiol. 2021;37:319–328.

10Kono T, et al. LBBAP vs His bundle pacing. J Arrhythmia. 2024. doi link

11Bailin SJ, et al. Bachmann's bundle pacing RCT. J Cardiovasc Electrophysiol. 2001;12(8):912–917.

12Infeld M, Nicoli CD, Meagher S, et al. Clinical impact of Bachmann's bundle pacing defined by electrocardiographic criteria on atrial arrhythmia outcomes. Europace. 2022;24(9):1460–1468. doi:10.1093/europace/euac029

13Cronin EM, et al. BB pacing review. Eur Heart J Suppl. 2023;25(Suppl G):G44–G55. doi link

14Lustgarten DL, et al. Bachmann Bundle Pacing. Heart Rhythm. 2024;21(9):1711–1717.

15van Schie MS, et al. BB lead placement. Europace. 2023;25(4):1432–1440. doi link

16BB pacing reduces VP burden. PubMed. 2017. PMID:28028946

17Yoshimoto D, et al. BB pacing bi-atrial strain. Eur Heart J. 2024;45(Suppl 1):ehae666.708.

18Tan ESJ, et al. LA pressure BB vs RAA. Pacing Clin Electrophysiol. 2026. doi link

19El-Chami MF, et al. Micra AV CED 2-year outcomes. Europace. 2024. doi link

20Medtronic. CE Mark Micra AV2 & VR2. January 2024. medtronic.com

21Garweg C, et al. Micra AV2 & Aveir DR. PMC. 2024. PMC11781367

22Knops RE, et al. Leadless pacing review. Micromachines. 2025;16(1):89. doi link

23Cantillon DJ, et al. Leadless pacemaker candidates. PMC. 2023. PMC10518884

24Pestrea C, et al. Comparative analysis of conduction system pacing learning curves for atrioventricular block: a single-operator experience. Heart Rhythm O2. 2025. doi link

25Chow CL, Wong C, Sutherland N, et al. Clinical Outcomes of Conduction System Pacing vs Right Ventricular Septal Pacing in Atrioventricular Block: The CSPACE Randomized Controlled Trial. J Am Coll Cardiol. 2025;86(8):563–573. doi:10.1016/j.jacc.2025.06.043

Be Prepared

Questions to ask your
cardiologist about pacemakers

Print this page and bring it to your appointment. These are the questions that can make a real difference to your long-term outcome.

Once a pacemaker lead is placed, it generally stays in that position for the lifetime of the device — 10 to 15 years. Getting the right type of pacing at the first implant is far better than needing an upgrade later. The questions below are designed to help you have that conversation with confidence.

About the type of pacing

💬 Am I a candidate for Left Bundle Branch Area Pacing (LBBAP) — also called conduction system pacing or physiological pacing? If not, why not?
💬 What are the long-term effects of conventional right ventricular pacing on heart function?
💬 What is my risk of developing pacing-induced heart weakening (PICM) with conventional pacing?
💬 Could conduction system pacing reduce that risk for me?
💬 How many LBBAP procedures has this centre performed, and what is your personal experience with this technique?
💬 If LBBAP is not available at this centre, can I be referred to one where it is?”
💬 “How many conduction system pacing cases have you done?”

About the atrial lead

💬 Where will my atrial lead be placed? Can it be positioned at Bachmann's Bundle rather than the right atrial appendage?
💬 I have a history of atrial fibrillation — does Bachmann's Bundle pacing reduce the risk of AF coming back?
💬 Does my ECG show any delay between my upper chambers activating? Would Bachmann's Bundle pacing help with this?

About leadless pacemakers

💬 Am I a suitable candidate for a leadless pacemaker?
💬 If I receive a leadless device, will it still pace from the right ventricle — meaning I won't get the benefits of conduction system pacing?
💬 What are the advantages and limitations of a leadless pacemaker in my specific situation?

About the procedure

💬 Will I be awake during the procedure? What sedation will I receive?
💬 How long will the procedure take, and when can I go home afterwards?
💬 What restrictions will I need to follow during recovery, and for how long?
💬 What signs or symptoms should prompt me to call you or go to hospital after the procedure?

About long-term care

💬 How will my heart function be monitored over time to check for any early weakening?
💬 Will I have remote monitoring — and how does that work?
💬 What happens when the battery eventually runs low?
💬 If my heart function declines with conventional pacing, is it possible to upgrade to a better pacing position later?

Tip: Write your answers in the space below each question, or ask for them in writing. Bring a family member or friend — two sets of ears are better than one. You are not being difficult by asking these questions; you are making an informed decision about your long-term health.

Notes from my appointment:

About This Centre

Why these questions matter at Melbourne Pacing Centre

Melbourne Pacing Centre has been performing conduction system pacing since 2017. We offer Left Bundle Branch Area Pacing (LBBAP) and Bachmann's Bundle pacing as standard options for eligible patients — not as special requests. If you are seeking a second opinion or would like to discuss your pacing options, you are welcome to contact us.

About the Centre

About Melbourne
Pacing Centre

Our experience, philosophy, and commitment to delivering the most physiological pacing available to every patient.

Our Experience

Performing conduction system pacing since 2017

Melbourne Pacing Centre is a specialist cardiac electrophysiology practice with a clear focus: providing the most physiological pacing available to every patient who needs a pacemaker.

We began performing conduction system pacing in 2017 — years before it became widely available or formally endorsed by international guidelines. Since then we have accumulated thousands of cases, developing the technical depth and clinical judgement that comes only with sustained, high-volume experience.

We are one of Melbourne's most experienced centres for Bachmann's Bundle pacing — a specialised technique that is not routinely available at most pacing centres.

Our clinicians hold academic appointments at the University of Melbourne and maintain active research programs. We present regularly at national and international cardiology meetings and contribute to the growing evidence base shaping the future of physiological pacing.

Philosophy

Our philosophy

We believe the best outcomes for a patient needing a pacemaker come when patients are well informed — including about options that might require referral elsewhere. A patient who understands the difference between conventional and physiological pacing is better placed to protect their long-term cardiac function, regardless of where they are treated.

This website is a patient-education resource. It explains what modern, evidence-based pacing looks like, and helps patients and GPs ask the right questions.

Our services

🭔

Left Bundle Branch Area Pacing

Our default ventricular pacing approach for eligible patients — now endorsed by international guidelines.^[8]

⚡

Bachmann's Bundle Pacing

Specialised atrial pacing to reduce AF risk — one of our areas of particular expertise and case volume.

🔮

Leadless Pacemakers

Micra AV2 and Aveir DR for appropriate patients — no leads, no pocket, significantly reduced infection risk.

⚙️

Cardiac Resynchronisation Therapy

CRT and/or LBBAP for heart failure for eligible patients.

📡

Remote Monitoring

All patients receive remote monitoring — overnight data transmission to our clinic for early detection of any issues.

🔄

Device Upgrade

Upgrading patients who developed PICM under conventional pacing — including LBBAP upgrade when indicated.

Our Specialist

Dr Vivek Mutha — Cardiac Electrophysiologist

👨‍⚕️

Dr Vivek Mutha

MBBSFRACPFESCCardiac Electrophysiologist

Dr Vivek Mutha is an experienced General Cardiologist, Arrhythmia and Device Specialist, and Lecturer at the University of Melbourne. He is one of Melbourne's leading practitioners in conduction system pacing — including LBBAP and His-bundle pacing — and has performed these techniques since 2017.

Training

Basic physician training at Monash Health; cardiology training at Northern Hospital, Austin Health, and Ballarat Base Hospital; advanced cardiac electrophysiology and complex device implantation at Monash Health.

Research & Education

Research interests include physiological pacing and heart failure device therapy. Presents regularly at national and international meetings. Passionate about GP education in cardiac electrophysiology — available for practice-based teaching sessions.

Hospital Affiliations

🏥 The Northern Hospital
🏥 Knox Private Hospital
🏥 Warringal Private Hospital
🏥 Northern Private Hospital
🏥 Mulgrave Private Hospital

View Profile at Heart of Melbourne Research Profile