A pacemaker is a small, lightweight, electronic device that is implanted (inserted into the body), ready to pace the heart (make it beat). It is prescribed for people whose hearts are beating too slowly. It is implanted in the chest.
The pacemaker keeps track of your heart's electrical activity. If it senses that the heart is beating too slowly or is pausing too long between beats, the pacemaker delivers electrical impulses that stimulate the heart and keep it beating at the proper rate (speed).
A slow heart rhythm may cause symptoms such as dizziness, fainting spells or fatigue. A pacemaker can give your heart the extra help it needs to relieve your symptoms and help you feel better. Also, having a pacemaker can give you more freedom to participate in the activities you enjoy.
A pacemaker has two main parts: a pulse generator and either one or two leads.
Pulse Generator
The pulse generator is a smooth, lightweight metal case containing a battery and circuitry. The battery supplies the electrical energy. The circuitry produces tiny electrical impulses and controls the timing at which these impulses are delivered to the heart. The pulse generator is about the size of a silver dollar.
Lead (or Leads)
A lead is an insulated, flexible wire that is placed in the heart. The lead carries electrical energy from the pacemaker to the heart. It also relays information about the heart's activity back to the pacemaker.
Most leads are threaded through a vein and go from the pacemaker to the inside of the heart. Depending on the type of pacemaker that is implanted, one or two leads may be used.
A pacemaker has two main functions. It keeps track of the heart's natural electrical activity (this is called sensing). It also sends electrical impulses to the heart to make the heart beat (this is called pacing).
For example, if the pacemaker senses that the heart is beating too slowly or pausing for too long, it sends tiny electrical impulses. These impulses are too slight to be felt, but they stimulate the heart muscle to contract and pump blood.
On the other hand, if the pacemaker senses that the heart is beating at a proper rate, it does on demand and stands by until it is needed. The instant the heart starts beating too slowly or pauses, the pacemaker will begin pacing again.
The pacemaker's sensing and pacing functions can be adjusted or programmed by your doctor to meet your particular needs.
There are two basic types of pacemakers, depending on the number of leads:
Single-Chamber Pacemaker
A single-chamber pacemaker has one lead. The lead is placed in either the right atrium or the right ventricle, depending on where the signal problem is.
For example, in people who have sick sinus syndrome and a normal conduction pathway, the lead is usually placed in the right atrium. The pacemaker stimulates the atria to contract. The impulse continues to the ventricles to complete the heartbeat.
If the conduction pathway between the atria and ventricles is blocked (heart block), the lead is usually placed in the right ventricle.
Dual-Chamber Pacemaker
A dual-chamber pacemaker has two leads. One lead is placed in the right atrium; the other is placed in the right ventricle. This is the most common type of pacemaker implanted today.
The dual-chamber pacemaker can monitor and deliver impulses to both heart chambers. The impulses are timed so that the upper chambers (atria) are stimulated to contract just before the lower chambers (ventricles), mimicking the heart's natural sequence.
This timing ensures that the heart's upper and lower chambers beat in sync with one another, therefore helping the heart beat more efficiently.
Rate-Adaptive Pacemakers
Normally, the heart rhythm slows down or speeds up many times during the day. The heart beats more slowly while you are resting or sleeping. When you are active, it beats faster because your body requires more oxygen and thus more blood to be circulated.
A rate-adaptive pacemaker uses special sensors that recognize body change, such as change in motion or breathing. By keeping track of these changes, the pacemaker helps you heartbeat speed up or slow down with your level of activity. This type of pacing mimics the heart's natural function and may allow a more active lifestyle.
Rate-adaptive pacemakers can be single-chamber or dual-chamber devices.
Implanting Your Pacemaker
Implanting a pacemaker is a minor surgical procedure that is usually done under local anesthesia. In some cases, the pacemaker is implanted during surgery for another heart problem, such as a coronary bypass. In these cases, general anesthesia is used.
Unless you are already in the hospital, you will most likely be asked to arrive early in the morning on the day of the procedure, or possibly the night before. Several routine tests will be done, such as an ECG and blood tests. (Blood tests may be done a day or two before the procedure.)
The doctor will review your medical history and examine you. (You may be seen by the doctor at the office several days before the procedure.)
The doctor or nurse will discuss the procedure, its purpose, potential benefits, and possible risks. This is a good time to ask questions and, most important, to share any concerns you may have. You will then be asked to sign a consent form.
An intravenous (IV) line will be inserted into a vein in your arm. This line allows drugs to be injected directly into the vein, if needed. To help you relax, you'll be given a sedative.
Before the procedure:
· You'll be asked not to eat or drink anything for 6 to 8 hours before the procedure. You may have sips of water to swallow your medications.
· Check with your doctor several days before the procedure. You may be asked to stop taking certain medications (such as aspirin) 1 – 3 days before the procedure.
· Make arrangements for someone to drive you to and from the hospital since you will not be permitted to drive after the procedure.
· Bring a list of all the medications you are currently taking. It is important for the doctor to know the exact names and dosages of any medications that you take.
· Tell the doctor or nurse if you have had any allergic reactions to drugs or if you have a history of bleeding problems.
· Pacemakers can be inserted near the right or left shoulder. If you prefer to have it implanted on a particular side, let the doctor know.
· For your comfort, empty your bladder as completely as possible before the procedure starts. (A bedpan or urinal will be available during the procedure.)
Most often, the pacemaker is implanted in the upper chest, near the right or left shoulder. Occasionally it may be implanted under the skin in the abdomen.
A local anesthetic is injected to numb the area where the pacemaker will be inserted. An incision is made below the collarbone and a pocket is created under the skin, where the pulse generator will be placed.
The lead is inserted through the chest incision and into a vein. With the help of an x-ray camera, the lead is passed through the vein and placed inside the heart. If a second lead is needed (dual-chamber pacemaker), this process is repeated.
After a lead is in place, it is tested to make sure it senses the heart signals clearly. Each of the leads is then connected to the pulse generator.
The pulse generator is set to treat your heart rhythm problem and placed in the pocket of your chest. The device is then tested to make sure it is working properly. Finally, the incision is closed and covered with a sterile dressing.
You will be sedated during the procedure. Be sure to let the staff know if you feel any pain or discomfort. The procedure usually takes one to two hours.
Implanting a pacemaker is a simple procedure with little risk. However, as with any surgery, problems or complications can occur.
Some people may develop bleeding at the incision or pocket site. Blood collects under the skin, resulting in local swelling and/or a bruise.
In rare cases, the procedure may lead to more serious complications, including puncture of a lung, damage to the heart and blood vessels, formation of blood clots, and infection. Deaths are very rare.
Occasionally, doctors attach the lead(s) to the outside of the heart and place the pacemaker's pulse generator underneath the skin in the abdomen. This method, called epicardial (outside the heart) implantation, is usually done in patients undergoing heart surgery and requires general anesthesia. It is also often used for children because their bodies will grow.
After the pacemaker is implanted, you will be taken to the recovery area. A nurse will take your pulse and blood pressure and will also check the incision for bleeding or swelling.
During your hospital stay, your heart rhythm will be monitored continuously. Your doctor may also test the pacemaker to make sure it is working properly. This is done from outside the body.
For a few days, it is normal to have some pain and stiffness around the incision. Your doctor will most likely prescribe pain medication to help make you more comfortable. Do not raise the arm on the side of the incision above shoulder level.
Most patients stay in the hospital overnight; some will stay an extra day. Before going home, you will be given instructions regarding care of the incision, physical activity, and medications. When it is time to leave, have a friend or family member drive you.
A few days after leaving the hospital, you will probably be able to go back to most of your daily activities. However, it may take a few weeks before the wound is completely healed.
For a few weeks, you may feel numbness or fullness in the area around the pacemaker; this is normal. You may also be aware of the pulse generator under the skin, but gradually you will adjust to it.
During the first few weeks:
· Follow your doctor's instructions regarding activity, exercise, and returning to work.
· Keep the incision site completely dry for a week or so, to help prevent an infection.
· Avoid lifting anything heavier than 10 to 15 pounds. Also, avoid excessive pushing, pulling, or twisting.
· For about 2 weeks, do not raise the arm on the pacemaker side above shoulder level.
· Call your doctor if the incision site shows signs of infection (pain, redness, swelling), there is drainage from the incision, or you develop a fever over 100 degrees.
· Call your doctor if you have twitching chest muscles, hiccups that won't stop, or a swollen arm on the side of the incision.
· Call your doctor if your symptoms recur, or if you experience lightheadness, chest pain, or shortness of breath.
· Be sure to check with your doctor or nurse about medications—which ones to continue and which ones to stop.
· Tell other doctors, dentists, and emergency personnel that you have a pacemaker.
If you have a pacemaker, it is important that you have follow-up visits with your doctor or pacemaker clinic. Your pacemaker may also be checked through telephone monitoring.
Follow-up visits are needed to help ensure that your pacemaker is working properly. They take place at the doctor's office or pacemaker clinic. A typical visit takes less than 30 minutes. Your visit schedule will depend on your medical condition and the type of pacemaker you have.
Follow-up visits allow your doctor or nurse to check the pacemaker's settings, its interaction with your heart, and the battery's status. During the visit, an electrocardiogram (ECG) will be done. The ECG records the electrical activity of both your heart and pacemaker.
A special magnet is often applied over the pacemaker, causing it to pace at a set rate that disregards your heart's natural beat. The magnet check allows the doctor or nurse to test the pacemaker's settings and battery status.
From time to time, you may have a more thorough checkup of the pacemaker. The doctor or nurse uses a programmer, a device that can talk to your pacemaker, to make sure it's working properly.
If your medical condition changes, the programmer can be used to reprogram the pacemaker. During reprogramming, the settings are adjusted to better treat your slow heart rhythm. This is done painlessly, from outside your body. In a way, it works like using a remote control for programming a VCR.
If you have a rate-adaptive pacemaker, you may be asked to perform physical activity, such as walking, during the visit. This allows the doctor to check the pacemaker's settings and see how well it can achieve faster heart rates during activity.
Telephone monitoring is a method of transmitting your ECG by telephone. This may be especially convenient if you live at a distance from the clinic or if traveling to the clinic is difficult.
If your doctor recommends it, you can subscribe to a telephone monitoring service. You will be given a special transmitter that allows you to record and transmit your ECG over the telephone line. You will also receive a transmission schedule showing you how often you need to use the service.
When you transmit your ECG, a receiving device in the monitoring office records the signals and prints a tracing. The tracing is analyzed by a technician and the information is forwarded to your doctor.
Pacemakers are powered by long-lasting lithium batteries. However, pacemakers need to be replaced eventually. The exact replacement time depends on your medical condition, the type of pacemaker you have, and the way it is programmed. In general, pacemakers are designed to last 6 to 10 years.
Since the battery is sealed inside the pulse generator, replacing the battery requires replacing the entire generator. This procedure is usually simpler than the initial one. The pacemaker pocket is opened, the leads are unplugged and tested, the new generator is tested, and the pocket is closed.
Occasionally, the leads need to be replaced. Replacing the leads is usually more complicated and riskier than it was to implant them the first time.
You will be given a wallet card that gives information about your pacemaker. It also includes your doctor's name and phone number. Carry it with you at all times. Show it to any health care provider you visit.
Also, because your pacemaker may set off security devices like those found in airports, libraries, and department stores, you may need to show your card to security personnel.
In addition to a pacemaker ID card, consider getting a medical alert bracelet or necklace that shows you have a heart rhythm problem and a pacemaker.
If you have a pacemaker, you will be told when to call your doctor or nurse. Call as instructed or in the following situations:
· If you experience any of the symptoms you had before the pacemaker was implanted.
· If you develop symptoms such as dizziness, fainting spells, palpitations, shortness of breath, chest pain, or lack of energy.
· If you experience twitching chest muscles or hiccups that won't stop.
· If you are going to have a medical procedure, especially if it involves surgery.
· If you have questions about your pacemaker, medications, or activities.
· If you plan to travel or move.
Your pacemaker will help you feel better by relieving symptoms caused by a slow heart rhythm. Rather than keeping you from living an active life, having a pacemaker may give you more freedom to do the things you enjoy.
Ask your doctor or nurse how soon you can resume your normal daily activities and hobbies. These may include walking, playing golf, gardening, driving, and returning to work.
Several weeks after your surgery, you may be ready to add more strenuous exercise to your routine. Be sure to consult your doctor prior to starting an exercise program. Types of exercise that are good for the heart include brisk walking, jogging, swimming, bicycling, tennis, aerobic workouts, and dancing.
Avoid activities that could lead to rough contact in the area around your pacemaker. Such activities include football, baseball, racquetball, soccer, and skiing. Also, avoid hunting if a rifle butt is rested on or next to your chest implant.
Once you have recovered from surgery, you will be free to travel with the pacemaker. If you plan to be away for more than 3 months, you should arrange with your doctor to see a specialist or clinic in the area you will be visiting. Get a copy of your medical records to take with you.
It is natural for patients and their families to feel anxious about the pacemaker at first. Other feelings, such as fear, depression, and anger, are normal too. The good news is that these feelings rarely last for more than a few weeks. Most patients gradually adjust to having a pacemaker and are able to resume their normal daily routine. If such feelings last for more than a couple of months, talk to your doctor.
Things that use magnets or electricity have magnetic fields around them. These fields are usually weak and won't affect your pacemaker. However, strong magnetic fields can interfere with the device and may temporarily affect the way it works. It is important to know which sources of interference do and do not affect your pacemaker.
You can safely operate most household and office appliances that are properly grounded and in good working order. These include:
· Kitchen appliances such as microwave ovens, toasters, blenders, and electric can openers.
· Televisions, AM/FM radios, VCRs, remote controls, CD players, garage door openers.
· Hand-held appliances such as hair dryers and shavers (avoid holding against the implant site).
· Major appliances such as washers, dryers, electric stoves, and refrigerators.
· Electric blankets and heating pads.
· Spark-ignited internal combustion engines such as lawn mowers and leaf blowers.
· Personal computers, printers, fax machines, electric typewriters, and copying machines.
· Machine shop tools like drills and table saws (keep tools 12 inches from the implant site).
To make sure your pacemaker works properly, you should avoid the following:
· Large generators, electric motors, arc welders, and other large industrial equipment.
· Transmission towers, high-voltage power lines.
· Large stereo speakers.
· Magnetic therapy products (such as massagers, mattress pads, chair pads, etc.).
· Battery-powered cordless power tools such as screwdrivers and drills.
· Maintaining or repairing any electrical or gas-powered appliances.
· Leaning over the open hood of a running car (alternators frequently contain magnets).
With proper precautions, most medical procedures are not likely to interfere with your pacemaker. Some procedures, however, produce strong magnetic fields and should be avoided. These include magnetic resonance imaging (MRI), electrocautery, diathermy, lithotripsy, and radiation therapy.
It is OK to walk through security archways, such as those at airports and stores. The archway will not harm your pacemaker, but it may detect its metal case and set off the alarm. If this happens, show your wallet card to security personnel.
Hand-held security wands, such as those used at airports, may interfere with the proper working of your pacemaker because they contain a magnet. Show your wallet card to security and ask to be hand searched in place of the hand-held wand.
At the entrance to stores and libraries, you may walk normally through the theft detection systems. Do not stay near the theft detection equipment, however.
A cellular phone can affect your pacemaker if the phone is held too close to it. This effect is temporary. Simply move the phone away from the pacemaker and the device will function normally again.
When using a cellular phone, hold the phone to the ear farthest from your pacemaker. Do not carry the phone in a breast pocket or on a belt within 6 inches of the implanted device.
