Pacemaker

Why it's done

Pacemakers are implanted to help control your heartbeat. They can be implanted temporarily to treat a slow heartbeat after a heart attack, surgery or overdose of medication. Pacemakers can also be implanted permanently to correct a slow heartbeat (bradycardia) or, in some cases, to help treat heart failure. To understand how a pacemaker works, it helps to know how your heart beats.

How your heart beats
The heart is a muscular, fist-sized pump with four chambers, two on the left side and two on the right. The upper chambers are the right and left atria. The lower chambers are the right and left ventricles.

For your heart to function properly, the heart's chambers must work in a coordinated fashion. Your heart must also beat at an appropriate rate — normally from 60 to 100 beats a minute in resting adults. If your heart beats too slowly or too rapidly, not enough blood flows through your body, leading to fatigue, fainting, shortness of breath, confusion, and other signs and symptoms.

Your heart's electrical system controls the chambers' pumping action. A normal heartbeat begins in your right atrium, in the sinus node. This cluster of cells — your natural pacemaker — acts like a spark plug, generating regular electrical impulses that travel through specialized muscle fibers.

When an electrical impulse reaches both the right and left atria, they contract and squeeze blood into the ventricles. After a split-second delay to allow the ventricles to fill, the impulse reaches the ventricles, making them contract and pump blood to the rest of your body.

What a pacemaker does

An implanted electronic pacemaker mimics the action of your natural pacemaker. An implanted pacemaker consists of two parts:

• The pulse generator. This small metal container houses a battery and the electrical circuitry that regulates the rate of electrical pulses sent to your heart.
• Leads. These flexible, insulated wires deliver the electrical pulses to your heart.

Pacemakers monitor your heartbeat and, if it's too slow, the pacemaker will speed up your heart rate by sending electrical signals to your heart. In addition, most pacemakers have sensors that detect body motion or breathing rate, which signals the pacemaker to increase your heart rate during exercise to meet your body's increased need for blood and oxygen.

Biventricular pacemakers

In addition to traditional pacemakers, biventricular pacemakers are a treatment option for people with heart failure whose hearts' electrical systems have been damaged. Unlike a regular pacemaker, a biventricular pacemaker stimulates both of the lower chambers of your heart (the right and left ventricles) to make the heart beat more efficiently. A biventricular pacemaker paces both ventricles so that all or most of the ventricular muscle pumps together. This allows your heart to pump blood more effectively. Because this treatment resets the ventricles' pumping mechanism, it's also referred to as cardiac resynchronization therapy (CRT). 

Risks

Complications from having surgery to implant your pacemaker are uncommon, but could include:

• Infection where the pacemaker was implanted
• Allergic reaction to the dye or anesthesia used during your procedure
• Swelling, bruising or bleeding at the generator site, especially if you are taking blood thinners
• Damage to your blood vessels or nerves near the pacemaker
• Collapsed lung
• Puncture of your heart muscle, which can lead to bleeding into the lining (pericardium) of your heart and may require emergency medical care

Life-threatening complications of pacemaker implantation are rare.

How you prepare

Before your doctor decides if you need a pacemaker, you'll have several tests done to find out the cause of your irregular heartbeat. These could include:

• Electrocardiogram. In this noninvasive test, sensor pads with wires attached, called electrodes, are placed on your chest and sometimes limbs to measure your heart's electrical impulses. Your heart's beating pattern can offer clues to the type of irregular heartbeat you have.
• Holter monitoring. Also known as an ambulatory electrocardiogram monitor, a Holter monitor records your heart rhythms for an entire 24-hour period. Wires from electrodes on your chest go to a battery-operated recording device carried in your pocket or worn on a belt or shoulder strap. While you're wearing the monitor, you'll keep a diary of your activities and symptoms. Your doctor will compare the diary with the electrical recordings to try to figure out the cause of your symptoms.
• Echocardiogram. This noninvasive test uses harmless sound waves that allow your doctor to see your heart without making an incision. During the procedure, a small, plastic instrument called a transducer is placed on your chest. It collects reflected sound waves (echoes) from your heart and transmits them to a machine that uses the sound wave patterns to compose images of your beating heart on a monitor. These images show how well your heart is functioning, and recorded pictures allow your doctor to measure the size and thickness of your heart muscle.
• Stress test. Some heart problems occur only during exercise. For a stress test, an echocardiogram or electrocardiogram is taken before and immediately after walking on a treadmill or riding a stationary bike. Other types of treadmill exercise tests also can be done to evaluate your heart, including an oxygen consumption test that measures how much oxygen your body is using.

What you can expect

During the procedure

Surgery to implant the pacemaker is usually performed while you're awake and typically takes about one or two hours. You'll be given a sedative to relax, and the area where your pacemaker is inserted will be numbed.

During surgery, a flexible, insulated wire (lead) is inserted into a major vein under or near your collarbone and guided to your heart with the help of X-ray images. One end of the lead (the electrode) is secured to your heart's right ventricle, while the other end is attached to the pulse generator, which is usually implanted under the skin beneath your collarbone.

In many cases, another lead is secured to your heart's upper right chamber (atrium) to keep your heart pumping in a coordinated manner. This is called a dual chamber pacemaker system because both the right atrium and right ventricle are stimulated in sequence.

After the procedure

You'll usually stay in the hospital for one day after having a pacemaker implanted. Before you leave, your pacemaker is programmed to fit your particular pacing needs. A return visit is often scheduled to make sure your pacemaker's settings are correct.

After that, you'll have your pacemaker checked via telephone every few months. You connect to a phone line with either a transmitter attached to wristbands on each of your arms or a wand placed over the pacemaker. These devices send pacemaker information to your doctor's office. A technician on the other end of the line checks your heart rate and rhythm and evaluates your pacemaker's function and remaining battery life.

After your procedure to implant your pacemaker, your doctor may recommend that you avoid vigorous exercise or heavy lifting for about a month. You may have some aches and pains near the area where your pacemaker was implanted. These pains can be relieved with over-the-counter medicines, such as acetaminophen (Tylenol, others) or ibuprofen (Motrin, Advil, others), but talk to your doctor before taking any pain relievers.

Special precautions

It's unlikely that your pacemaker would stop working properly because of electrical interference. Still, you'll need to take a few precautions:

• Cellular phones. It's safe to talk on a cell phone, but avoid placing your cell phone directly over your pacemaker implantation site when the phone is turned on. Although unlikely, your pacemaker could misinterpret the cell phone signal as a heartbeat and withhold pacing, producing symptoms, such as sudden fatigue.
• Security systems. Passing through an airport metal detector won't interfere with your pacemaker, although the metal in it may sound the alarm. But avoid lingering near or leaning against a metal-detection system. If security personnel insist on using a hand-held metal detector, ask them not to hold the device near your pacemaker any longer than necessary or ask for an alternative form of personal search. To avoid potential problems, carry an ID card stating that you have a pacemaker.
• Medical equipment. If a doctor is considering any medical procedure that involves intensive exposure to electromagnetic energy, tell him or her that you have a pacemaker. Such procedures include magnetic resonance imaging, therapeutic radiation for cancer treatment, and shock wave lithotripsy, which uses shock waves to break up large kidney stones or gallstones. If you're having surgery, a procedure to control bleeding (electrocautery) also can interfere with pacemaker function.
• Power-generating equipment. Stand at least two feet (60 centimeters) from welding equipment, high-voltage transformers or motor-generator systems. If you work around such equipment, your doctor can arrange a test in your workplace to determine whether it affects your pacemaker.

Devices that are unlikely to interfere with your pacemaker include microwave ovens, televisions and remote controls, radios, toasters, electric blankets, electric shavers and electric drills. 

Results

Once your pacemaker is implanted, it should last five to 10 years, which is the average battery life. When a pacemaker's battery wears out, the entire pacemaker's pulse generator is replaced, and you'll need another procedure to fix your device. The leads of your pacemaker can be left in place, and the procedure to change your pacemaker's battery is often quicker and requires less recovery time than the procedure to first implant your pacemaker.

Pacemakers are a standard treatment for many conditions affecting your heart's electrical system. By preventing a slow heart rate, pacemakers can treat symptoms, such as fatigue, lightheadedness and fainting. Because most of today's pacemakers automatically adjust your heart rate to match your level of physical activity, they can allow you to resume a more active lifestyle.

Pacemakers and end-of-life issues

If you have a pacemaker and become terminally ill with a condition unrelated to your heart, such as cancer, it's possible that your pacemaker could prolong the process of dying. Doctors and researchers have varied opinions on turning off a pacemaker in end-of-life situations.

If you have a pacemaker implanted and are concerned about turning off your pacemaker, talk to your doctor. You may also want to talk to family members or another person designated to make medical decisions for you about what you'd like to do in end-of-life care situations. 

References:

https://www.irishheart.ie/iopen24/pacemakers-t-7_19_70.html

http://circ.ahajournals.org/content/105/18/2136

http://www.hse.ie/eng/health/az/P/Pacemaker-implantation/FAQs-recovering-from-pacemaker-implantation.html