What is a pacemaker

A pacemaker is a small medical device that gives off electrical impulses to your heart, that’s placed in your chest or abdomen to correct certain heart problems and to help control abnormal heart rhythms. A pacemaker monitors your heart rhythm and triggers an electrical impulse if your heart is beating too slowly (bradycardia, heart rate <60 beats per minute) or too fast (tachycardia, heart rate >100 beats per minute) to make your heart beat at a normal rate. Newer pacemakers can monitor your blood temperature, breathing, and other factors. They also can adjust your heart rate to changes in your activity. A pacemaker consists of a lithium battery, a tiny computer and a pulse generator in a small titanium box, along with one, two, or three leads (wires) that are inserted into the heart thus connecting the pacemaker to your heart. Your doctor or heart specialist may suggest you have a pacemaker inserted if you have an irregular heartbeat, heart block or some other heart conditions.

Pacemakers are used to treat arrhythmias. Arrhythmias are problems with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm.

A heartbeat that’s too fast is called tachycardia (heart rate >100 beats per minute). A heartbeat that’s too slow is called bradycardia (heart rate <60 beats per minute).

During an arrhythmia, the heart may not be able to pump enough blood to the body. This can cause symptoms such as fatigue (tiredness), shortness of breath, or fainting. Severe arrhythmias can damage the body’s vital organs and may even cause loss of consciousness or death.

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.

A pacemaker can relieve some arrhythmia symptoms, such as fatigue and fainting. A pacemaker also can help a person who has abnormal heart rhythms resume a more active lifestyle.

There are different types of pacemakers and your doctor will discuss which one is best for you. Pacemaker pulse generators are checked two to three times a year and must be replaced every five to ten years.

To have a pacemaker inserted, you will have minor surgery under local anesthesia to numb the area of any incisions with IV medication to help you relax. Pacemaker implantation takes about one to three hours in the Electrophysiology Lab with special X-ray equipment.

During surgery, your doctor or cardiologist will insert a wire into a large vein under your collarbone and thread it through to your heart. The doctor will check it is in the right place with an X-ray. The small box containing the battery and pulse generator is inserted in a little cut just under the skin of your chest or abdomen. It is attached to the wire from your heart. Sometimes a second wire is needed.

Once your pacemaker is implanted, the battery should last 5 to 15 years, which is the average battery life. When a pacemaker’s battery wears out, the pacemaker’s pulse generator is replaced. The leads of your pacemaker can be left in place — though they may need to be replaced eventually — 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.

Pacemaker indications

Pacemakers are implanted to help control your heartbeat. Your doctor may suggest you have a temporary pacemaker while your heart recovers from a heart attack, heart surgery or drug overdose.

Pacemakers can also be implanted permanently to correct a slow heartbeat (bradycardia) or, in some cases, to help treat heart failure.

A permanent artificial pacemaker may be recommended if you have:

• Arrhythmias including heart block
• Heart disease
• Other conditions that affect your heart rate
• Atrial fibrillation (AF): A common heart rhythm disorder in which the heart beats too fast and chaotically. Sometimes, people with AFib can also have slow rhythms. Medications used to control atrial fibrillation may result in slow rhythms, which are treated by pacemakers.
• Heart failure: A condition in which the heartbeat is not strong enough to carry a normal amount of blood and oxygen to the brain and other parts of the body. A special pacemaker can be programmed to increase the force of heart muscle contractions. This is called “biventricular pacing” or “resynchronization” therapy.
• Syncope: A condition best known as “Fainting,” usually not serious. Some patients faint when their heart rate becomes too slow. A pacemaker prevents slow heart rates and can cure syncope in some patients.

Doctors recommend pacemakers for many reasons, however the most common reasons for a permanent pacemaker are bradycardia and heart block. Bradycardia is a heartbeat that is slower than normal (less than 60 beats per minute) causing symptoms such as fatigue, dizziness or Fainting spells. Heart block is a disorder that occurs if an electrical signal is slowed or disrupted as it moves through the heart. Heart block can happen as a result of aging, damage to the heart from a heart attack, or other conditions that disrupt the heart’s electrical activity. Some nerve and muscle disorders also can cause heart block, including muscular dystrophy.

People who have arrhythmias find their heart beats slower or faster than normal or has an irregular rhythm. Their heart may then not be able to pump enough blood to your body. This can make you feel tired, shortness of breath, dizzy or faint. It can be dangerous.

There are other treatments for arrhythmia. Your doctor will discuss with you whether a pacemaker is the best treatment for you and your problem.

Your doctor also may recommend a pacemaker if:

• Aging or heart disease damages your sinus node’s ability to set the correct pace for your heartbeat. Such damage can cause slower than normal heartbeats or long pauses between heartbeats. The damage also can cause your heart to switch between slow and fast rhythms. This condition is called sick sinus syndrome.
• You’ve had a medical procedure to treat an arrhythmia called atrial fibrillation. A pacemaker can help regulate your heartbeat after the procedure.
• You need to take certain heart medicines, such as beta blockers. These medicines can slow your heartbeat too much.
• You faint or have other symptoms of a slow heartbeat. For example, this may happen if the main artery in your neck that supplies your brain with blood is sensitive to pressure. Just quickly turning your neck can cause your heart to beat slower than normal. As a result, your brain might not get enough blood flow, causing you to feel faint or collapse.
• You have heart muscle problems that cause electrical signals to travel too slowly through your heart muscle. Your pacemaker may provide cardiac resynchronization therapy for this problem. Cardiac resynchronization therapy devices coordinate electrical signaling between the heart’s lower chambers.
• You have long QT syndrome, which puts you at risk for dangerous arrhythmias.

Doctors also may recommend pacemakers for people who have certain types of congenital heart disease or for people who have had heart transplants. Children, teens, and adults can use pacemakers.

Before recommending a pacemaker, your doctor will consider any arrhythmia symptoms you have, such as dizziness, unexplained fainting, or shortness of breath. He or she also will consider whether you have a history of heart disease, what medicines you’re currently taking, and the results of heart tests.

Figure 1. Pacemaker

Normal pacemaker of the heart

To understand the causes of heart rate or rhythm problems such arrhythmias, it helps to understand how the heart’s internal electrical system works.

Your heart is made up of four chambers — two upper chambers (atria) and two lower chambers (ventricles). The rhythm of your heart is normally controlled by a natural pacemaker called the sinoatrial (SA) node — or sinus node — an area of specialized cells in the right atrium. The sinoatrial (SA) node produces electrical impulses that normally start each heartbeat. This natural pacemaker produces the electrical impulses that trigger the normal heartbeat. From the sinus node, electrical impulses travel across the atria to the ventricles, causing them to contract and pump blood to your lungs and body.

From the sinus node, electrical impulses travel across the atria, causing the atrial muscles to contract and pump blood into the ventricles.

The electrical impulses then arrive at a cluster of cells called the atrioventricular (AV) node — usually the only pathway for signals to travel from the atria to the ventricles.

The atrioventricular (AV) node slows down the electrical signal before sending it to the ventricles. This slight delay allows the ventricles to fill with blood. When electrical impulses reach the muscles of the ventricles, they contract, causing them to pump blood either to the lungs or to the rest of the body.

When anything disrupts this complex system, it can cause the heart to beat too fast (tachycardia), too slow (bradycardia) or with an irregular rhythm.

Figure 2. The anatomy of the heart

What does a pacemaker do

Faulty electrical signaling in the heart causes arrhythmias. Pacemakers use low-energy electrical pulses to overcome this faulty electrical signaling. Pacemakers can:

• Speed up a slow heart rhythm.
• Help control an abnormal or fast heart rhythm.
• Make sure the ventricles contract normally if the atria are quivering instead of beating with a normal rhythm (a condition called atrial fibrillation).
• Coordinate electrical signaling between the upper and lower chambers of the heart.
• Coordinate electrical signaling between the ventricles. Pacemakers that do this are called cardiac resynchronization therapy (biventricular pacemaker) devices. Biventricular pacemakers are used to treat heart failure.
• Prevent dangerous arrhythmias caused by a disorder called long QT syndrome.

Pacemakers also can monitor and record your heart’s electrical activity and heart rhythm. Newer pacemakers can monitor your blood temperature, breathing rate, and other factors. They also can adjust your heart rate to changes in your activity.

Pacemakers can be temporary or permanent. Temporary pacemakers are used to treat short-term heart problems, such as a slow heartbeat that’s caused by a heart attack, heart surgery, or an overdose of medicine.

Temporary pacemakers also are used during emergencies. They might be used until your doctor can implant a permanent pacemaker or until a temporary condition goes away. If you have a temporary pacemaker, you’ll stay in a hospital as long as the device is in place.

Permanent pacemakers are used to control long-term heart rhythm problems. This article mainly discusses permanent pacemakers, unless stated otherwise.

Doctors also treat arrhythmias with another device called an implantable cardioverter defibrillator (ICD). An ICD is similar to a pacemaker. However, besides using low-energy electrical pulses, an ICD also can use high-energy pulses to treat life-threatening arrhythmias.

Pacemaker types

Single chamber pacemaker

This type of pacemaker usually carries electrical impulses from the pulse generator to the right ventricle of your heart.

Dual chamber pacemaker

A dual chamber pacemaker carries electrical impulses from the pulse generator to both the right ventricle and the right atrium of your heart. The impulses help control the timing of contractions between the two chambers.

Rate responsive pacemaker

Rate Responsive Pacemakers adjust the heart rate to a patient’s level of activity. They pace faster when a patient is exercising and slower when a patient is resting.

Newer and smaller leadless cardiac pacemaker

Smaller pacemakers about the size of a pill have been developed and are currently undergoing clinical trials. This new, leadless cardiac pacemaker can be implanted directly into the heart, where it emits an electrical impulse to control the heartbeat. Because a lead isn’t required, this pill size leadless pacemaker can minimize the risk of infection and speed recovery time.

Biventricular pacemaker

Cardiac resynchronization therapy is a procedure to implant a biventricular pacemaker in your chest to make your heart’s chambers contract in a more organized and efficient way.

Cardiac resynchronization therapy is used to treat the delay in heart ventricle contractions that occur in some people with advanced heart failure. Heart failure means your heart’s pumping power is weaker than normal and may not be able to pump out enough blood to support your body. This can be worsened if your heart’s chambers aren’t in sync with each other. With heart failure, blood moves through your heart and body at a slower rate, and pressure in the heart increases. A delay between the contraction of the right and left ventricles often occurs with heart failure, so the walls of the left ventricle are unable to contract at the same time.

Cardiac resynchronization therapy uses a biventricular pacemaker that delivers electrical signals to both of the lower chambers of your heart (ventricles). The signals tell your ventricles to contract at the same time, maximizing the amount of blood that’s pumped out of your heart. Cardiac resynchronization therapy may reduce your symptoms of heart failure and reduce your risk of heart failure complications, including death.

A biventricular pacemaker is an electronic, battery-powered device that is surgically implanted under the skin. A biventricular pacemaker has 2 or 3 leads (wires) that are positioned in the heart to help the heart beat in a more balanced way. The leads are implanted through a vein in the right atrium and right ventricle and into the coronary sinus vein to pace the left ventricle.

Figure 5. Biventricular pacemaker

How biventricular pacemaker works

When your heart rate drops below the set rate (programmed by your doctor), the biventricular pacemaker generates (fires) small electrical impulses that pass through the leads to the heart muscle. These impulses make the lower chambers (ventricles) of the heart muscle contract, causing the right and left ventricles to pump together. The end result is improved cardiac function.

Sometimes the biventricular pacemaker also contains an implantable cardioverter-defibrillator (ICD), which can deliver stronger electrical shocks if your heart rhythm becomes dangerously erratic.

Who is eligible to receive a biventricular pacemaker?

People with heart failure who have a poor ejection fraction (<35%) are at risk for fast, irregular and sometimes life- threatening heart rhythms. Ejection fraction is the measurement of how much blood is being pumped out of the left ventricle of the heart. Biventricular pacemaker may be appropriate for people who:

• Have severe or moderately severe heart failure symptoms
• Are taking medications to treat heart failure
• Have delayed electrical activation of the heart (such as intraventricular conduction delay or bundle branch block)
• Have a history of cardiac arrest or are at risk for cardiac arrest

Together, you and your doctor will determine if this treatment is right for you. You will receive an instruction sheet that describes how to prepare for the procedure.

Should I take my medications?

If you take Coumadin, the results of your INR test (a blood test to evaluate the blood clotting) must be within a suitable range before the implant procedure can be performed. Usually you will be instructed to stop taking anticoagulant medications, including aspirin or Coumadin (warfarin), a few days before the procedure.

Your doctor may also ask you to stop taking other medications, such as those that control your heart rate. Do not discontinue any of your medications without first talking to your health care provider. Ask your doctor which medications you should stop taking and when to stop taking them.

If you have diabetes, ask the nurse how to adjust your diabetes medications or insulin.

Can I eat?

Eat a normal meal the evening before your procedure. However, DO NOT eat, drink or chew anything after 12 midnight before your procedure. This includes gum, mints, water, etc. If you must take medications, only take them with small sips of water. When brushing your teeth, do not swallow any water.

What should I wear?

Remove all makeup and nail polish. Wear comfortable clothes when you come to the hospital. You will change into a hospital gown for the procedure. Please leave all jewelry (including wedding rings), watches and valuables at home. The clothing you are wearing that morning will be returned to the person who accompanies you.

What should I bring?

You will not need a robe or toiletries when you first arrive. You may pack these items – your family member will need to keep your bag until after the procedure. Bring a one-day supply of your prescription medications. Do not take these medications without first talking with the doctor or nurse. You may bring guided imagery tapes or music and the appropriate player.

What happens before the procedure?

Before the procedure begins, a nurse will help you get ready. You will lie on a bed and the nurse will start an IV (intravenous line) in a vein in your arm or hand. The IV is used to deliver medications and fluids during the procedure.To prevent infection and to keep the pacemaker insertion site sterile:

• An antibiotic will be given through the IV at the beginning of the procedure
• For men: The left or right side of your chest will be shaved
• A special soap will be used to cleanse the area
• Sterile drapes are used to cover you from your neck to your feet
• A soft strap will be placed across your waist and arms to prevent your hands from touching the sterile area

Will I be awake?

A medication will be given through your IV to relax you and make you feel drowsy, but you will not be asleep during the procedure (with the endocardial or transvenous approach).

Will I be monitored?

The nurse will connect you to several monitors that allow the health care team to check your heart rhythm and blood pressure during the procedure. The nurse continually monitors you during the procedure.

Monitors During the Procedure

• Defibrillator/pacemaker/cardioverter: Attached to one sticky patch placed on the center of your back and one on your chest. This allows the doctor and nurse to pace your heart rate if it is too slow, or deliver energy to your heart if the rate is too fast.
• Electrocardiogram or EKG: Attached to several sticky electrode patches placed on your chest, as well as inside your heart. Provides a picture on the monitors of the electrical impulses traveling through the heart.
• Blood pressure monitor: Connected to a blood pressure cuff on your arm. Checks your blood pressure throughout the procedure.
• Oximeter monitor: Attached to a small clip placed on your finger. Checks the oxygen level of your blood.
• Fluoroscopy: A large X- ray machine will be positioned above you to help the doctors see the leads on an X-ray screen during the procedure.

Biventricular pacemaker implant procedure

Cardiac resynchronization therapy requires a minor surgical procedure to implant a biventricular pacemaker in your chest.

You’ll likely be awake during the procedure, though the area where the biventricular pacemaker is implanted is numbed and you’ll receive medication to help you relax (conscious sedation). The procedure typically takes a few hours.

During surgery, insulated wires (leads, or electrodes) are 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 each wire is secured to the appropriate position in your heart, while the other end is attached to a pulse generator, which is usually implanted under the skin beneath your collarbone.

Types of cardiac resynchronization therapy devices include:

• Cardiac resynchronization therapy with a biventricular pacemaker. The device used for cardiac resynchronization therapy has 3 leads that connect the pacemaker to the right upper chamber of your heart (right atria) and both lower chambers (ventricles).
• Cardiac resynchronization therapy with a biventricular pacemaker and an implantable cardioverter-defibrillator (ICD). People with heart failure who also have a risk of sudden cardiac death may benefit from an implantable cardioverter-defibrillator (ICD) that can detect dangerous heart rhythms and deliver a stronger correcting shock of energy than a pacemaker can deliver. In these cases, a cardiac resynchronization therapy device that works as both a pacemaker and an implantable cardioverter-defibrillator (ICD) may be recommended.

You’ll usually stay overnight in the hospital after cardiac resynchronization therapy. Your doctor will test your device to make sure it’s programmed correctly before you leave the hospital. Most people can return to their usual activities after a few days.

The transvenous (endocardial) technique is technically challenging. In some cases, this technique may not be successful due to the size, shape or location of the vein(s). If the transvenous (endocardial) approach cannot be used or is unsuccessful, the epicardial approach will be used.

The epicardial approach may also be used to place the cardiac resynchronization therapy if you are already having surgery to treat another heart condition. With the epicardial (surgical) approach, general anesthesia is given to put you to sleep during the procedure. The leads are guided to the heart with the aid of the fluoroscopy machine. Two leads are guided to the right atrium and right ventricle, while the third lead is guided through the coronary sinus to the left ventricle. The lead tips are attached to the heart muscle, while the other ends of the leads are attached to the pulse generator. The generator is placed in a pocket created under the skin in the lower abdomen. The hospital recovery time is generally 3 to 5 days. Although recovery with the epicardial (surgical) approach is longer than that of the transvenous approach, minimally invasive techniques enable a shorter hospital stay and quicker recovery time. Your doctor will determine the best implant procedure approach for you, depending on your condition.

How long does the procedure last?

The device implant procedure may last from 2 to 5 hours.

Will I have to stay in the hospital?

Yes, you will be admitted to the hospital overnight. Usually you will be able to go home the day after your device was implanted, unless the epicardial approach was used during the procedure.

What should I expect during the recovery?

In your hospital room, a special monitor, called a telemetry monitor, will continually monitor your heart rhythm. The telemetry monitor consists of a small box connected by wires to your chest with sticky electrode patches. The box displays your heart rhythm on several monitors in the nursing unit. The nurses will be able to observe your heart rate and rhythm.

You will also have a holter monitor a small recorder attached to your chest with sticky electrode patches. The holter monitor records your heart rhythm for 12 hours to ensure that the pacemaker is functioning properly.

What tests will be done after the procedure?

A chest X-ray will be done after the device implant to check your lungs and the position of the device and leads. Before you are discharged, the holter monitor will be removed, and the results will be given to your doctor. You will then go to the Device Clinic.

What happens at the Device Clinic?

• You will sit in a reclining chair. Small sticky patches (electrodes) will be placed on your chest and connected via wires to a computer. A nurse will place a small device called a programmer directly over the cardiac resynchronization therapy device. The programmer allows the nurse to change the device settings and to check the device and lead function. You may feel your heart beat faster or slower. Although this is normal, please tell the nurse what symptoms you are experiencing. The results of the device check are reported to your doctor, who then determines the appropriate settings for the device. The holter monitor results also are reviewed.
• Home-going instructions including incision care, activity guidelines and follow-up schedule also are reviewed.
• An echocardiogram may be performed as part of the Device Clinic evaluation or at your next follow-up appointment.
• If an echocardiogram (echo) is performed at your pacemaker check, the pacemaker nurse will be there during your echo and will change your pacemaker at least 3 times. The echo will be repeated with each change to evaluate heart function. The pacemaker will keep the settings that demonstrated your best heart function.

How will I feel?

You may feel discomfort at the pacemaker implant site during the first 48 hours after the procedure. The doctor will tell you what medications you can take for pain relief. Please tell your doctor or nurse if your symptoms are prolonged or severe.

This information is about procedures and may include instructions specific to Cleveland Clinic. Please consult your physician for information pertaining to your specific procedure.

How does a pacemaker work

An implanted electronic pacemaker mimics the action of your natural pacemaker. A pacemaker consists of a battery, a computerized generator, and wires with sensors at their tips. (The sensors are called electrodes.) The battery powers the generator, and both are surrounded by a thin metal box. The wires connect the generator to the heart.

An implanted pacemaker consists of two parts:

1. 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.
2. Leads (electrodes). One to three flexible, insulated wires are each placed in a chamber, or chambers, of your heart and deliver the electrical pulses to adjust your heart rate.

A pacemaker helps monitor and control your heartbeat. The electrodes detect your heart’s electrical activity and send data through the wires to the computer in the generator.

If your heart rhythm is abnormal, the computer will direct the generator to send electrical pulses to your heart. The pulses travel through the wires to reach your heart.

Newer pacemakers can monitor your blood temperature, breathing, and other factors. They also can adjust your heart rate to changes in your activity.

The pacemaker’s computer also records your heart’s electrical activity and heart rhythm. Your doctor will use these recordings to adjust your pacemaker so it works better for you.

Your doctor can program the pacemaker’s computer with an external device. He or she doesn’t have to use needles or have direct contact with the pacemaker.

Pacemakers have one to three wires that are each placed in different chambers of the heart:

• The wires in a single-chamber pacemaker usually carry pulses from the generator to the right ventricle (the lower right chamber of your heart).
• The wires in a dual-chamber pacemaker carry pulses from the generator to the right atrium (the upper right chamber of your heart) and the right ventricle. The pulses help coordinate the timing of these two chambers’ contractions.
• The wires in a biventricular pacemaker carry pulses from the generator to an atrium and both ventricles. The pulses help coordinate electrical signaling between the two ventricles. This type of pacemaker also is called a cardiac resynchronization therapy device.

Pacemaker programming

The two main types of programming for pacemakers are demand pacing and rate-responsive pacing.

A demand pacemaker monitors your heart rhythm. It only sends electrical pulses to your heart if your heart is beating too slow or if it misses a beat.

A rate-responsive pacemaker will speed up or slow down your heart rate depending on how active you are. To do this, the device monitors your sinus node rate, breathing, blood temperature, and other factors to determine your activity level.

Your doctor will work with you to decide which type of pacemaker is best for you.

Pacemaker surgery preparation

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 your 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 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 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 electrocardiogram is taken before and immediately after walking on a treadmill or riding a stationary bike. In some cases, an echocardiogram or nuclear imaging may be done. 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.

Pacemaker surgery

Placing a pacemaker requires minor surgery. The surgery usually is done in a hospital or special heart treatment laboratory.

Before the surgery, an intravenous (IV) line will be inserted into one of your veins. You will receive medicine through the IV line to help you relax. The medicine also might make you sleepy.

Your chest is cleaned with an antibacterial soap, and an IV line is placed in your arm on the same side as the pacemaker.

Your doctor will numb the area where he or she will put the pacemaker so you don’t feel any pain. Your doctor also may give you antibiotics to prevent infection.

First, your doctor will insert a needle into a large vein, usually near the shoulder opposite your dominant hand. Your doctor will then use the needle to thread the pacemaker wires into the vein and to correctly place them in your heart.

An x-ray “movie” of the wires as they pass through your vein and into your heart will help your doctor place them. Once the wires are in place, your doctor will make a small cut into the skin of your chest or abdomen.

He or she will slip the pacemaker’s small metal box through the cut, place it just under your skin, and connect it to the wires that lead to your heart. The box contains the pacemaker’s battery and generator.

Once the pacemaker is in place, your doctor will test it to make sure it works properly. He or she will then sew up the cut. The entire surgery takes a few hours.

After the pacemaker 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, most pacemakers can be checked remotely using wireless technology. Using your cellphone or radiofrequency signals, your pacemaker transmits and receives information between you and your doctor’s office, where your doctor can access the data — including your heart rate and rhythm, how your pacemaker is functioning, and remaining battery life.

Remote transmissions can be made at scheduled intervals or at unscheduled times if your pacemaker sends an alert, or you can send a transmission if you have a concern. Remote technology means fewer trips to the doctor’s office, but you’ll still need to be seen by your doctor in person for scheduled checkups.

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 (Advil, Motrin IB, others), but talk to your doctor before taking any pain relievers.

Ongoing Care

Your doctor will want to check your pacemaker regularly (about every 3 months). Over time, a pacemaker can stop working properly because:

• Its wires get dislodged or broken
• Its battery gets weak or fails
• Your heart disease progresses
• Other devices have disrupted its electrical signaling

To check your pacemaker, your doctor may ask you to come in for an office visit several times a year. Some pacemaker functions can be checked remotely using a phone or the Internet.

Your doctor also may ask you to have an EKG (electrocardiogram) to check for changes in your heart’s electrical activity.

Battery Replacement

Pacemaker batteries last between 5 and 15 years (average 6 to 7 years), depending on how active the pacemaker is. Your doctor will replace the generator along with the battery before the battery starts to run down.

Replacing the generator and battery is less-involved surgery than the original surgery to implant the pacemaker. Your pacemaker wires also may need to be replaced eventually.

Your doctor can tell you whether your pacemaker or its wires need to be replaced when you see him or her for followup visits.

Pacemaker precautions

Most people with pacemakers can play sport, swim, have sex and keep up other physical activities. They should avoid contact sport though such as football. You’ll need regular check-ups by your specialist to make sure the pacemaker is working properly.

Occasionally electrical devices with a strong magnetic field, including mobile phones, microwave ovens and high tension wires, can interfere with a pacemaker. Talk to your doctor if you are experiencing any problems.

Your doctor will give you a medical ID bracelet or a card to keep in your wallet to let people know you have a pacemaker. You’ll also get instructions about being careful with some electrical equipment and medical procedures.

Pacemaker 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:

• Cellphones and MP3 players (for example, iPods). It’s safe to talk on a cellphone, but avoid placing your cellphone directly over your pacemaker implantation site when the phone is turned on. Although unlikely, your pacemaker could misinterpret the cellphone signal as a heartbeat and withhold pacing, producing symptoms, such as sudden fatigue. To be safe, some experts recommend not putting your cell phone or MP3 player in a shirt pocket over your pacemaker (if the devices are turned on). You may want to hold your cell phone up to the ear that’s opposite the site where your pacemaker is implanted. If you strap your MP3 player to your arm while listening to it, put it on the arm that’s farther from your pacemaker.
• 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 (MRI scan), therapeutic radiation for cancer treatment (radiotherapy) and shock wave lithotripsy (ESWL), 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 2 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.

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.

Talk to your doctor if you have a pacemaker and are concerned about turning it off. 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.

Pacemaker risks

Pacemaker surgery is usually safe and your body won’t reject a pacemaker. 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 surgery
• 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
• Swelling, bruising or bleeding
• Blood vessel or nerve damage

Life-threatening complications of pacemaker implantation are rare.

Talk to your doctor about the risks of pacemaker implant surgery.