This page provides information on different types of pacemakers and how they function. It also includes information on how to prepare for your pacemaker implantation and instructions on what to do following implantation. If you or a family member has any additional questions, please feel free to discuss them with your doctor or nurse at any time.

Your heart and how it works

As your heart beats, it pumps blood throughout the body. Normally, the heart beats from 60 to 100 times per minute. The beating is caused by special cells called the sinoatrial node (SA node) - sometimes called sinus node - that produce electrical signals that cause the heart to contract and pump blood. The SA node is sometimes referred to as the heart's "natural pacemaker" and is located in the right atrium.
Sometimes there may be interference with the electrical signals traveling through the heart, and an abnormal heartbeat may result. To bring your heart into a normal rhythm, your doctor may recommend an artificial pacemaker.

Pacemaker system and function

A pacemaker is a small, battery-powered device that is implanted inside the chest to help regulate the heart rhythm by producing electrical signals to start your heartbeat. The pacemaker is about two inches in diameter and weighs about one ounce.

The pacemaker is a metal case that contains a long-life battery and an electronic circuitry designed to control the timing and rhythm of the heartbeat. The case portion of the pacemaker is implanted into the chest just under the skin through a small incision. Pacing leads - the wires that connect to your heart and allow signals to flow - are connected at the same time. More than 100,000 pacemakers are permanently implanted in patients each year in the United States.

Pacemaker sensing and timing

Pacemakers are designed to sense whether or not the heart is producing electrical signals naturally within a specified time. If natural beating activity does not occur within a specified time, the pacemaker will automatically "pace" or send an electrical signal to the heart, causing it to beat. The pacemaker then adjusts itself to a new timing cycle. It continues to monitor for signals of natural heart activity. If there are none within the time frame allowed, it will pace again.

DIFFERENT TYPES OF PACEMAKERS

Demand pacemakers: Most pacemakers work only when they are needed. These are "demand" pacemakers. Single chamber pacemakers are designed to pace only in the ventricle or atrium. Dual chamber pacemakers are designed to pace in both chambers of the heart.

Rate-responsive pacemaker: These units pace in response to the amount of physical activity you are expending. By monitoring sensors that detect your breathing rate and levels of bodily movement, they can increase or decrease your heart rate accordingly. These pacemakers can also be single or dual chamber.

Patient preparation

Testing instructions: Do not eat or drink after midnight the day of the procedure.
Take all medications as prescribed with a small sip of water unless directed otherwise by your doctor.

Be sure to tell your doctor if:

* You have an allergy to seafood, x-ray dye or iodine.
* You know or suspect that you are pregnant.
* You are taking blood thinners.
* You have a history of bleeding problems.
* You are diabetic.

Prior to your procedure, blood tests, x-rays and an electrocardiogram (ECG) will be ordered by your doctor. Family members will be taken to a waiting room where the doctor will speak with them after your procedure.

The pacemaker implantation procedure

Your pacemaker will be implanted at the electrophysiology lab or in the hospital operating room. A physician specially trained in pacemaker implantation performs the procedure. There are two types of implantation: transvenous (through the veins) and epicardial (next to the heart).

TRANSVENOUS IMPLANTATION

You will wear a hospital gown and you may wear your eyeglasses, hearing aid, and dentures. At the start of the procedure, a nurse will give you a sedative to help you relax, but you will not be asleep. If you don't already have an intravenous needle (IV), one will be started. An antibiotic will be given through your IV at the beginning of the procedure to help prevent infection.
The nurse will connect you to three different monitors:

• Electrocardiogram or ECG: Several sticky electrode patches placed on your chest, to monitor your heartbeat throughout the procedure.
• Oximeter monitor: This small device will be attached to the tip of your finger to monitor the oxygen level of your blood.
• Blood pressure monitor: A blood pressure cuff will be placed on your arm to automatically check your blood pressure throughout the study.

The transvenous implantation procedure is done under local anesthesia and begins by administration of an anesthetic to the site where the pacemaker will be implanted - usually just below the collarbone. You may feel a slight "stinging" sensation during the injection.

This is a sterile procedure. To prevent infection, you will be covered with sterile drapes from head to foot. A soft strap will be placed across your arms and waist to prevent your hands from coming in contact with the sterile field. One side of your chest will be shaved and cleansed with an antibacterial soap where the incision will be made.

A small (three-inch) incision is made in the skin through which the pacemaker will be implanted. While watching x-ray images as a guide, the doctor will thread the pacing leads or wires through a vein and into the heart chamber. Once all the leads are in place, the "pacing" procedure is started. This is a test to insure that the leads and pacemaker are delivering the correct amounts of electrical energy to the heart. You may feel as though your heart is racing as the pacemaker increases the heart rate. Tell your doctor or nurse of any symptoms you feel. Report any pain or discomfort immediately.

After the leads are tested, they will be connected to your pacemaker. Your doctor will adjust the rate of your pacemaker along with other settings. The final pacemaker settings are programmed after the implantation. Transvenous pacemaker implantation usually takes 2 - 5 hours.

What are the risks of pacemaker implantation?

Pacemaker implantation is generally very safe. However, as with any invasive procedure, there are risks, which your doctor will discuss with you. Special precautions are taken to decrease these risks. Any specific questions should be directed to your doctor.

EPICARDIAL IMPLANTATION

Epicardial implantation is performed under general anesthesia by a surgeon in a hospital operating room. The technique involves making an incision in the chest to expose the exterior surface of your heart. The tips of the leads are attached directly to the outside of the heart muscle. The pacemaker is placed under the skin in the upper abdomen.

You will wear a hospital gown and will be asked to remove your eyeglasses, hearing aid and dentures. At the start of the procedure, a nurse will give you a sedative to help you relax. If you don't already have an intravenous needle (IV), one will be started.

This is a sterile procedure. To prevent infection, you will be covered with sterile drapes from head to foot. A soft strap will be placed across your arms and waist to prevent your hands from coming in contact with the sterile field. One side of your chest will be shaved and cleansed with an antibacterial soap where the incision will be made.

From this point on, the implantation procedure is essentially the same as the transvenous procedure, except you will be asleep and under the care of the doctors and nursing staff in the operating room.
Following the procedure, you will be taken to the recovery room where you will be monitored by the nursing staff. From there, you will be admitted to the hospital overnight.
Once in your room, a telemetry monitor will monitor the function of your pacemaker. The telemetry monitor will be connected to the electrodes attached to your chest, and is used to monitor your heart rate and rhythm.

What tests or procedures will be done before I leave the hospital?

The day after your implant, you will have a chest x-ray to check your lungs and to check the position of your pacemaker and lead(s). Your Holter monitor will be removed.
Care after your procedure

After returning to your room, you will be allowed to eat and have visitors. You may be given pain if you have discomfort around the incision site. If antibiotics are ordered, they will be given through your IV. You will be placed on complete bed rest until the day after your procedure. You should not attempt to get out of bed without first asking the nurse. If you need to go to the bathroom, ring for the nurse for assistance.

Before being discharged from the hospital, you will be given a temporary pacemaker identification (ID) card to carry with you at all times. In a few weeks you will receive a permanent ID card from the manufacturer of your pacemaker. In case of emergency, this card enables the health professionals who may be treating you to know the type of pacemaker you have. Federal law requires that medical device manufacturers maintain an accurate record of all people in the United States who have a pacemaker. If you change doctors, move to another address, or receive a new telephone number, please contact the doctors' office as soon as possible.

Going Home instructions

Most patients will be discharged from the hospital the day after the pacemaker surgery. As part of the healing process, tissue grows around the leads that were placed in your heart. To help promote healing and to prevent movement or accidental dislodgment of the leads:

• Avoid heavy activity for seven days, including pushing or pulling heavy objects or lifting more than 10 pounds.
• Avoid raising the arm above your shoulder on the side where your pacemaker was installed.
• Do not do any continuous or repetitive arm movements such as sweeping, lifting or arm exercises.
• It is important to inspect your incision every day in the first few weeks. Call your doctor immediately if you experience: redness, swelling, drainage or discoloration at the incision site, extreme tenderness, pain, and if the site feels warm to the touch or if you have chills or fever.
• Keep all follow-up appointments with your doctor.
• Following the advice of your doctor. You should be able to return to driving and normal daily activities within a few weeks.

Symptoms you should report to your doctor include:

• Chest pain.
• Shortness of breath.
• Dizziness or fainting spells.
• Swelling of ankles, feet or legs.
• Hiccups that last longer than 15 minutes.
• Infection or skin breakdown around the pacemaker site.
• Palpitations or unusual increase in heart rate.

If you call the office during an emergency, have your transmitter available to transmit your heart rhythm over the phone. The person taking the call will notify a doctor of your symptoms, along with your heart rhythm, and give you further instruction as necessary.

Keep all follow-up appointments with your doctor. Pacemaker follow-up is important to ensure that your pacemaker continues to function correctly, interacts with your heart properly and gives information regarding battery status.

Your monitoring schedule is determined by your doctor and may become more frequent as your pacemaker nears replacement time. Your pacemaker may be monitored during office visits, over the telephone, or through a combination of the two. You will be given detailed information regarding monitoring, maintaining, and replacing your pacemaker.

Special precautions

Travel: Before traveling for an extended period of time, it is important that you get the names and addresses of doctors who can treat you when you arrive at your destination. This information is vital in case of emergency. You can continue to check your pacemaker over the phone with the office on a routine basis, even while living out-of-state.

Medication: You may be placed on medications following your implant. Report all side effects from medications to your doctor. Do not stop taking any medicine unless directed by your doctor.

Electrical devices: Your pacemaker has built-in safety features to protect it from interference from other electrical devices that may disrupt its operation. However, if you suspect that something has interfered with your pacemaker - for example, if you experience dizziness or notice that you have a very rapid heart beat - simply move away from, or turn off, the electrical device. Your pacemaker will not be permanently affected and will return to normal operation.

You can safely operate most household appliances, tools, and office equipment that are properly grounded and in good repair, including: microwave ovens; garage-door openers; electric blankets; and home workshop equipment. Keep electric tools at least 12 inches from the pacemaker implant site. A safe practice for operating hand-held electrical devices is to hold the device several inches away from your pacemaker to help reduce the chance of interference.

You may safely operate citizen-band and ham-radio base stations at government-authorized power levels using remotely located antennas. The antenna should be located at least 30 feet from you and connected to the transmitter by a non-radiating transmission line.

Ask your doctor about special situations, such as working with high-current industrial equipment, welding equipment and powerful magnets, or about working in restricted areas such as near transmitting towers and antennas.
If you have any specific questions about a situation or a piece of equipment that may interfere with your pacemaker, contact your doctors' office.

Cellular/cordless phones: Some studies have shown that there may be a possible interaction between pacemaker operation and cellular phones.

When using a cellular phone:

• Keep the cellular phone at lease six inches away from your pacemaker implant site.
• Use the phone on the ear opposite your pacemaker implant site.
• Do not carry the phone in a breast pocket, on a belt or within six inches of your pacemaker while in standby or listen mode
• Carry the cellular phone on the side of your body opposite your pacemaker implant site
• For cellular phones transmitting above three watts, maintain a minimum separation of at least 12 inches between the base of the antenna and the pacemaker.

Medical procedures

Be sure to tell any medical personnel that you have a pacemaker. Most non-surgical medical procedures are unlikely to interfere with your pacemaker. Let your doctor know before you schedule a surgical procedure of any kind.

If you have a Rate-Response Pacemaker with a sensor that detects changes in breathing, it may be necessary to program the rate-responsive feature to OFF before the procedure is done.

This information should not be considered specific medical advice and is not meant to replace professional medical services. Please speak to your physician regarding symptoms, diagnosis, treatment, and any other pertinent questions regarding pacemakers.