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Pacemakers and How they Work

It is not unusual for a person who finds out that he or she (or a loved one) needs a pacemaker to feel suddenly isolated and alone. There is not a great deal of information online, either. But here's a surprise. Pacemakers have helped literally millions of people all over the world for the past five decades.

People get pacemakers to correct a problem with the heart known as a cardiac arrhythmia.

But you probably do not know a lot about pacemakers. There isn't a lot of information about them, even online.

First of all, pacemakers may seem like some futuristic bionic device, but they've actually been around for over 50 years. That's right, I Love Lucy was not yet in re-runs when the first pacemakers were implanted.

Second, pacemakers have proven themselves to be a safe, effective technology. The pacemaker is implanted in your upper chest; an insulated wire is passed through a vein into your heart. The wire is plugged into the pacemaker, which then delivers electricity (not drugs or artificial ingredients) to your heart. They send the heart tiny amounts of electricity.

A healthy heart produces electrical impulses on its own. If you need a pacemaker, it is likely because your heart does not produce these electrical impulses fast enough or conduct the electricity through the heart muscle quickly enough to keep your heart going at the right rate. The pacemaker just "fills in the missing beats" by sending electricity to the heart. Electricity is electricity, after all.

Pacemakers are tiny devices about the size of a pocket watch. They are made of titanium, a lightweight metal that doctors call "biocompatible." This means it is compatible with the human body; the body does not react to it or reject it.

It is hermetically sealed and runs on a battery. In fact, most of the interior real estate of a pacemaker is taken up by a lithium-iodide battery.

Your pacemaker is designed to run for years on that battery! How long the device actually lasts depends on many factors but the doctor can help you predict it. Pacemaker patients go for checkups at least twice a year, and part of the checkup will tell you how the battery is doing.

Pacemaker batteries are incredibly advanced technology because they don't suddenly stop working like a car battery. Instead, it operates at full capacity and can signal the device (and the doctor will know how to get this information) when it is starting to wear out. You will have some "grace" time to schedule your replacement.

When a pacemaker wears out, you don't replace the battery. First of all, most of the device is the battery and it's hermetically sealed. Instead, doctors go back and remove the old pacemaker and replace the new one. The leads or wires are unplugged but left in place. When the new pacemaker is implanted, the old leads are plugged into the new device.

Replacement surgery or "pacemaker revision" as it sometimes called is a much faster procedure than the first implant. In fact, it is often done on an outpatient basis.

Surgery to implant a pacemaker may seem scary, but for your hospital team it is a fairly simple procedure. Doctors call this "minimally invasive" surgery because the incision they have to make is quite small. It is typical for a pacemaker to be implanted in a cardiac catheterization or electrophysiology lab rather than a full-blown operating room.

As the patient, you may be surprised to find out that the doctors prefer you to be awake. You will be draped (that is, you won't be able to see where they make the incision) and given some sedatives to relax you, but most pacemaker recipients do not require full anesthesia.

You will get some numbing medicine for your chest. A small incision is made and a spot is created just under the skin and tissue for the pacemaker. A tiny incision is made in a vein and the insulated wire is passed through the vein and into your heart.

This wire is called a "lead" and you may get one, two or even three of them, depending on the type of pacemaker you get.

Interestingly, it is the lead that takes most of the time during your implant procedure. The doctor gently advances the lead through the vein. He and the rest of the implant team (you'll have several people in the room with you besides the doctor) will observe what's happening on monitors. They use a large device called a fluoroscope to get video X-rays which show how the lead is navigating its way into your heart.

Once in the heart, the doctor needs to get it to attach or "fixate." It is not very hard to fixate the lead, but some parts of the heart conduct electricity better than others. This is highly individual, so the doctor is going to want to test the first landing site to see how good it is. This is done using a small hand-held device that sends a small amount of electricity through the heart to force it to beat.

You will not feel this at all. However, you may notice when this is going on, because it can be quite loud. The doctor is busy looking at where the lead is fixated while some member of his team is busy testing the lead. They may be shouting numbers across the room. Somebody else is probably watching the EKG (that's another monitor) and may shout out more numbers. If you don't know what's going on, it can be confusing or even disconcerting.

Once the doctor fixates the lead(s), the other end of the wire is plugged into the pacemaker, the pacemaker is placed in the little space in your chest, and the incision is sewn up. The whole procedure can take up to two or three hours (depending on how many leads are used and your individual case) but it may be less.

A typical pacemaker recipient needs a few days to recover from the surgery and then a few weeks before they can go back to their old routines. While there may be a few restrictions on pacemaker patients, most people feel better than they did before and report that they can actually do more even with a few restrictions.

Right after your implant, you will likely be asked to see your doctor a few times. This is to check on the surgical incision and run some preliminary tests and make adjustments to your pacemaker.

Once the initial phase is completed and your system is stable, the doctor will give you a plan for regular checkups, typically once a quarter or every six months. Please make every effort to keep these appointments, even if all the doctors end up telling you is that you're doing just fine.

That's because your pacemaker can report or communicate to the doctor about how it is doing, suggest adjustments that may help it to work better, and will tell you how much service life is in the battery.

Millions of people have pacemakers. You may even know some people who have them that just never mentioned them. That's because many pacemaker patients report that after a while, they "forget" about the device. With no pills to remember and only occasional doctors' appointments, it's pretty easy to forget about this silent servant.

NOTE: Pacemaker patients have learned lately that the earbuds used in iPods and other similar music players can interfere with pacemakers.

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