Pacemaker

The doctor usually advises a pacemaker due to some of the following conditions:

• Aging and heart problems – Aging damages the ability of the sinus node to set the appropriate pace for the heartbeat. This may result in a very slow heartbeat or very long gaps between the normal heartbeats. This further causes sick sinus syndrome, which may occur due to the switching of the heartbeats between fast and slow rates.
• Bradycardia
• Arrhythmias
• When the supply of oxygen in the blood is inadequate. This may further lead to difficulty in breathing, fatigue, lightheadedness or fainting, or damage to vital organs, which may eventually may lead to death
• Syncope (fainting-spells)
• Hypertrophic cardiomyopathy
• Heart failure – This treatment is also known as biventricular pacing or cardiac resynchronization therapy (CRT).
• Pacemaker assists in regulating the normal heart rate after a medical procedure known as arterial fibrillation which is performed to treat arrhythmias.
• In cases, where the medications like beta blockers are advised to the patient. These medications lower the heart rate and a pacemaker might be required to bring the lowered heart rate to normal.
• Doctors might also recommend a pacemaker in cases of congenital heart defects.
• Patients with QT syndrome
• In some patients who have undergone a heart transplant, might require a pacemaker as well.

Pacemaker implantation is a very safe procedure with many benefits but some complications are always associated with a non-invasive procedure. Following are some of the complications associated with the surgical placement of a pacemaker under the skin of the heart:

• Infections at the site of implantation of the pacemaker
• Allergic reactions from the anesthesia or dye used during the pacemaker implantation procedure.
• Lungs might collapse during or after the procedure
• Damage to the nerves or the blood vessels adjacent to the pacemaker.
• If the patient is taking blood-thinning medications then, this may cause bruising, swelling and bleeding at the procedure site.
• Portions of the heart muscle might puncture during the procedure, which may lead to heavy bleeding in the pericardium.
• Rarely, pacemaker may lead to some life-threatening complications.

The doctor will explain the pacemaker implantation procedure in detail to the patient. Before conducting the procedure, the doctor will check the condition of the patient’s heart and the reason for the irregular heartbeat. There are some tests which are recommended by the doctor before the surgery:

• Echocardiogram - An echocardiogram is a type of ultrasound test which produces images of the heart valves and heart muscles. This test assists the doctor to examine the proper function of the heart by recording the heart beats. The images produced by the echocardiogram can be further used to detect any heart abnormalities in the heart valves and muscles. Also, the quality of the pictures produced by this test is more enhanced as compared to the X-ray. Echocardiogram also helps in recording the pumping of the heart. Echocardiogram or Echo, when used with Doppler ultrasound and color doppler, assists in monitoring the blood flow carefully across the valves of the heart.

In this procedure, a clear gel is applied on the skin over the chest and a transducer is placed over it. The transducer is pressed firmly against the patient's chest and an ultrasound beam is aimed at the heart through the chest. The sound waves are then transmitted through the body and reflections or echoes from the heart are captured which further form a live image or moving images of the patient's heart.

• Electrocardiogram - An electrocardiogram is a noninvasive and safe procedure to monitor the electrical signals in the heart. Every time the heart beats, an electrical impulse moves through the heart. This electronic pulse is generated by some special cells in the right upper heart chamber. This test helps the doctor to understand the irregularities in the rhythms or patterns of the heartbeat in a patient's heart, which further helps in detecting various abnormalities or heart problems. This is a short and safe procedure and the patient can get the report of the test the same day, the ECG is performed. In this test, the electrodes or the test sensors are used to record the pattern of the heartbeat. The nurse or the technician attaches some electrodes or test sensors to the patient’s body with the help of some adhesive tapes. This is done in order to detect the electric currents of the patient’s heart. Usually, 12 to 15 electrodes will be attached to the patient's chest, arms, and legs. These electrode patches are attached to the body with the help of a gel. The ECG test usually takes a few minutes to complete.

• Holter monitoring - If there is any irregularity observed in the heartbeat, then the doctor might advise another type of an ECG test known as Holter monitoring. This is a portable, ambulatory electrocardiography monitor which helps in recording cardiac rhythms or cardiac activity for at least 24 or 48 hours. In this type of ECG, the electrode wires attached on the patient’s chest are connected with a small device operated with a battery. This device can be carried in the pocket, worn on a shoulder strap or belt. When a Holter is attached, the patient is asked to maintain a diary of the activities done in the entire day along with the timings and any symptoms noticed. The doctor will then compare the recordings in the Holter with the activities mentioned in the diary. This would further enable the doctor to understand the symptoms related to the activity done and changes in the electrical signals.

• Stress test - The stress test, consisting of an ECG, is advised when the heart of the patient is unable to perform or function properly under stress. During this test, the patient might be asked to walk on a treadmill, however, in some rare cases, the patient might get a heart attack during the stress test or while walking on the treadmill. This may happen because of an irregular heartbeat due to physical activity done during the stress test.

• There is another type of stress echo known as a Dobutamine stress test, which includes an ECG test to be conducted for the patient. If the patient is not able to perform an exercise or walk on the treadmill, then an injection is given with a drug, that makes the heart pump faster as if the patient is exercising. This test is usually done to detect heart problems that occur while performing physical activity.

During the procedure:

In this procedure, the patient is awake and only the area to be operated is anesthetized. It takes only a few hours to complete the pacemaker installation. The patient is given some sedatives to remain calm and relaxed during the procedure.  One or more electrodes are attached under the collarbone and are guided to the patient’s heart with the help of various X-ray images. A pulse generator is attached near the collarbone of the patient, from one end and to the heart, from the other end.

After the procedure:

The patient is made to stay in the hospital for a day. The pacemaker is set according to the pace requirements of every patient before leaving the hospital.  

Pacemakers can help the doctor to assess the data of the heart readings through the wireless technology called the radiofrequency signals or phones.  This data from the pacemaker usually gives the information around the proper functioning of the pacemaker, normal heart rhythm and heart rate and about the remaining battery in the pacemaker.

The data can be received at a scheduled time and also at unscheduled times , when the patient is facing some issue and wants to send the signal to the doctor. This remote wireless technology saves time and multiple trips to the doctor. However, still the follow-up visits are mandatory.

The doctor might advise refraining from the following activities after the pacemaker implantation:

• Strenuous physical activity or exercise
• Avoid lifting heavy objects for at least a month
• Avoid smoking

The doctor may also suggest taking some painkillers e.g. ibuprofen or acetaminophen, to relieve pain from the surgical site.

A pacemaker is a standard solution for heart problems, affecting the heart rate. The pacemaker helps in preventing bradycardia and hence, helps in treating related problems like difficulty in breathing, fatigue and lightheadedness or fainting.

Presently with the advanced technology, the pacemakers automatically adjust to the patient's heart rate and hence, helps the patient in adopting an active lifestyle. The life of the battery of the pacemaker lasts for at least 5 to 10 years. However, when the battery life gets over, another procedure is done to replace the entire pulse generator. This replacement procedure, to change the battery, is fast and requires very less recovery time as compared to the first pacemaker implantation procedure.

There are some special precautions, which the patients are advised to take by the doctor after the pacemaker implantation. Though it is rare that the working of the pacemaker is interfered by electrical appliances, but still the patient should keep the following points in mind:

• Cellphones – The patients are advised not to keep the cellphone near or over the pacemaker site as the pacemaker can take wrong signals from the cellphones considering them to be the heart rate and cause sudden tiredness to the patient.
• Security systems – Some places may have some metal detectors placed or hand metal detectors to check the person. In such scenarios, the patient must ask the security staff to avoid holding the metal detector device close to the pacemaker site and to be on a safer side the patient should carry an ID or doctor's prescription stating the implantation of a pacemaker.
• Medical equipment – It is always important to inform the doctor about the pacemaker installation before going for any other medical procedure, which uses electromagnetic energy. E.g. MRI, shock wave lithotripsy and therapeutic radiations for treatment of cancer. Electrocautery procedure may also cause interference in the working of the pacemaker.
• Power generating machines – The patient is advised to stay at least 2 feet away from power generating devices like motor generator, transformers or welding machines. If the patient is working in such an environment then the doctor would might want to check if the working of the pacemaker is affected or not.

Devices such as electric drills, microwave ovens, radios, TV, electric shaver, remote controls, and toasters will not affect the pacemaker function.

Q1. What are the different types of pacemaker?

A1. There are various types of pacemakers as highlighted below:

• Single chamber pacemaker – This type of pacemaker helps in transmitting electrical signals from the pulse generator placed under the collar-bone of the patient, to the right chamber or ventricle of the heart.
• Double chamber pacemaker - This type of pacemaker helps in transmitting electrical signals from the pulse generator placed under the collar-bone of the patient, to both the right atrium and the right ventricle of the heart. These electrical impulses assist in managing the time of contractions between these two right chambers.
• Biventricular pacemaker – This type of pacemaker is mostly suggested for the patients suffering from damaged electrical systems i.e. in the case of heart failure. This pacemaker makes both the lower right and left ventricles function effectively. It stimulates both the ventricles to pump together. This results in the proper and effective functioning of the heart. This treatment is also known as CRT (Cardiac Resynchronization Therapy).