Cardiac Pacemaker Frequently Asked Questions

More than 1 million million permanent pacemakers (PPMs) are implanted worldwide annually. Around 100,000 devices are implanted annually in Germany, and only over 20,000 in India. PatientsEngage team answers the frequently asked questions on Pacemakers so people can make informed decisions.

What is a pacemaker?

A pacemaker is a small device used to correct our heart rate when it is slower than the normal heart rate (known as bradycardia). It is implanted through a surgery in the chest or abdomen from where it sends electrical impulses to make sure that the heart beats at a steady, normal rate.

Our heart functions through electrical activity. The part of the heart that maintains its rhythm is the sinoatrial node which makes it the “natural pacemaker”. Sometimes, the sinoatrial node malfunctions and it disrupts the electrical pulses traveling through the heart. In such cases a pacemaker may be needed to help a person’s slow heart rate resume to a normal, steady speed.

Where is the pacemaker placed and how big is it?

• Pacemakers are tiny devices approximately 5×4 cm and 6 to 7mm thick. Sometimes the pacemaker shape may be visible under the skin. It is usually placed under the skin, just below the collarbone via a small incision. The procedure is done under local anaesthesia to combat any pain or discomfort during the procedure. It can also be placed under General Anaesthesia (GA), though this is less common like instances where the wires are attached to the outside of the heart, which requires a small incision below the ribs (mostly done in children or when other heart surgeries are being performed) or in cases where the patient is extremely anxious.

What conditions are treated with a cardiac pacemaker?

Some heart conditions cause it to beat slower than normal and thus require assistance of a pacemaker. Those conditions are:

• Sinus node disease
• Heart block
• Prior heart attack
• Long QT syndrome
• Hypertrophic obstructive cardiomyopathy (you can read more about it here)
• Dilated cardiomyopathy (read more here)
• Tachycardia-bradycardia syndrome
• Chronotropic incompetence
• Cardiac resynchronization therapy
• Recurrent instances of fainting (carotid sinus syndrome) (read more here)
• Resting heart rate of fewer than 60 beats per minute
• Atrial fibrillation
• Coronary artery disease (read more here)
• Congenital heart defects (read more here)
• Heart failure (for biventricular pacemakers only)

Types of pacemaker?

• Single-Chamber Pacemaker: This type has one lead to send electrical impulses to either the right atrium or the right ventricle.
• Dual-Chamber Pacemaker: It has two leads, one in the right atrium and one in the right ventricle, for more coordinated heart rhythm control.
• Biventricular Pacemaker (CRT): which is also known as Cardiac Resynchronization Therapy (CRT) devices, these use three leads to help both ventricles contract simultaneously. They are mainly used for heart failure patients.
• Leadless Pacemaker: It is a small, self-contained device implanted directly into the heart without wires (leads). The advantage is reduced chances of infection and faster recovery.
• Rate-Responsive Pacemaker: It automatically adjusts the heart rate based on the patient's physical activity level.

Does the heart need to be stopped during a pacemaker operation?

No, the heart does not need to be stopped during a pacemaker operation.

Does one “feel the pacemaker”?

Initially, one may feel the weight of the device in their chest but gradually most people get used to it. Sometimes people may also be able to see or feel the pacemaker under the skin, though they tend be less prominent over time. One will not really feel the pacemaker working because the electrical impulses sent by it are very low in intensity and are designed to be imperceptible to the patient.

What are the risks of the procedure?

Pacemaker insertion is usually a low-risk procedure. About 1 in 100 people experience serious complications during the procedure or immediately afterwards. Complications are rare but some immediate concerns are:

1. Infection at the site of implantation
2. Bleeding or bruising
3. Allergic reaction to materials used
4. Damage to blood vessels or nerves
5. Lead dislodgement or fracture

Other complications can include bleeding around the heart, or deflating the lung on one side, or leads moving once they have been secured in place, but all these conditions can be treated.

How long is pacemaker surgery recovery?

Complete recovery from pacemaker surgery typically takes 4 to 6 weeks. Most people can assume their daily routine within 3 to 7 days, Full healing of the incision and imbedding of the leads usually requires more time.

How often does one need follow-up appointments?

The pacemaker is checked the day after the implantation and then at six weeks. After that it will be checked annually. At the follow-up appointment, the doctor assesses the discharge rate of the pacemaker, measure the strength of the electrical impulse, and record the effects of the impulse on the heart.

Most pacemaker batteries last for 6 to 10 years after which the batteries may need to be replaced. As the battery life gets depleted (after 5–15 years), follow-ups may become more frequent, every 1 to 3 months.

Do pacemakers need to be adjusted periodically?

Yes, pacemakers need to be checked and adjusted periodically by the cardiologist at the follow up appointment to ensure they are working correctly, the battery is okay, and the settings are optimized for one’s health.

Adjustments are made using an external computerized device called a programmer. A "wand" is placed over the chest to communicate with the pacemaker via magnetic or radio signals. One of the either things may happen during the adjustment:

Reprograming of Settings: Change in the pacing rate if one’s medical condition or lifestyle has changed (one has become more or less active).

Checking the Battery Life: This is done to assess how many years of battery life remain to plan for a replacement.

Monitoring of the Wires: This helps to ensure that the leads are still securely attached and functioning with the right amount of electrical resistance.

When does one have to replace their pacemaker?

A pacemaker needs to be replaced when its battery gets closer to the end of its lifespan, which is usually every 5 to 15 years. Since the battery is hermetically sealed inside the device, it cannot be swapped without replacing the entire metal box (generator).

What does one need to do or not do after having a pacemaker fitted?

Immediately after the procedure one should not wet the wound until it has healed. It will be covered by a dressing which should be kept dry.

• Any strenuous activity (sports, lifting, pushing or pulling heavy objects) should be avoided for the six weeks.
• Before any procedures the concerned doctor or Dentist should be informed about the pacemaker.
• One should carry a pacemaker ID Card.
• All cell phones and other electronic devices should be kept at least 6 inches away from the pacemaker.
• The cardiologist’s medications and lifestyle recommendations should be followed diligently.

What are the symptoms of a failing pacemaker?

One can know if their pacemaker is failing if they have symptoms like:

1. Dizziness
2. Chest Pain
3. Irregular heartbeat
4. Fatigue
5. Palpitations

Some other symptoms which require immediate medical attention for which one must see a doctor immediately are:

1. Persistent hiccups
2. Twitching of the muscles of the abdomen or chest
3. Pain, swelling, and redness at the surgical site
4. A sensation that the generator is loose in the pocket under the skin

Does the pacemaker get affected by electrical equipment?

Anything that produces a strong electromagnetic field can interfere with a pacemaker.

Most common household electrical equipment (hairdryers and microwave ovens)

They are not an issue if they are used least 15cm away from the pacemaker. For an induction hob, a distance of at least 60cm between the stove top and the pacemaker should be maintained. Alternatively use a backburner. One may also use these measures alternatively:

• Using a correct Pot Size: The magnetic field is contained when the pan completely covers the induction coil. People are advised to use pans that match the size of the cooking zone, which prevents the field from leaking.
• Taking a Step Back : Many users simply adopt a stance where they stand slightly back from the hob, using long-handled spoons to stir, rather than leaning against the counter.
• Choosing Different Technology: Many people with pacemakers choose to install ceramic/halogen or gas hobs instead of induction to avoid any risk.
• Modern Device Technology: Modern pacemakers are generally better shielded against electromagnetic interference (EMI) than older models, reducing the risk of malfunction.

Mobile phones
It is safe to use a mobile phone as long as it is kept more than 15cm from the pacemaker. Any headset or in ear devices should be used on the opposite side of the pacemaker.

Shop security systems
Walking through metals detectors do not affect the pacemaker, but one should not stand too close to this type of security device for long.

Airport security systems
Airport security systems do not usually cause problems with pacemakers but one should carry their pacemaker identification card and inform the security staff that they have a pacemaker.

Does a pacemaker affect the sex life?

Normal sex life can be resumed on recovery after getting a pacemaker but one should avoid positions that puts pressure on the arms and chest for the first 4 weeks of recovery. The risk of sex triggering a heart attack is low (around 1 in 1 million).

Can one travel with after getting a pacemaker?

Air travel or a car drive is considered okay if one is cleared by their doctor. Airport security detectors are generally safe. If one is screened by a handheld wand, inform the screener that these wands should not be held over the device area for more than a few seconds.

Can one exercise with a pacemaker?

After full recovery which usually takes about 4–6 weeks after surgery, most people can do:

• Aerobic Activities: Brisk walking, jogging, stationary cycling, and dancing.
• Swimming: Highly recommended after waiting for 6-12 weeks for the leads to stabilize as it is low impact.
• Light Strength Training: Using light hand weights or resistance bands with high repetitions (15+) is safer for the heart than lifting heavy loads.

What to Avoid

• Avoid sports with a high risk of chest trauma, such as rugby, boxing, martial arts, or wrestling, as a direct hit could damage the pacemaker.
• Be cautious with sports like tennis, volleyball, or golf because the repetitive, forceful arm swings can sometimes lead to long-term wear on the pacemaker leads.
• Avoid lifting objects over 10–15 pounds or performing overhead lifts for the first 6 weeks.

Are tight clothes an issue?

• Tight clothing around the upper chest and shoulders can be an issue for pacemaker patients, during the initial 4- to 12-week of the recovery period. Tight clothes do not damage the device itself but they can cause significant pain, friction against the incision, and delay healing. Tight clothing may also restrict the arm and shoulder movement, which is already limited in the first few weeks to prevent pulling on the leads.

One may use modified clothing like:

• During the first few weeks, one may wear loose-fitting, soft, or wireless bras.
• If a bra strap causes discomfort, placing a small, soft pad such as a cotton pad over the incision site may be helpful.
• Wearing button-down shirts, loose tops, or front-zip jackets is advised to avoid lifting arms overhead when dressing.
• Some companies offer sports tops with built-in padding in the chest to protect the device.

When can one wear tight clothes again?

One may typically return to wearing regular, tighter clothing once your doctor confirms that the incision has healed completely and there are no signs of infection, which takes a few weeks.

What to expect after the placement of a pacemaker in children?

• After the surgery, soreness is common but manageable with over the counter medications like acetaminophen or ibuprofen.
• Children with pacemakers can generally return to normal activities, though contact sports may need to be restricted to protect the device.
• A paediatric cardiologists will monitor the device and battery life regularly, adjusting settings to match the child's growth.

Can one have an MRI with a pacemaker?

One should stay away from devices with large magnets or magnetic fields that can be created from motors of cars or boats when they have a pacemaker. An MRI is an imaging test which uses magnets. Most modern-day pacemaker are approved to have an MRI. But it’s best to discuss it first with your doctor to make sure it's safe. Electromagnetic interference can be created by other machines which may affect the normal function of the pacemaker.

What should one do if they hear a beeping sound their pacemaker?

One should contact their cardiologist immediately. It could be a sign of an issue with the pacemaker needing immediate attention.

References

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