Living with a Pacemaker

Last May, while my wife was out of town with her family, I decided to go to the fitness center where we have been members for the last three years. I walked on the indoor track for about a mile, when suddenly, I passed out. I knew I was losing consciousness, so I started to lower my body towards the floor. But, it happened so suddenly that I didn't have time and I fell against the inner railing, knocking off my glasses and giving me a good smack on the head.

I regained consciousness in a minute or so. By then, there were several people around me and 911 had been called. In a few minutes, a team of EMTs walked in and surrounded me. They connected leads for a portable EKG machine and said that it appeared I might have some "conduction" problems with my heart. I told them that I had open-heart surgery. That could explain the irregularities on the EKG, but they weren't sure. In any case, the fainting spell ("syncope" in doctor-speak) wasn't normal and they said I needed to go to the ER to get checked out more fully.

Soon, I was in an ambulance on the way to the hospital. This was not the first time I had left the fitness center by ambulance! Sixteen months earlier, while walking on the same indoor track, I had fainted and been taken to the hospital. They performed a cardio scan and determined that I was close to having a heart attack - one of my heart arteries was 90% blocked and two were 80% blocked. Due to the locations of the blockages and other factors, they said my only option was to have a triple bypass and I had open-heart surgery the next day.

So, I knew the ambulance routine. They gave me baby aspirin (even though I was now taking it daily) and they continued to take EKG readings and send them to the hospital while we drove there in the ambulance. The EMTs were calm but efficient and they let me know by their actions that I was in good hands. When we got to the ER, they placed me in an examining room and began a series of tests - more EKGs, x-rays and sonograms of the chest, and CAT scans of the head (to check for concussion). They found nothing to indicate why I had fainted, so they prepared a room for me to be admitted for more tests.

The next day, they performed a stress test, where I walked on an elevated treadmill while they monitored my heart. They found nothing conclusive and discharged me from the hospital. Before they discharged me, a cardiologist that specialized in pacemakers gave me a prescription to gradually reduce my beta-blocker medicine and said I would be getting a heart monitor in the mail. I was to wear it for two weeks, so they could see what my heart was doing. They said it was possible that I might need a pacemaker!

Beta-blockers are a form of medicine used for hypertension, which I have. They reduce the heart rate and cause a corresponding reduction in blood pressure. I was taking the maximum dosage for the beta-blocker they had prescribed and so this was a possible cause for a low heart rate that might lead to fainting. My wife, who is a nurse, was convinced that I would be fine once they got my medication dosages "adjusted".

In a week or so, I received a package in the mail. It contained a heart monitor and another unit that received data from the monitor and sent it over the phone to the monitoring company. They would then send a report to my cardiologist every day. The monitor also had a button for me to press any time I felt "funny" or had a fainting event.

I wore the monitor for the next two weeks and had no events. A day before the end of my monitoring period, I went in to talk to my regular cardiologist. He said that I had Sick Sinus Syndrome. This meant that the "sinus node" of my heart, which is responsible for starting each heart beat, was not providing a consistent rhythm and occasionally would cause my heart rate to drop. This condition might require a pacemaker "down the road" but he didn't see any urgency in the matter.

So I completed my two weeks and mailed everything back to the monitoring company. The next day, on a Friday, I got a call from the pacemaker cardiologist that I had talked to in the hospital. He said that they had seen some evidence of a heart "block" and he was scheduling me for implant surgery the following week. Since he was going on vacation, he had asked another surgeon to perform the implant, but if this surgeon wasn't able to do the surgery before next Thursday, he would come back in from his vacation and do it himself. So, I knew that this was serious!

A heart "block" is an event where the sinus node starts a heartbeat, but the electrical pulse is not conducted from the auricle to the ventricle. This means that the blood is not pumped out of the heart during this time. Obviously, it is bad enough that my heart was not always consistent in starting a beat but now they said that the heart did not always respond properly to that pulse! This was why I had fainted on the track.

My wife heard all of this and still wondered if the doctors were "pushing" the pacemaker too much. She still felt that if I could get the right medication dosages, everything would be okay. But she finally changed her mind when I fainted at the supper table the evening before I was scheduled to have the pacemaker implanted! I was now taking a fourth of the original beta-blocker dose and it was clear something else was causing my syncope.

By this time, I had read up on pacemakers. I learned that the first clinical implantation of a pacemaker was in 1958, in Sweden. The device failed after three hours. A second device was then implanted which lasted for two days. The patient, Arne Larsson, went on to receive 26 different pacemakers during his lifetime! He died in 2001, at the age of 86. Today, there are nearly 200,000 pacemakers implanted every year in the United States.

I now have a pacemaker implanted under the skin in the left upper chest. It has two electrodes which attach to my heart through veins. One electrode is connected to the right atrium, site of the sinus node that starts the heartbeat. The other electrode is attached to the right ventricle, where it can monitor the conduction of the electrical pulse through the heart. Both electrodes can act as monitors when the heart is functioning correctly on its own. They can also act as electrical stimuli when the sinus node doesn't start a new beat within a programmed period of time (usually one second, or 60 beats per minute) or when the AV node doesn't continue the electrical pulse to the ventricle. Some pacemakers only have the first electrode, when proper conduction is not an issue for the patient.

So, how does it feel? After recovering from the implant surgery, it didn't take long for me to notice an increase in energy; I felt better than I had in years! My cardiologist said that this was the typical response and most patients wish they had done it much sooner. Ok, I know what you REALLY want to hear - does it "hurt" when the pacemaker is "shocking" the heart? NO! I can't feel anything different; the pacemaker is calibrated to use an electrical signal as close to the natural levels as possible.

The modern pacemaker is about 1.5 inches across and less than 0.5 inch thick. It is barely noticeable by looking at my chest (of course, you can see the incision scar), but it feels like a hard, flat lump on the chest wall when you press on it. The electronics and battery are sealed in a metal enclosure that is relatively impervious to external signals. With one exception: there is a magnetic switch that activates the two-way radio link to an external device, which can be used for downloading collected monitoring data or for re-programming the unit. This is why pacemaker wearers need to be careful when around strong magnetic fields. I cannot have an MRI due to this restriction. However, the technology keeps improving and my cardiologist said the next generation of pacemakers would be able to work within an MRI machine.

I haven't mentioned that the pacemaker needs to be replaced when the battery runs down. This is usually about every 8 years or so; it depends on how often the unit is "pacing". According to the last checkup, my pacemaker is "pacing" about 40% of the time. As battery technology continues to improve, the replacement period will continue to lengthen. When the pacemaker is replaced, the original incision is re-opened and the electrodes are disconnected from the old pacemaker and attached to a new one. Then the incision is closed up. This means that a pacemaker wearer is continuously "updated" to the latest technology. As a former engineer, I can appreciate this!

I mentioned "my last checkup"; I now have regular appointments to collect the data from my pacemaker and to monitor the battery life. The first time was done in the doctor's office, but now I just use a small device to connect with the phone line and transfer the data from my pacemaker to the pacemaker manufacturer. My pacemaker is manufactured by Medtronic in Minneapolis, Minnesota, the largest maker of these devices. Right now, I just perform this update at home every three months and then my cardiologist's nurse calls me with the results. When the battery gets low, they will monitor more closely and will schedule a replacement surgery when I have only a couple of months of battery life left.

Since I now have metal implanted, I can no longer use a metal detector, so wherever I fly or go through other security checkpoints, I must be "patted down" by a personal inspector. I've done this several times at airports now and I'm getting used to it. It's a very small penalty for the renewed life that the pacemaker provides me!

REFERENCES:

http://yourtotalhealth.ivillage.com/pacemaker.html

http://en.wikipedia.org/wiki/Artificial_pacemaker

http://www.medtronic.com/our-therapies/pacemakers/index.htm