Natural Pacemaker System of your Heart

First let us discuss some of the basic facts about

your heart and how it works. your heart is a pump
made of special muscle tissue. lt pumps blo6d
throughout the body sending oxygen dnd
nourishment to all the cells and oiqans in vour
body. ln order to beat regularly. yo-ur heart'
responds to electrical impulses produced by a
special centre called a natural pacemaker.
Everybody has a natural pacemaker (Sino-Atrial
Node).

Your natural pacemaker (S-A node) is located in

the upper right portion of your heart. From this
centre. the impulses (i.e. electrical activitv) travel
down special electrical pathways in your-heart,
causing your heart to contract inytnriricalty and
pump blood, Your natural pacemaker

Ventricular
Systole
Systole
regulates how fast vour heart must beat in order to ensure proper
blood and gx-ygen tb flow through your oooy. nn uu"iugu amount of
h#ri!rt"
between 60 & 80 beats per min-ute in an ariurt, but heiri ,rt". at rest is
number of reasons.
.rn vary for a
 Why Do You Need a Pacem aker?
e Most pacemakers are recommended when a patient experiences symptoms
that are due to an inappropriately slow heart rate.

There are many causes of a slow heart rate. Most of these commonly involve
the heart's own pacemaker, the S-A node or the heart's own electrical
conduction system (wiring systems).

These diseases can cause your heart to:

V Beat too slowly - all of the time;
V Beat too slowly - occasionally;
I Beat too slowly or too quickly - at different times.

When any of these things happen, your heart does not pump enough blood to
meet your body's need. As a result you may feel tired, weak, sluggish, dizzy,
light-headed or short of breath. ln certain cases, the problem is severe enough
to cause the patient to "faint".

Medical science has an answer to your problem - it is to place a new

pacemaker in your body.

Natural Blocked
Electrical Pathway lmpulse

Blocked or Delayed lmpulse

 What is a Pacemaker?
A pacemaker is actually a two-part system. To implant the pacemaker only a
r5 minor operation using local anaesthetic is required'

The two parts of the Pacemaker are:

1) The pulse generator, commonly called "pacemaker"'
2) The pacing leads or lead (some systems use one lead while others
require two leads).

.tat

SUBCIAVIAN VEIN

M]IURY VEIN

-----ilffin'o'
,r.
i,,rjit

, 1i'

The pulse generator controls the pacing System. lt contains the battery and
elecironic iircuitry which produce the electrical impulses as needed and acts as
a brain within thssystem. Atypical pulse generator is very small in size, often
Less than two incheswide and a quarter inch thick, most weigh about an ounce
oitl5. The pacing lead is the wire which goes from the generator to the inside
of the heart iarryiig the electrical signal. The whole system is extremely
ieliable anO depbnJable and works in a manner similar to your natural
pacemaker.
* Types of Pacemaker
Most pacemakers are single chamber, i.e. they stimulate only one chamber of
the heart. They need one pacing lead which not only can deliver a small

iYt
Sensed verlricLrlar comprex Venlr cJ'ar pace

This ventricular demand pacemaker generates st muli at

a preset rate and suppresses its output whenever the
patient s spontaneous rhythm is faster than the preset rate
of the pacemaker.

Sensed ventricular complel

I

tv\v/ \
t
and
Sensend A and pace'
Atrial pace' Ventflclular
V complexes pace

The DDD or dual chamber pacemaker can pace and

sense in either of the chambers and its f unction
closely simulates the natural pacemaker of the heart

electrical impulse to the heart muscle, but can also sense when the heart is
beating properly on its own and signal the pacemaker to hold off on the next
electrical impulse. (demand pacing).

Many pacemakers, inserted in recent years, are dual chamber pacemakers,

i.e. onb electrode is implanted in the right atrium (upper chamber of the heart)
and the other in the right ventricle (lower chamber of the heart). An impulse
goes first to the atrium and then a split second later, the other impulse goes to
 the right ventricre. ,n]:-T?r_u
learry approximates the action of the normar heart
;l3,ili"r5i?:',il'.1'il:i:f $iff "Jilf ,o,etotnli"o"',li,,ilo,.uo,.,i;'
variety of functions thar you may
ff;3: ?ffi,ffi[:;:lr,l.J,, or may not need.

Telemetry
It is a "two-way,,
conversation between your
pacemaker and your
doctor,s
computerised programmers.
r hts two-way
conversation
arows your doctors to more
accurately evaluate and
aoJUSt your pacemaker according
to your needs. This is simpt/ - '
done by computer assessment
trom outside your body even
though the .,generator.. is
rmptanted inside your body.

Programmability
It a'ows your
doctor the opportunity to reprogram
pacemaker as needed to the erectricar settings of your
improve iol"r quatity of life.

Rate Modulated pacemaker

some pacemakers can recognize
when your body needs
rate. These devices are care"d
rrt" ,"i..irureo pacemi[;;an increased
;i
heart
have rhe abirity
o*n pioj,.tion
:[:TjL,;;"in[?:1!"",t '
e sensors to monitor your "terl.i,.i.rr
i#oJ,r., but they
heart rate. body,s n""O tolln rncreased

a pacemaker which is best suired

Iii!::::T,I#,'ffS:: to your needs and

Pacemaker lmplantation
lmpranting a pacemakelr!
noy av^erycomroll
"c.i.'iJ.'c't procedure which, most often, is
n i",i,,ii i" ii i,,",,
3:i? i : fl : ii.?;j :il:i l,*jl
I "'."
The procedure normally requires
only minimal anaesthetic which
will be reraxed but awaie,. ilow"e"v!r.'v., means you
anaesthetic to ressen any discomfort #,i, have a rocar injection of
at the mrnor operation site (incision
site)
 What Happens Before the Surgery ?
As with many surqeries, you wiil be
asked not to eat or drink for severar hours
belore surgery. preparatibn otten oegins with
wastring. v_our upper chest area,
usrng antibacteriar soap to protect th6 incision
from in-fectionr. hrv hair on the
upper chest and shourder wiil be shaved.
vou wirr rruu" iv tine ptaceo in a
vein in your arm. This is used to giv; you
medication, if "n
required.

What Happens During the Surg ery ?

You will be taken to a speciar room
furi of equipment and peopre. you
a bed with your arms safery.".rr.o wiil rie on
ii-your sioes with padding praced at your
important tt.,at vb, oo nol ;;."t, rp
or move you, air's during the
31335;jl5
ECG erectrodes wi, be praced on your
chest, back. arms or Iegs. so that your
hearr beat can be monitored Oriingih"
;ric"oure.
Your chest wi'
be washed again and then covered with
speciar drapes and
sheets A rocar anaesthetic, iimirai to irrii;hi;;"i;;iiri;,,:,r1
t'J nrmb you,.
to numb ihe incision;;;"--" '-
gums and teeth, wiil be injected
 A small incision is made under the right
or reft coilar bone as considered
appropriate by your doctor. A needrels introduced
into a ,e,n iylng near tne
surface of the chest crose to the coilar b;;;. ih;;
inserted through the needre into the vein-ano
ir;; ;#;irler reao is
is advanced to the heart under
X-ray imaging. When in the heart, ttre teal is secured
in the right position. Next,
a space is created under the skin on the front of the
chest iniir,e putse
generator is slipped into this pocket. After the pacemaker
has been tested to
make sure it is working properry, the skin poc(et
procedure.
ir."*n ,p,-.J;pteting the

when the pacemaker and the reads are being inserted, you
pressure. lf you begin to feer any discomfort,let may feer some
the docior t<noii, immeJiatety
so you can receive some additionar medication to
xeep-ih" ;r;; numb. you
may be asked to take deep breaths and to cough
vigorousty, wnit. yo* doctor
watches an
|-1ay of your heart on X-ray video. This is done to ensure secure
placement of the leads.
 What Happens After the Surg ery ?
S You will probably spend a short time
in a recovery room and then will be
shifted back to your hospital room.
You may have a little soreness around
' the incision line, where the pacemaker
was implanted. This is often treated
with pain medication, if needed.
. You can usually go home, anywhere
within a day or two after surgery - it all
depends on your particular case.

What About the Recovery Period ?

You will probably be aware of the pacemaker for a while. This is a normal
feeling and generally will lessen with time. sometimes, there will be a black and
blue mark in the area of the pacemaker. This is from the surgical procedure
and will go away with time. lf however your incision becomei red, warm, more
painful, swollen or starts to drain fluid, notify your doctor immediately. Also call
your doctor promptly if you develop a fever. Do not wait for your neit scheduled
visit.

During the first few days after surgery, avoid sudden, jerky movement with your
arms or stretching or reaching over your head. your doctor will tell you when to
resume your usual bathing routine and other normal activities.

The symptoms you experienced from the original abnormal heart rhythm should
diminish and, hopefully disappear altogether. lf you notice new sensation as
your body adjusts to your pacemaker, tell your doctor. This will help the doctor
adjust the electrical settings of your pacemaker to better suit your particular
needs.

M
ffL&0rffiffit

,,*,1

@
C
What About Follow-UP Care ?
Pacemakers are extremely dependable devices. However, it is important to
periodically check the pacemaker to make sure that it iS functioning properly
and that its settings remain appropriate for your medical needs.

When your pacemaker is implanted, it is adjusted or programmed to fit

your needs. These needs may change over time and when they do, it is a
simple process to re-program your pacemaker during a visit to Cardiology
Clinic or Cardiopulmonary Department.

A typical follow-up will usually include a

brief physical examination, an electro-
cardiogram, and a detailed evaluation
of how well your pacemaker is
performing. Examining and adjusting
your pacemaker is quick and painless.
Your doctor has special equiPment
(computerised program mer) that
communicates with the Pacemaker,
allowing adjustment of its function
without any additional surgerY.

How Long Should a Pacemaker Last ?

Advances in technology have made pacemakers safe, reliable and long-lasting'
Modern batteries lose power slowly, not all at once, accordingly, there is no
danger of unexpected failure. However, periodic checks.of battery function are
important. Pacemaker longevity depends upon how hard the battery inside the
pulse generator has to work, based upon how much energy'is required to pace
your heart and how the system is programmed for your need. ln general,
pacemaker batteries last anywhere from 10-15 years, but could last longer or
shorter depending on any one specific circumstance.

Pacemaker batteries usually do not stop suddenly. One of the purposes of your
follow-up care is to monitor battery Status. Your pacemaker will give ample
warning (months ahead of time) that the batteries are reaching depletion. At
this time your doctor will schedule replacement procedure. The same minor
Surgery is required to replace the pulse generator as performed during the
original implantation. Normally, this is easier than the original procedure
because the leads are already implanted and usually do not require
replacement. They are simply reconnected to the new pulse generator.
After Discharge from Hospital
1. Carry a pacemaker card which contains youi. pacemaker information and a
copy of your pacemaker programming parameters with you at all times,
2. Return gradually to your usual lifestyle.
3. lf you experience any of the following symptoms, notify your doctor:
V Shortness of breath
V rainting, dizziness
V Chest pain
V Excessive hiccoughing
V Muscle twitching in the pacemaker area
V Swelling of the feet / ankles
V Redness or drainage at the insertion site
Do not wait for the severity of the symptoms to increase.
4. Tell your dentist, local doctor, care giver, work supervisor and airport security
guard that you have a pacemaker.
5. Do not miss your scheduled pacemaker appointment follow-up.

Medications
1. Take your preseribed medication and follow your doctors' instructions.
2. Do not take unprescribed medication, change your medication prescription or
timing of medications without your doctor's consent.
3. Bring your medication with you at every doctor's appointment and
pacemaker follow-up appointments.

Activities and Exercise

1. Do not hesitate to use the arm gently in the first few days after pacemaker
insertion, on the affected side, to prevent stiffening of the shoulder.
2. Continue routine activities such as:
V walxing
V Bathingrshowering
? Travelling/driving car
? Gardening
V Performing prayers
V Returning to work
3. Refrain from playing games that involve vigorous activity or contact sports.
4. Do not lift weights or heavy items.
5. Follow your nurse/doctor's advice in returning to your daily activity.

10
 Precautions with Etectrical Devices
1' You may comfo,*dy use common househo/d appriancessucn
as:
I Microwave oven
I Hair dryers
I Vacuum cleaners
! Shavers
y Television/radio
y Toaster/blenders
Avoid use of malfunctioning household
appliances.
2 Do not touch erectricar equipment with
open wire conditions.
3. Avoid crose contact with. generator,
werding equipment, transmitters
internal combustion engiries and
tnaiire running.
4' Maintain a minimum separation of 6 inches
(15 cm) between a hand herd
cellular phone and the pacerate, site.-

Hospital or Medicar Environment tnterferences

speciar precautions be taken if a pacemaker patient is
:l.^yrd
the following procedures: considered for

v MRt
I Lithotripsy
I Diathermy
V Externat Defibrillation
I Electrocautery
I lrradiation therapy

X-Ray and thermal treatment does

not effect pacemaker.
(Refer to the technicar manuar
of the specific pacemaker for further guidance).

For further information, please contact:

CARDIO PULMONARY DIAGNOSTIC SERVICES
Aga Khan University Hospital
Nazerati_Watji Buitding Tet: 4865780
email : cardiology@ atu. e"Ou - wwwlaku.
edu

11
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