Introduction
There was an advancement in cardiac surgery towards the mid of the 20th century which resulted in the requirement of an artificial activation of the heart muscles. During the initial years, it was evolved as huge external equipment. After that, there has been an advancement in the technology and it has led to the development of miniatures of electronic circuits and finally evolution/growth of completely implantable equipment.
In the 1930s, the first cardiac pacemaker had been developed by Hyman. In this electrical activation to alter or produce cardiac mechanical activities, in this a hand crank (It is an arm which is fixed at a right-sided angel to a shaft which is rotating) produced an electric current that drove a DC generator in which the electrical impulses were passed on the right atria of the patient via the needle electrode, which was located intercostally.
There have been several changes in the cardiac pacemakers:
In the 1950s, there were AC-Powered pace-makers tied up to an extension cord (Furman)
In the 1950s, The “Wearable” Pacemakers had come that was working on the “battery-powered transistorized (Lillehei/ Bakken).
In 1958’s, there was an invention of a complete Implantable Pace-Maker (Elmqvist/Senning)
In 2015, the basic system was still not developed remarkably for Implantable Pace-makers.
In 2016, a piece of equipment was designed i.e. leadless pacemaker which completely gets fitted in the cardiac chamber.
Future planning to come up with a device that does not require a battery.
What is a pacemaker?
If there is an issue with the rhythm or the beats of the heart, the pace-maker identifies the problem and transmits its electrical impulses for the heart to beat properly and regularly at proper times (The role of a pace-maker is it can produce or forms a pulse).
It consists of computer chips and a battery which is tiny but lasts long. This battery is placed in a secure case. The electrical impulse used by this device is of low-energy just for the beating of the heart at a normal rate. This device also stores the information related to your heart. The physician can study the information, which is stored using a specific computer named as a programmer. The programmer converses with the device from the outside of the body via a wand that is situated on top of the skin. With the help of a programmer i.e. a specific computer, a physician can better analyze the programmed therapy required for the rhythm of the heart and regulate the settings whenever required.
This is a surgical procedure in which the pacemaker is inserted in the upper chest or abdomen. This pacemaker produces pulses which are passes via special wires termed as leads, which are usually situated inside of the heart. The role of the leads is that it helps the pace-maker aware of the heart’s rhythm. This is of utmost importance as the device needs to send its pulse at an accurate time/moment.
The lead is defined as an insulated wire that is inserted in the patient’s heart and then attached to the pace-maker equipment. The lead transfers the signals of the heart to the pace-maker equipment. It then takes back the energy from the equipment to the heart to balance the rhythm of the heart.
What is the requirement of a Pacemaker?
Pace-maker is required when the heart rate becomes slow or not normal, fainting, dizzy feeling, fatigue, breathlessness, palpitations and unconscious. Pace-makers can also be used when a person is suffering from bradycardia (slow heart rate i.e. less than 60 beats per minute) or heart block.
The heart produces its electricity, which results in the proper sequence of contractions and relaxations of the heart, this helps circulate blood i.e. oxygen and nutrient-filled to different parts of the body. At some point in time due to a medical condition, these electrical signals do not work properly. If the heart does not beat or beats slowly, the pacemaker results in electrical activation. An insertion of pace-maker contributes to the heart beating properly.
The pace-maker helps with the overall improvement in the life-style and more energetic and active.
Diagnosis of the problem
To conclude, whether a pace-maker is required or no, the physician will collect your information i.e. signs and symptoms and health-related history. Some of the tests will be done to see whether the heart is beating and the rhythm are proper or no. This also is detected via a painless test named electrocardiogram (ECG). Also, you could be asked to wear a monitoring device to keep track of your heartbeat and heart rhythms like a Holter monitor or event recorder.
When does the Pacemaker know when to Pulse?
The Rhythm of the heart can be sensed by the “Pace-Maker.” It can be organized or scheduled in such a way that gives out the pulse or we need to wait till the heart beats on its own. The physician/doctors can help you adjust the pace-maker to give correct help for an extensive scale of lifestyle and activities.
The heart rate can be increased or decreases depending on the patient’s physical activity such as climbing stairs or doing any exercise. To fulfill the needs of both lifestyle and activities, the doctor can give you the device accordingly.
How does it feel to have a pacemaker in the body?
For many people, they do not realize that there is a pace-maker. The pace-maker contains a very small electrical pulse. Even if the pulse is felt, the doctors can change the setting and can make it more comfortable.
Battery-Life of a Pacemaker
The pace-maker lasts for about five to ten years. The battery will last longer depending on several factors such as the type of the battery, how frequently the pulse is sent, the medical condition of the patient and many other causes. The battery does not stop working immediately. It starts slowing down over months, this gives enough time for a replacement of a new pace-maker. The battery is checked, at each visit to a doctor for a follow-up. If the energy of the pace-maker slows down, it has to be changed again with a new pace-maker via surgery.
Even if a lead needs to be changed, it has to be done via surgery.
Types of Pacemaker
The earliest pace-maker in the year 1950s was the size similar to that of a hockey puck i.e. a sports equipment. The battery would go on, only for a year. The latest pace-makers are smaller in size and can energize up-to three heart chambers. The battery for this pace-maker lasts for about five to ten years.
The pace-makers which are the simpler ones are called as single-chamber because their connection is like “one lead in one chamber of the heart, majorly the right ventricle.”
The other pace-makers have two leads named as Dual Chamber. These are located as one in the right atrium and another in the right ventricle. In both the chambers, they can sense and pulse.
Few of the pace-makers also have three chambers, one in the right atrium, one in the left ventricle and one in the left ventricle. This helps the beating of the heart in a synchronized manner for those who are right and left beats do not beat in a synchronized manner. This chamber is termed as a Biventricular pacemaker or cardiac resynchronization therapy (CRT).
The different pace-makers as mentioned above are modulated by the rate i.e. when the patient gets energetic and mobile, the speed of the pace-maker also increases and when the patient is at rest, the pace-maker slowdown. These types of pacemakers are also termed as “rate-responsive” or “rate-modulated.” These pacemakers have an attached sensor that informs them about the activity of the individual.
The risks and benefits of the pacemaker
By putting a pacemaker, heart diseases cannot be cured. They do not help treat the cause that is affecting the heartbeats to be slow or not regular. But since they can keep the cardiac rhythm regular, the quality of life can be improved for that individual who is having abnormal heart rhythms.
Benefits of Pacemaker
The pace-maker is beneficial as it helps regulate the rate of the heart i.e. the speed of the heartbeat and rhythm i.e. the pattern of heartbeats and helps in electrical activation to the heart when it stops beating or slow beating.
It helps in relive from various signs and symptoms such as light-headedness, dizziness, fainting. Some people feel energetic. It also contributes to improvements in the quality of life and the mind gets fresh and peaceful. It also provides happiness, increases in enjoyment and being healthy and productive or creative,
Risks of Pacemaker
The risks contribute to problems ranging from the operation to inserting the pace-maker and also the leads in the body. It could also include things like infection, the side-effect of drugs given during an operation, blood vessel, the heart wall or other organs getting damaged. These problems or issued could be solved or cured.
Risks observed in the insertion procedure could be bleeding; Blood clot formation; Affecting the adjoining nerves, muscles or tendons; a lung or vein is punctured, harm to the heart, irregular heart rhythm, heart attack, stroke, death.
Some risk factors observed after the insertion of pace-maker includes development of an infection, near the equipment that is abrasion, device could shift from the original site of implantation, lead goes out of the place in the heart, electrodes are affected, the pace-maker equipment is not able to find out the rhythms properly, there is a malfunction observed in the device resulting in no proper delivery of the therapy.
Some feelings after surgery last for only some time like discomfort or fatigue feeling. Some individuals also do not feel comfortable in the place where the pacemaker was inserted. There are various safety characteristics observed in modern pace-makers. In some cases, the pace-makers do not function appropriately as it is being caused by the exterior origin of electromagnetic energy.
Sometimes the pulse becomes non-effective when the point of the lead moves into the heart. In very few cases, the pace-maker device may slide out of the pocket and goes into the chest.
It should be a compulsion to monitor the pacemaker device, with proper follow-ups to the doctor.
The procedure is done for the surgery
To insert a pace-maker is a regular procedure done. This procedure takes approximately one to two hours and the patient might need to remain in the hospital under care for a few hours or a few days.
The operation or surgery differs from patient to patient and it needs to specific to their case, so important to discuss it once with the doctor or physician.
Things to be done before surgery
It will be told by the physician how to get ready for the operation before the surgery takes place. Medications might also be stopped before the surgery. Before the operations, patients may have to avoid consuming water and food a few hours before the operation. The blood tests may be done before the operation. The patient may have to fill up the form as asked by the physicians.
The final day i.e. the procedure day
Firstly, the patient is taken to the operating room, where the upper chest will be shaved and washed + cleaned by the nurse.
There will be an IV (Intravenous) attached in the arms and blood pressure cuff around the arm. In different areas of the body, electrodes will be situated.
It will be seen that sometimes the individuals would take local anesthesia to deprive the sensation in that area where they are planning to locate the pace-maker to see the entire procedure. On the other hand, if the patient does not want to see the procedure than general anesthesia will be given, where medications will be given for the patient to go off to sleep.
During the procedure
Once the upper chest has been shaved and cleaned, a cut is been made by the doctor which is as long as one or two inches or approximately two to four centimeters. The physician then looks for a vein and directs the lead into the heart. This is done using a fluoroscope i.e. an X-Ray, to find out where it is going. The leads should not be felt in the heart.
Under a skin, a tiny pocket is been made. In the pocket, is situated the pace-maker which is then attached to the leads. Finally, the pace-maker is to be tested to see whether it is working appropriately or no. Sometimes, during the insertion of the pace-maker and the lead, the pressure might be felt. If the pressure or discomfort increases, kindly inform the physician or the doctor.
After surgery details
After surgery, the patient will be transferred to a recovery room, where the nurses will be taking care of the patient to see your health. Where the pacemaker was inserted, there would be a soreness seen. After these medicines would be given to avoid the pain if required. The pace-maker will be tested by a physician to see to it, that it is working.
What instructions to be followed once back home after surgery?
- Initially, it is important to heal or recover. The injury will take time to heal and will happen slowly. Initially, you would know if the pace-maker is there in the body, over some time it will not be of any notice to you.
- See to it that the wound remains clean and dry. If any changes are seen which is not normal on the wound, then instantly connect back to the doctor.
- Important to only indulge in mild movements. Avoid any sort of lifting, stretching and excess movements that need more movement of the arms.
- Try avoiding playing with the pace-maker or pushing it under the skin.
- Important to do timely check-ups with the doctor.
- Important to carry your patient identification card with you. This card contains all the information about the pace-maker, types of pace-maker and the other necessary information.
- Important to listen to the physician related to your medicines, to come back to routine activities/work.
- A regular follow-up visit is important, in-case if the patient is not able to come “the doctors ask patients to “send in” the important information instead of coming in.” This is referred to as “remote monitoring.”
Living with a pacemaker
This is not difficult. It is safe enough to perform all the activities to be done. Some things to be considered could be electrical signals that affect the pacemaker. Important to carry your identity proof card. Also important to keep the heart healthy, regular exercise and proper diet under the advice of the physician.
Signals like cellular phones (when talking on the phone it should be done on the opposite side and also the phone needs to keep on the opposite side) to avoid signals; electromagnetic anti-theft systems (situated near the entry or exit of the stores or shops, one can pass by but avoid leaning), avoid magnets (MRI Test, also avoid large speakers for music concerts), strong electrical fields (radio-towers, heavy-duty power equipment, car engines)
Conclusion
Though pace-maker is a tiny device, it brings about a great change and improvement in the way you feel. Pace-maker helps to be more energetic, by keeping the heart to beat or rhythm in place. It helps feel good about health and heart. This helps to keep a track of the things in life that is the most important to us.
Sirisha B