Living With A Pacemaker (common questions answered) - in Plain English!

0:00 This is Dr. Joshua Cooper and this video reviews the basic purpose and function of a pacemaker. And I'll review all the most common questions I'm asked about living life with a pacemaker. A pacemaker is a small computer and battery all in one sealed compartment that is implanted under the skin of the chest. It is connected to one or more wires that are threaded into a vein and attached to the inside of the heart. A pacemaker is an extremely effective treatment for all types of slow heartbeat problems. There are two main types of slow heartbeat problems, which I will explain after we first look at how the heart's electrical system works. Normally, each heartbeat starts in the top right part of the heart at a spot called the sinus node. This is the heart's natural

0:46 pacemaker that electrically fires over and over to start each heartbeat. Electrical signals then sweep across the top half of the heart, which squeezes first. In order for a signal to get from the top to the bottom part of the heart, it must cross over a special electrical bridge called the AV node. This bridge creates a slight delay, but then allows each signal to travel down a fast electrical tree, which makes the bottom pumping chambers beat in a coordinated way. It's the bottom chambers that do the main pumping and create the pulse that sends blood throughout the body. When we do an EKG or heart monitor, we see the electrical signals from the top and bottom parts of the heart, which shows us if the electrical system of the heart is working properly.

1:33 Here's an EKG that shows the heart working normally. On each beat, we can see the electrical squiggles from the top and then the bottom part of the heart, one after the other. This shows that the sinus node natural pacemaker spot and the AV node bridge are both working properly. So now let's discuss how the heart's electrical system may not work properly and how a pacemaker works to fix the problem. If the sinus node part of the electrical system doesn't work properly, then the heart is not able to start each beat on time and the heart can slow down. Here we see on EKG a longer space between the beats which in this case creates a slow pulse of 34 beats per minute. This type of slow heartbeat can

2:18 cause a variety of symptoms including weakness lightadedness fainting feeling tired with walking or other activities or shortness of breath. If no treatable cause is found, an electrical pacemaker can be implanted. The pacemaker will substitute for the sinus node function by sending faster electrical signals to the top part of the heart, restoring a proper heart rate. Here we can see a pacemaker working to speed up the pulse rate by using tiny electrical pulses that we can detect on an EKG, but a person cannot feel other than feeling better with all the symptoms going away that they may have had from too slow a heartbeat. The second type of electrical problem that can cause too slow a heartbeat is the AV node electrical bridge not

3:05 working. When that happens, electrical signals cannot properly get from top to bottom. And in the worst case scenario, the top chambers may keep going just fine, but the bottom chambers just stop and the pulse is zero, which of course would be a medical emergency. Most of the time, however, this problem isn't quite that severe. And either some of the beats get down to the bottom, or the bottom chambers can wake up on their own and create a slow heartbeat all by themselves, independent of what is going on up top. Either way, the pulse is slower than it should be, and the person may have all the same symptoms that I mentioned on the previous slide, and the problem could get even worse over time, leading to an even slower pulse with more severe symptoms. The solution here

3:51 again is an electrical pacemaker, but this time the pacemaker needs to pace in the bottom part of the heart after watching the top half to determine each time it should kick in in the bottom. Here's a pacemaker keeping the top and bottom parts of the heart coordinated, watching for each beat in the top and working as a substitute electrical bridge to transmit each signal down to the bottom to keep top and bottom coordinated and keep the heart beating at the proper speed. So, why might the heart's electrical system stop working properly? The most common cause is simply that the heart's electrical system can decline as we get older. But otherwise, the electrical system can be damaged from a certain type of

4:37 medical condition of which there are many. A heart attack could damage the electrical system. An infection such as Lyme disease or an infection on a heart valve can affect the electrical system as well. And there are inflammatory conditions such as one called sarcoidosis that can also impact the electrical system and make it not work properly. Sometimes there are medicines that we use that may be needed for another issue that could slow down the heartbeat by slowing the electrical system. If the medication can be stopped, that may solve the problem. But sometimes the medicine is needed for a condition such as atrial fibrillation, and now we're at a problem where the medicine is needed for one issue, but it can make another problem worse. Sometimes the electrical system can be injured during a heart surgery or heart

5:24 procedure such as an open heart surgery for a valve problem like a valve repair or valve replacement in the operating room. But also minimally invasive procedures to fix a heart valve can also damage this electrical system such as a taver procedure on the aortic valve. So let's get to the most common questions that people ask me about their pacemaker. One of the most common first questions that people ask is whether there's any maintenance needed for the pacemaker. We have a special device in the office called a programmer that we use to perform pacemaker interrogation, which isn't as scary as it sounds. That just simply means getting information from the pacemaker in the office. We can place a little device called a wand over the pacemaker and then we can wirelessly communicate with the pacemaker through

6:10 the clothing and through the skin in order to retrieve information and change the settings if we wish. Alternatively, and sometimes in addition to office visits, we will send patients home with something called a remote home monitor. This plugs into the wall and actually allows us to retrieve information while the patient is still at home. We often do this at regular intervals, for example, every 3 to 6 months. But also, information can be obtained in between those routine checks by pushing a button or telling the monitor to send us information if we have a particular question about how the pacemaker is working or whether there have been any arrhythmias. Either way, whether we get information in person in the office or in the hospital or through a remote home monitor, each time we check the

6:56 pacemaker, we get a very detailed report. This tells us all about the pacemaker, including the battery status, how the wires are working, the heart rates that the pacemaker has seen, how often it needs to pace, and all sorts of other information about the patient, the pacemaker, and any arrhythmias that may have occurred. Another question that I often get asked is whether a pacemaker can treat atrial fibrillation. And the short answer is no. Atrial fibrillation is a very rapid heartbeat in the top part of the heart that makes the bottom pumping chambers beat faster and more irregularly than normal. And the pacemaker simply watches those things happen. It's not able to prevent a fast heartbeat. It simply treats a slow heartbeat. So if somebody's in atrial fibrillation, the

7:43 pacemaker may often sit silently and just see that the atrial fibrillation is happening in the top and that irregular beating is happening in the bottom. Now if the bottom chambers decide to go too slow because too few signals are making it across the AV node bridge, then of course the pacemaker will kick in whenever necessary in the bottom to make sure that the pulse rate does not fall below whatever the lower programmed rate may be. That said, the pacemaker does give us a lot of information about atrial fibrillation if and when it occurs because the pacemaker also can act as a permanent heart monitor. And in that function, it can dutifully record the date, time, and duration of any arrhythmia episodes that it may have

8:28 seen, particularly atrial fibrillation. The pacemaker will record the electrical signals in top here seen in blue and in bottom seen in purple. And every time it sees an abnormal rhythm, it will save snapshots of the heart's rhythm electrically that we can then retrieve either in person or through remote monitoring from home. And it keeps a log of every single event that we tell it to. It'll record the date, the time, the duration, and even the average heart rate that occurs during each single arrhythmia event. Another one of the most common questions that I get asked is how the pacemaker will impact someone's quality of life and daily activities. For example, can I no longer use a microwave oven? And of

9:16 course, the answer nowadays is yes. In the olden days with very old-fashioned microwave ovens and very old-fashioned pacemakers, there was indeed an interaction. But that was decades ago, and there is no longer any problem whatsoever using a microwave. And likewise, people wonder about other things in their daily life that use electricity. For example, cell phones and computers are perfectly fine to use. Same with household appliances and even the same with routine power tools. None of these things generate electrical signals that are strong enough to interfere with pacemaker function. People are wondering also about travel. Can they go through an airport metal detector or a security checkpoint at another location?

10:01 Pacemakers of course have metal just like a belt buckle. And so if you were to walk through a metal detector with a pacemaker in place, depending on how sensitive it's set, it may alarm and beep. It will absolutely not damage the pacemaker whatsoever, but you may end up needing a patown search after the metal detector goes off, just like if you had another piece of metal in your body, such as a metal hip. Everyone with a pacemaker gets an identification card for your wallet. And at the airport or other security checkpoint, you can let them know that you have a pacemaker in place, and they'll often wave you around and just do a pat down search right up front. And often that actually speeds up your travel through that security checkpoint. Another very appropriate concern that patients may have is whether or not they

10:47 can have routine medical testing with a pacemaker in place such as an MRI. Now, an MRI machine uses extremely powerful magnets to generate pictures and therefore it can interfere with pacemaker function because of that very strong magnetic field. The good news is that we can actually change the settings in the pacemaker to special MRI safe settings so that the MRI procedure can be safely performed in somebody with a pacemaker. And after the MRI is done, the settings are programmed back to the way they were before. So yes, absolutely you can have an MRI with a pacemaker in place. All modern pacemakers and wires have been tested to show that they are MRI safe. even in patients who have

11:34 older wires and older pacemakers at many MRI centers can still be done safely and other centers are following suit as many studies have been showing that all pacemakers and wires appear to be safe in the MRI environment. But you need to ask your MRI center whether they are comfortable doing imaging in somebody with your particular pacemaker and wires especially if it's an older type of system. In terms of other testing like X-rays and CAT scans and ultrasounds, those are all perfectly fine and there are no changes that need to be made to the pacemaker in order to get these medical tests done safely. So people may ask, is there anything that I can't do? And the answer is that

12:20 there are very few things that generate a strong enough electromagnetic field to interfere with a pacemaker. An MRI is the most common field that someone may be exposed to. But people have interesting careers, including those that expose them to very high electromagnetic field strength, such as people who work on high voltage power lines. Not common, but absolutely this environment can interfere with pacemaker function. And somebody in this line of work needs to be very cautious. Similarly, people who use arc welding either professionally or as a hobby need to be cautious because if the chest is close enough to the arc welding site, the electromagnetic field that is generated could be picked up by the pacemaker and the pacemaker may

13:05 misbehave. People who have a work environment that they're exposed to a strong enough electromagnetic field that can impact a pacemaker. Usually the employer will have posted signs having done electromagnetic field strength testing in the work environment to alert somebody that it is not safe to be in that particular space with a pacemaker in place. Many people are aware that pacemakers can be sensitive to magnets and when a magnet is placed near a pacemaker, it can impact pacemaker function. And they'll therefore ask me whether a magnet will turn off their pacemaker. It's a great question because we may be exposed to magnets in our daily life. Sometimes in some cell phones or earbuds or jewelry or other situations where a

13:52 magnet may be near the torso. And it's very important for someone with a pacemaker to understand how a magnet will impact pacemaker function. All pacemakers have a magnetic safety switch inside. And when a very strong magnet is placed against the skin right over the pacemaker, it will activate that safety switch. But it doesn't turn off the pacemaker. To the contrary, it actually tells the pacemaker to pace no matter what. Don't look at anything. Don't look at the heartbeat. Just pace. And when the magnet is removed, the settings turn back to normal. Here's an example of somebody who had a magnet placed over their pacemaker and it's just pacing away completely ignoring the heartbeats that are happening. And sometimes the pacemaker will try to stimulate the

14:39 heart at a time. It's not ready because a beat just happened. But at other times, it will generate a heartbeat on that paced beat. So again, a magnet will impact a pacemaker, but it will absolutely not turn it off. It tells the pacemaker to pace no matter what. Well, you may ask, why does pacemakers even have a magnetic safety switch? What would be the circumstances that that would be important? Well, pacemakers, of course, are designed to pace and prevent a slow heartbeat. And when they see a heartbeat happen on its own, then a pacemaker will stop pacing because it doesn't need to pace at those times. But sometimes a pacemaker that needs to pace is fooled into thinking that it is seeing the heartbeat when it really isn't. For example, here is a patient

15:25 who has a pacemaker and there are periods of time that the pacemaker stops pacing, leaving the patient with symptoms of lightadedness and near fainting. Why is this happening? If the pacemaker sees electrical signals that it thinks are from the heart but aren't really, then the pacemaker may decide, "Oh, I don't need to pace because the heartbeat is happening on its own." And this situation might occur if, for example, there's a broken wire that is giving electrical signals to the pacemaker that aren't from the heart, but are from the little broken ends of the wires scratching together and generating small electrical signals. Well, in that situation, the pacemaker is malfunctioning because of that broken wire. And in an emergency situation, we may not need have time to wait for an

16:11 electrophysiologist to come with a programmer to reprogram the pacemaker. And so, in an emergency room or other environment, we can simply tell the pacemaker to stop malfunctioning by placing a magnet over it by activating that safety switch and tell it, you know what, stop looking, just pace. I drew, by the way, the magnet as a blue donut because often in a hospital setting or an emergency room setting, the strong magnet that we have available is shaped like a blue donut. It's usually on the code cart and people can grab it quickly and place it over a pacemaker in a situation where the pacemaker is not pacing and we think that it should. So when that magnetic switch is activated, the person will start pacing again and there will be no pauses in the heartbeat. And then the arrhythmia team

16:57 can be called and they can come and quickly sort things out while the magnet is in place and keeps the pacemaker pacing and doing what it's supposed to do. A really important question that people may have either at the time their pacemaker was implanted or sometimes many years later is the question of what happens to my heart if I'm passing away if I have a medical condition or I'm at the end of my life and I have a pacemaker in place. Will my heart keep beating after I die or will the pacemaker prevent me from dying peacefully and prolong the process? The short answer is no. When somebody stops breathing and is passing away, the organs, including the heart, will stop working. The acid levels build up in the

17:44 blood, the oxygen level drops, the carbon dioxide level goes up, and the organs, including the heart, will stop working. And here's an example of a telemetry strip, a heart recording from somebody who's passing away with a pacemaker in place. And these events occur over a few minutes. Here, the pacemaker can be seen creating a heartbeat. You can see the little black electrical signals from the pacemaker and the brown EKG beats of the heart beating and following with each pacemaker signal. As this person is passing away, we can see that the EKG pattern starts to change because the heart is getting sicker. And further along the process, the heart muscle will stop to work and we'll start to see

18:29 pacemaker signals but no heartbeat attached to them. And as the person passes away, the pacemaker will keep sending little signals to the heart, but the heart along with the other organs has stopped working and the person will pass away. Uh, and the pacemaker is not going to prolong that process in any meaningful way. To reinforce that point, here I have two heart recordings from two patients in an ICU setting who are passing away. On the left with a pink EKG, somebody without a pacemaker. and on the right in brown somebody with a pacemaker. And I wanted to just compare the process. These recordings are shown over a fiveinut period of time as each of these two

19:14 patients was passing away from a serious medical condition. At the top we can see the heartbeating in both cases. And as the person was passing away and the heart was getting sicker along with all of the other organs, we can see that the heart starts slowing down even with a pacemaker in place on the right. And at the bottom within a 5-minute period in each case here the heart has stopped. Again on the right we see electrical signals from the pacemaker but the heart stops beating and the pacemaker is not prolonging life in this case. A similar type of question may come up if somebody is considering or planning to enter a paliative care or hospice care type of setting whether it's in the hospital or at home and they may ask

20:01 whether their pacemaker should be deactivated or programmed off in that setting. And the short answer is usually no. And the reason is that the pacemaker was put in for a reason. The pacemaker's job was to prevent symptoms that occurred from a heartbeat that was too slow. If you take the patient in the bottom here with a pulse of 78 and you take away their pacemaker essentially by turning it off, it doesn't need to physically be removed. It can be turned off with a programmer, then what you've done essentially is return that person to the situation that they were in before the pacemaker was placed. and it may be worse than when the pacemaker was first put in because their electrical problems may have progressed over time.

20:46 And what we've essentially done is we've returned that person to an abnormal slow heartbeat with all of the symptoms that may go along with it of weakness, lightadedness, shortness of breath, being tired with walking or even passing out and fainting and potentially risk injuring oneself. This is really the opposite of what we try to do in a paliotative care or a hospice care situation which is to eliminate and minimize symptoms. And so by turning off a pacemaker, you actually may create a whole new set of symptoms that the pacemaker was preventing. And factoring this in with considering the fact that when somebody's passing away, the pacemaker generally does not meaningfully prolong their life or prolong their death, leaving the pacemaker just as the way it was is

21:33 appropriate. Of course, every situation is different and you should talk to your cardiologist or your electrophysiologist about your specific situation and your concerns to make sure that you have the exact care plan that you desire, factoring in what life would be with and without a pacemaker at times that you have to make difficult decisions, including hospice care. Let's switch gears back to talking about pacemakers themselves because people will ask me, are there other types of pacemakers than the kind that we've been talking about, which is the pacemaker sitting under the skin of the chest attached to wires that travel in a vein and on inside the heart? And the answer is yes. The main alternative type of pacemaker is called a leadless

22:19 pacemaker. And it's pretty amazing. It's a tiny little capsule that's inserted into the heart itself. There's no wires. There's nothing that sits up under the skin of the chest. But the pacemaker is a self-contained little capsule that sits inside the heart itself. It's placed there using a long tube that is threaded in a vein at the top of the thigh in the groin area up inside the heart. This pacemaker, leadless pacemaker, is inserted into the heart and released. And of course, that long tube is removed from the body, leaving just this pacemaker in place. And there's now also a two-chamber version where there's a little leadless pacemaker placed in the top part and one in the bottom part and they can communicate with each other to keep top and bottom coordinated. And no doubt in

23:04 the future there will be other types of pacemakers as well that'll have pros and cons as this one does. So if you need a pacemaker, you can talk to your doctor about the different types and what would be the most appropriate type for your situation. One last question that I'm sometimes asked is whether there is any other purpose of a pacemaker aside from treating a slow heartbeat. And the answer is yes. There are some situations where electrical stimulation of the heart is used not to prevent a slow heartbeat but to coordinate the heart in a better way. And what I mean by that is there are some people that are really sensitive to uncoordinated pumping between the walls of the bottom chambers. In particular, this main pumping chamber, the left ventricle, the

23:50 bottom left chamber of the heart. And in that type of person where the coordination of pumping is really important, we can recoordinate the heart in two different ways. One is using a three-wire pacemaker system called a bentricular pacemaker. Bventricular because you put wires in both ventricles, the right ventricle and the left ventricle. And then we can stimulate the heart from two places on opposite sides of the main pumping chamber at the same time and thereby recoordinate the pumping of that chamber in people where this is really important. A second way that we can achieve coordination of that bottom left chamber is to use a two-wire pacemaker. But that bottom wire is put in a very specific place intended to actually

24:37 capture this branch of the electrical tree that may not be working on its own properly called the left bundle branch. This is called a left bundle branch pacemaker or a conduction system pacemaker. And again, it's used in specific circumstances where the coordination of the bottom pumping chamber walls is not perfect, and we think that it would help the patient for that coordination to be better. So, your doctor may talk to you about putting in a pacemaker, not because of a slow heartbeat, but because of a coordination problem, and one of these types of pacing could potentially help. I hope this presentation was helpful in answering any questions that you may have had about how pacemakers work and what it is like to live life with a pacemaker in place. If you have further

25:23 questions that I failed to address in this video, make sure that you ask your doctor and or leave comments and questions below because it is so important, as with all of medical care, that all of your questions are answered and you feel at peace with any medical decisions or treatments that you may