Common Pacemaker Questions and these Pacemaker Questions Answered

So I asked for questions and that is what I received!

Remember this is not meant to be used as medical advice, each patient is far to different to do that! Please read my disclaimer first before reading this post 🙂 Thanks.
Yes Carl is it normal to feel my pacer pacing I am feeling this all the time I had a check up about 3 weeks ago the tech said everything was fine.
It would be impossible for me to claim I knew what you were feeling without a full follow up and knowledge of your medical history but I will just run through a few scenarios I have come across where patients can feel something due to a pacemaker! I am not saying these apply to your specifically.
So I have come across a few patients who could seemingly distinguish between a paced beat and an intrinsic beat (one initiated by the pacemaker and one initiated naturally). Though these are few and far between and if I am totally honest I still remain sceptical – most patients can not feel there pacemaker kicking in…….

What patients can often feel is either Diaphragmatic pacing (where the phrenic nerve is stimulated by the same impulse being used to stimulate the heart) this is, I am told, a similar sensation to hiccups and is most common in devices that pace the left ventricle as well as the right (biventricular pacemaker/ICD) or Pacemaker Syndrome. Now pacemaker syndrome sounds dramatic, ultimately it is an umbrella term for a whole range of symptoms caused a dyssynchrony between the contraction of the top of the heart and the bottom of the heart. This is more common in pacemaker patients (it can occur in patients without pacemakers and is called pseudo-pacemaker syndrome) and it requires a full post to explain well. Essentially, the order of play in the heart is the top heart contracts whilst the bottom heart relaxes, this means the blood from the top heart can move as it should down into the bottom chambers. When the bottom heart contracts the valve between the bottom and top heart closes so that the blood doesn’t just get pushed back into the top heart (Atrium) it gets pushed out of the heart and around the body. In some pacemaker set ups this order of play is jeopardised by the more pressing issue of keeping the heart beating! If the top heart contracts at the same time as the bottom heart this the valve between the two chambers will be closed. This causes a back flow of blood and a pressure wave sent backwards in a non physiological manor. An analogy for this would be to imagine putting your thumb on the end of a hose pipe, the pressure would increase nearer the tap end! The most common sensation this leads to is a pulsing in the neck commonly known as cannon waves.You could bring these up in your next follow up and I am sure the technician will run through them explaining why they could or couldn’t be applicable to you.

Hi Carl, my pacer is protruding more from my chest than before…I was told that this is normal because they are not sewn in place but will move around in the pouch they are placed in…is that true? Thanks!

Unfortunately pacemakers can protrude and be quite prominent in their subcutaneous (under the skin) pockets. This is mostly dependent on the size of the actual device and size of the recipient. At the centre where I work the size of the patient is a big consideration for the pacemaker given, Sorin for example have a very small bradycardia pacemaker making it suitable for patients with a low body fat content. If the protruding pacemaker becomes problematic I.e. it catches or rubs causing skin lesions then the option is there for placing the pacemaker else where. The primary example of this is sub pectoral, which is in the same area as the standard implant but it is buried under the muscle as opposed to just above it. This is a longer procedure and more traumatic making box changes more difficult and arduous. Essentially there are options worth discussing with your cardiologist if you are unhappy with the position of the device but they are not plan A because its not as straight forward!

What do the letter/number codes mean on our pacemaker ID card?? Mine has Symptoms Primary B1 E3 and B2 then for Symptoms Secondary under Aetiology F1. – thanks in anticipation xxx

This is our short hand for 3 things that explain exactly why you have had the pacemaker implanted. Symptom, Presenting ECG and Aetiology (Cause).
I have listed them on a Blog Post Here…. Full Coding For Pacemaker Implant.
What do you know about Heart block, causes etc if had since birth? Not sure if you can answer or not!
I am not a doctor so causes of heart problems is not my bag! I specialise in managing them using pacemakers. If i am honest with you, unfortunately it would not be right for me to try and answer this question 🙂

Why am I getting more and more dependent on my PM? When I first got it I was paced 2%atrial and 35% ventricle, but now it’s 12% atrial and 65% ventricle. Thanks in advance!

As a general rule of thumb disease processes that lead to conduction disorders (Heart Blocks, Sino Atrial Disease, Sick Sinus Syndrome) do deteriorate, i.e. they can be intermittent at first (come and go) until they are chronic (always there) this being said, that is not always the case! but can explain an increase in pacing required. Another HUGE cause is how the pacemaker is set up, many changes that are made to a pacemaker can have a direct impact on percentage pacing, most of a technicians purpose is to get the balance between minimising pacing and minimising symptoms, it becomes a balancing act. So it may be worth asking in your next check if any changes were made that would increase your pacing percentages or if any changes could be made to try and decrease. 
Just to give you an example… If your pacemaker was set to 60 bpm this would allow 1s after a heart beat for your own heart to beat again. If after 1s your heart hadn’t beat of its own accord the pacemaker would kick in. If your pacemaker was set to 70bpm the pacemaker would give your heart 0.86s to beat before it kicked in. This small change could quite dramatically increase your amount of pacing because you heart has less of a chance to beat of its own accord before the pacemaker kicks in. I hope this makes sense!:)

Over 1 yr ago had a pacemaker placed, scar has never completely healed smooth over. Ep said something must have been rubbing scar bra or something…its not…feel like I’m been blown off. Could it be a lead or part of the pacemakers box??

Refer to my previous answers about a prominent pacemaker and you can see that some are more prominent than others. There are also cases where leads are quite prominent also and you were right to have your EP take a look. Unfortunately some scars do heal thicker than others even without an external factor like a rubbing bra or a car seat belt. If you are still concerned it may be worth going to your GP to discuss it as this will offer you a second opinion to your EP. Never be afraid to get a second opinion, the worst that can happen is that they agree 🙂

What is the craziest way anyone has showed you a pacemaker problem? Today I had to fake sneeze, fake laugh, and wiggle to show that my pacer wasn’t setup correctly.

I once had a patient who claimed that they felt faint during their hot yoga sessions, I did try to explain it was probably the heat and the exercise causing their symptoms… this wasn’t good enough. I had to leave the ECG rolling whilst the patient ran through a selection of Yoga positions. Until then I always thought a downward facing dog was one that was in trouble!

Could a change of settings reduce tiredness? If so which settings ?

If you mean tiredness that comes as a result of diminished cardiac output, then yes potentially. A change in settings can definitely improve exercise tolerance. Things like rate response and increased base rate. Different types of pacemaker can also have an impact the best example being a Biventricular pacemaker. The problem is that ‘tiredness’ is such a huge term for symptoms with a huge amount of causes. So it is really difficult to answer your question but ultimately a pacemaker can definitely improve exercise tolerance.

In your professional opinion, what are the main things you would advise pacemaker patients to avoid e.g. machinery and electrical equipment. I know there are a lot of myths about what we can come into contact with but I do feel that certain things to cause a disturbance!!Many thanks!! 

Firstly let me say that you are quite right that there are a lot of myths about what you can and can’t do with a pacemaker, the American Heart Association have been kind enough to put this list together of things that pose a real risk and things that produce a slight risk, I have read it through and it pretty spot on (obviously). Any individual items of machinery or equipment you want to discuss, take the user manual to your next check and the tech will advise you. Here is the link I hope it helps. American Heart Association (Do’s and Don’ts)

What is the most appropriate pace maker for elderly with complete HB?

If the heart block is permanent (and the only issue that needs to be corrected by the pacemaker) then I would go with a simple Dual Chamber device, it doesn’t need to have any algorithms that increase or encourage intrinsic heart beats. If the CHB is intermittent then you would be looking at a pacemaker with either a long AV delay algorithm or an AAI-DDD Algorithm. I will be introducing Algorithms to my website soon and explaining how they work. Essentially an AAI-DDD Algorithm will give the heart every opportunity for the signals from the top of the heart to reach the bottom of the heart before it intervenes. Like I said if the conduction block is permanent this is not suitable and a less expensive device will be adequate.

Is there any reason we should not ride on roller coasters etc with a pacemaker?

This is a good question! It is not something I routinely warn against when discussing pacemakers but now you mention it I would give the following guidance. Magnets are a good thing to avoid with a pacemaker (as a general of thumb) and so is any large external force placed on the should of the pacemaker. So I would avoid any with over the shoulder safety harnesses and rides that use strong magnetic breaks. However!! I would check with your cardiac physiologist before hand as they will be able to take your case on its own merits. Like everything its risks versus quality of life, when you see us in clinic we rarely say NO flat out we usually explain and discuss the risks so you can make an informed decision.
A complete explanation of these topics and more is available in the book Pacemakers Made Easy by Carl Robinson.

Thank you so much for all your questions!
Time for my Spaghetti Bolognese. 
Cardiac Technician

Image courtesy of David Castillo Dominici / FreeDigitalPhotos.net

Comments 2

  1. I am 26 I’ve I my pacemaker a year next month. I had a pocket revision in May but now it feels as if it’s coming right out of my chest. It itches at the top and bottom of the scar right where it is sticking out of my chest. My cardiologist says it’s fine and working properly. So what should I do it gets worst everyday

  2. Profile photo of Bruce Center

    Had TAVR 2 months ago. Last week my pacemaker, which I had before the surgery, was reset down to 60. This is right around where my rate was before surgery and I think is now as I sense it starting to pace often. Would it be better to set it at 50, as it was before or maybe go up to 70 and let it pace about all the time. It was set at 80 at surgery and just lowered last week. Don’t like feeling these palpitations all the time. Rarely feel them at night when I am sure it is pacing all the time.

Leave a Reply

Your email address will not be published. Required fields are marked *