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When Should You Consider a Pacemaker?

A permanent pacemaker is a heart rhythm device implanted through a minor surgery.

You're usually a candidate for a pacemaker if you have an abnormally slow heart rate with symptoms of fatigue, shortness of breath, lightheadedness or passing out.

Could a pacemaker help you better cope with a heart rhythm condition?

Learn more from Dr. Mike Mangrum, a UVA specialist in heart rhythm disorders.
When Should You Consider a Pacemaker?
Featured Speaker:
Mike Mangrum, MD
Dr. Mike Mangrum is board-certified in internal medicine, cardiovascular disease and cardiac electrophysiology; he specializes in treatments for heart rhythm disorders.

Learn more about Dr. Mike Mangrum

Learn more about UVA Heart Rhythm Disorders

Melanie Cole (Host):  Doctors recommend pacemakers for many reasons. Could a pacemaker better help you cope with a heart rhythm condition? My guest today is Dr. Mike Mangrum. He’s board certified in internal medicine, cardiovascular disease and cardiac electrophysiology at the UVA Health System. Welcome to the show, Dr. Mangrum. Tell us, what is a pacemaker? People don’t always understand what this even is intended to do.

Dr. Mike Mangrum (Guest):  Yes. Well, a pacemaker is a small device that emits a low-energy electric pulse that prompts the heart to beat. Now, to fully understand what it does, you have to sort of step back and have a better understanding of the heart’s electrical system and I’ll describe that briefly. The heart has 4 chambers to it. It has the two upper chambers which are called the “atria” and the two bottom chambers are called the “ventricle.” The heartbeat actually starts in the upper chambers—the right atrium—in an area called the “sinus node.” The electrical pulse, normally, is emitted from that. It’s conducted to the middle part of the heart called the “AV node” and then down to the ventricles. So, when that happens normally, you get a nice, normal heartbeat; but, what an electrical pacemaker does is that it takes over those particular functions of the heart in which the patient may have either a slow heart rate or there’s a problem with the conduction of their electrical system.

Melanie:  Okay. What a great explanation. That was fantastic. And, to think of the heart as an electrical pump really is a great way to think about it. So, what types of conditions—because when someone has something like “atrial fibrillation,” and they hear all these things--when is a pacemaker generally indicated?

Dr. Mangrum:  Well, that’s a great question and how I would think about it is that a pacemaker is to treat slow heart rates. There are other devices that treat fast heart rates, but a pacemaker is used to treat slow heart rates. When I talked about the different components of the heart’s electrical system, the pacemaker really is indicated for 3 reasons. The first reason is when the electrical impulse fails to trigger. That’s called “sinus node dysfunction.” The second indication is when there is a problem with the conduction from the top to the bottom chambers of the heart and that’s called “AV node” conduction problems or “heart block.” Then, the third indication is actually there is an indication for congestive heart failure when there is, in addition to the congestive heart failure, some conduction problems below that AV node that we spoke about. So, those are really the indications for a pacemaker. It’s sinus node dysfunction, heart block and, in a subcategory, a patient with congestive heart failure that has conduction problems.

Melanie:  Okay. So, if we’re talking about heart block or congestive heart failure, which you hear more and more about it. Dr. Mangrum, with the pacemaker, you insert these. How long do these last? Somebody with congestive heart failure, they confuse that with heart attacks all the time but it’s not. How long does this last? Is this something you live with for a very long time or do you have to change them or just the batteries?

Dr. Mangrum:  Yes. The pacemaker—and I’ll speak about what I would say is about 99% of the pacemakers. The pacemaker has two general components to it. There are the wires that are called “leads” and then, there is the hard part of it which is called a “pulse generator.” The pulse generator is generally implanted underneath the skin below the collar bone. In that pulse generator is the battery and the circuitry for emitting the pulse. The battery lasts, on average, around 7-8 years. Now, there are some patients that it may last 10 or even 15 years. It depends a little bit on the usage of it. What would happen after that period of time is that that area would have to be opened back up underneath the skin and that pulse generator would be removed and another one placed back in there. The wires, or the leads, would be retained in the heart and it’s just a matter of replacing that pulse generator. Now, I said that that represented about 99% of the pacemakers. What I just wanted to mention is that there is an evolving pacemaker called a “leadless pacemaker.” I think, as time goes on, we will see more and more of these but these are implanted by way of a large vessel in the leg and actually inserted into the heart muscle itself and then everything is removed. So, there’s only a very small piece that is implanted inside of the heart that’s about the size of a bullet and that stays inside the heart. In that, it has all the circuitry and battery and everything is in there.

Melanie:  How cool is that? That is absolutely fascinating. So, Dr. Mangrum, let’s bust up a few myths about pacemakers. People have always heard if they have a pacemaker, they can’t use a microwave oven; they can’t use, oh, cell phones; they might set off something at the airport; and, what about exercise and pacemakers? If it’s meant to maintain the pace of the heart, what if your heartbeat goes up because you’re exercising? So, answer some of those questions.

Dr. Mangrum:  For most people, with a pacemaker, you would live your normal life. Most pacemakers that are implanted now are even MRI conditional, meaning that you can have an MRI with your new pacemakers. With the older pacemakers, there may be some issues with that but the new pacemakers now, most of them are what’s called “MRI conditional.” You don’t need to worry about microwave ovens any more. We recommend for cell phone usage to use the opposite hand of where the pacemaker is implanted. Remember I said the pacemaker is usually implanted underneath the collarbone? So, you would use the other hand and try not to store the cell phone in your breast pocket where the pacemaker is. Another common question is going through airports. What you would do is, you would show the security there, before the scan, that you have a pacemaker. The body scans are okay for the pacemakers. The ones that are detecting metal, you would tell the security people that you have a pacemaker and they will search you manually.

Melanie:  That’s so cool. Now, it would seem that pacemakers, because they’re helping that slow pumping of the blood and helping to maintain a good, normal sinus rhythm, do they strengthen the heart, Dr. Mangrum? Do they help in someone, maybe with congestive heart failure, can they actually help to, not necessarily reverse, but maybe help a little bit with the strengthening of some of those nodes?

Dr. Mangrum:  Yes. Yes. If you have conduction problems and congestive heart failure, then there is a special type of the pacemaker—it’s called a “biventricular” pacemaker, or a “CRT” which stands for “cardiac resynchronization therapy.”  It’s a pacemaker that has 3 leads to it. A pacemaker can have 1 lead, 2 leads or 3 leads. In this particular one, you would have 3 leads. In about 70% of patients who have heart failure with this conduction problem--and this conduction problem is called “bundle branch block.” About 70% of those patients will have a significant improvement in their heart function and not only in their heart function, but also in their function in terms of their being able to ambulate, walk around, less shortness of breath and that sort of thing.

Melanie:  In just the last few minutes, Dr. Mangrum—and it’s such really great information and so beautifully put. Why should patients come to UVA for treatment of their heart rhythm disorders? Give your best advice for people that are suffering from these.

Dr. Mangrum:  Well, I’ll tell you. The University of Virginia established the first heart rhythm center in the state of Virginia. This was in 1981. Over the years, UVA has been at the forefront of technologies, both with slow heart rates and with fast heart rates. There is a very comprehensive group of physicians. We have 7 adult electrophysiologists, which are the doctors that really focus on your heart’s electrical system, and one pediatric electrophysiologist. So, I would say we have a lot of experience. Speaking of pacemakers today, we put about 500 pacemakers in per year, for instance. So, we have a large volume. We have a lot of experience and we have access to some of the newer technologies like the leadless pacemakers that are coming out. I think UVA, for those of us who live in central Virginia, I think it’s a great resource for us. Who should consider a pacemaker?  I think if you have slow heart rates and there’s no reversible cause for those slow heart rates, then you may be a candidate for a pacemaker.

Melanie:  Thank you so much for being with us today. You’re listening to UVA Health Systems Radio. For more information, you can go to That’s This is Melanie Cole. Thanks so much for listening.