Editing Pacemaker (section)

=== Insertion ===
A pacemaker may be implanted whilst a person is awake using [[local anesthetic]] to numb the skin with or without [[sedation]], or asleep using a [[general anesthetic]].<ref name=":1">{{Cite book|last=Ramsdale, David R.|title=Cardiac pacing and device therapy|date=2012|publisher=Springer|others=Rao, Archana.|isbn=978-1-4471-2939-4|location=London|oclc=822576869}}</ref> An antibiotic is usually given to reduce the risk of infection.<ref name=":1" />  Pacemakers are generally implanted in the front of the chest in the region of the left or right shoulder.  The skin is prepared by clipping or shaving any hair over the implant site before cleaning the skin with a disinfectant such as [[chlorhexidine]].  An incision is made below the collar bone and a space or pocket is created under the skin to house the pacemaker generator.  This pocket is usually created just above the [[pectoralis major]] muscle (prepectoral), but in some cases the device may be inserted beneath the muscle (submuscular).<ref>{{cite journal |last1=Pena |first1=Rafael E. |last2=Shepard |first2=Richard K. |last3=Ellenbogen |first3=Kenneth A. |title=How to Make a Submuscular Pocket |journal=Journal of Cardiovascular Electrophysiology |date=December 2006 |volume=17 |issue=12 |pages=1381–83 |doi=10.1111/j.1540-8167.2006.00665.x |pmid=17081202 |s2cid=38032736 |doi-access=free }}</ref> The [[Lead (electronics)|lead or leads]] are fed into the heart through a large vein guided by X-ray imaging ([[fluoroscope|fluoroscopy]]). The tips of the leads may be positioned within the [[Ventricle (heart)|right ventricle]], the [[Atrium (heart)|right atrium]], or the coronary sinus, depending on the type of pacemaker required.<ref name=":1" /> Surgery is typically completed within 30 to 90 minutes.  Following implantation, the surgical wound should be kept clean and dry until it has healed.  Some movements of the shoulder within a few weeks of insertion carry a risk of dislodging the pacemaker leads.<ref name=":1" />

The batteries within a pacemaker generator typically last 5 to 10 years. When the batteries are nearing the end of life, the generator is replaced in a procedure that is usually simpler than a new implant. Replacement involves making an incision to remove the existing device, disconnecting the leads from the old device and reconnecting them to a new generator, reinserting the new device and closing the skin.<ref name=":1" />

==== Periodic pacemaker checkups ====
[[File:PaceMakerRemoteMonitoringDevicesTwoKinds.jpg|thumb|Two types of remote monitoring devices used by pacemaker patients]]
Once the pacemaker is implanted, it is periodically checked to ensure the device is operational and performing appropriately; the device can be checked as often as is deemed necessary. Routine pacemaker checks are typically done in-office every six months, though will vary depending upon patient/device status and remote monitoring availability. Newer pacemaker models can also be interrogated remotely, with the patient transmitting their pacemaker data using a transmitter at home connected to a cellular telephone network.

During in-office follow-up, diagnostic tests may include:
* Sensing: the ability of the device to "see" intrinsic cardiac activity (atrial and ventricular depolarization).
* Impedance: A test to measure lead integrity. Large and/or sudden increases in impedance can indicate a lead fracture, while large and/or sudden decreases in impedance can be caused by insulation failure.
* Threshold amplitude: The minimum voltage (generally in hundredths of volts) required in order to pace the atrium or ventricle connected to the lead.
* Threshold duration: The time that the device requires at the preset amplitude to reliably pace the atrium or ventricle connected to the lead.
* Percentage of pacing: The percentage of time that the pacemaker has been actively pacing since the previous device interrogation, which shows how dependent the patient is on the device.
* Estimated battery life at current rate: As modern pacemakers are "on-demand" and only pace when necessary, battery lifespan is affected by how much the pacemaker is utilized. Other factors affecting battery life include programmed output and algorithms (features) that use battery power.
* Any events that were stored since the last follow-up, in particular [[arrhythmias]] such as [[atrial fibrillation]]. These are typically stored based on specific criteria set by the physician and specific to the patient. Some devices have the availability to display intracardiac electrograms showing the onset of an event as well as the event itself, which helps to diagnose its cause or origin.