Since heart pacemakers were developed in the 1950s, they have become smaller, safer and the go-to solution for many patients with life-threatening heart problems.
Dr. George Waits IV
"It doesn't fix everything in the heart, but certain patients who have dangerously slow heart rates can benefit from a pacemaker implant," said Dr. George Waits IV, a heart specialist at Novant Health Cardiology - Kimel Park Main in Winston-Salem.
More than 3 million people worldwide have one, and an estimated 600,000 are implanted each year, according to the American Heart Association.
Waits recently described how the battery-operated devices work, dispelled some common myths about them and discussed a revolutionary in-the-heart device he recently deployed for the first time at Novant Health Forsyth Medical Center.
Pacemakers are battery-powered devices that sense a patient's heart activity and activate as needed to reach a targeted number of beats per minute. In other words, they let the patient's own heart do what it is able to and step in as needed to maintain the desired pace, so the body gets the blood and oxygen it needs. Some people require an assist all the time, others rarely.
Who needs a pacemaker?
Traditionally, doctors recommended them for patients with fewer than 60 beats per minute at rest and symptoms like dizziness, fainting, shortness of breath and fatigue. But that's begun to change, according to Waits. "What we've learned in the era of smartwatches and continuous monitoring is that frequently the patient's heart rate can go even slower," he said. "But it must be coupled with symptoms to require a pacemaker."
How pacemakers work
Think of pacemakers as tiny computers, equipped with circuit boards, a battery and a series of timers, Waits said. Traditional ones are implanted through an incision below the shoulder. One to three wires are then threaded through a vein into the heart's chambers and connected to a battery-equipped pulse generator. About the size of a matchbox, the generator sits in a pocket between the skin and the muscle, going to work as needed to control heart rates. Replacing the battery, like the initial implant surgery, is typically an outpatient procedure.
Early pacemakers could be disrupted by microwave ovens, TV remote controls, hair dryers and even electric blankets, but those no longer pose problems, Waits said. Patients won't have trouble with airport scanners either — and each receives an ID card to show security, if needed.
But patients should be aware that pacemakers may have to be reprogrammed before and after magnetic resonance imaging (MRI), and earbuds and cell phones should be kept away from them. (Use the phone on the opposite side of the body or rely on speaker, doctors advise.)
What's new with pacemakers
Some state-of-the-art pacemakers may be placed inside the heart itself. Waits was recently certified to implant such a device, the Aveir leadless pacemaker. His first patient to receive one was operated on in November 2024.
Smaller than a AAA battery, Aveir is threaded into the heart through a small tube (catheter) inserted through a vein in the thigh. "No incisions are required," Waits said. Instead of wires and a transmitter, Aveir relies on negative and positive electrical charges in blood cells to communicate. It can be implanted in either chamber of the heart — or in both.
Waits said it’s ideal for patients who are at risk of infection in the pocket where a traditional pacemaker is placed as well as for those with end-stage kidney failure who must avoid compromising any veins. For patients with certain occupational challenges — for example, painters whose work requires them to lift their arm above their head — it's a quicker path back to work. With most traditional pacemakers, they are advised to keep their arm below chest-level for six months.
Waits predicts some patients will choose the new device for cosmetic benefits — there's no scar and no bulging pulse generator in the chest. And the risk of complications is low, less than 1%. The device, made by Abbott, was approved in 2023 by the U.S. Food and Drug Administration.
"I don't see it as replacing the traditional system, but I do see it as having a role," he said.
After pacemaker surgery
After getting a pacemaker, it's important to make sure it's working as intended. Some patients use a smartphone app to keep tabs on their battery levels. All are monitored remotely by the doctor’s staff, and regular follow-up visits are a must — at one week, six weeks and three months after surgery, then yearly.
On average, the devices will help the heart pump as nature intended it to for eight to 10 years — and then, the battery or the device itself, can be replaced.
Meet Dr. George Waits IV
When he was 10 years old, his father had a heart attack, and George Waits IV saw healing in action. He didn't understand all the treatments doctors were providing, but he appreciated that they kept his dad alive and helped him return to their shared joy — making music together.
"That was an impactful part of my childhood, and I was always fascinated with electronics and devices," Waits said. While studying engineering at the University of Alabama in Birmingham, he discovered a lab linked to the medical school that studied cardiac electrophysiology — electrical activity in the heart. After taking part in studies using pig hearts, his career path was set.
"I just developed a real fascination for the heart system, and realized I enjoyed taking care of people more than being in a lab, isolated with the pigs," he recalled.
After a residency at Wake Forest University School of Medicine and fellowships at Houston Methodist-Texas Medical Center and Medical University of South Carolina, he joined the Novant Health team in September.
His mission is personal: "I want to help more dads return to being dads, playing music and enjoying their kids," he said.
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