Individuals who require an internal artificial pacemaker to regulate their heartbeat will need to undergo pacemaker surgery to have the device implanted in the body. The procedure is performed under local anesthetic, though patients are generally hospitalized overnight for careful monitoring. Patients are given a mild sedative to keep them calm and relaxed but are otherwise awake and alert throughout the procedure. To insert the pacemaker, the surgeon makes a two to three inch incision just below the patient’s collarbone. An electrode lead is inserted into a nearby vein and slowly advanced towards the heart. A fluoroscope is used to guide the doctor as he advances the lead, providing him with a detailed image of the interior of the vein. Once the lead enters into the heart, it is attached to the tissue so that the positioning of the lead may be tested. To test positioning, the surgeon sends small electrical signals down the lead and evaluates the heart’s response to the impulses. A suitable position is one that allows the full strength of the signal to reach the heart, thereby signaling the heart to contract and beat. It may be necessary to reseat the lead within the vein several times before an ideal position is achieved. Once the lead has been placed and secured in the heart, the generator portion of the pacemaker is implanted under the skin. This small box, measuring just a half an inch long by a half an inch wide, is connected to the electrode lead and inserted though the incision into a small pocket just under the skin. The doctor then sutures the incision closed and hooks the patient up to a heart monitor for observation. The whole procedure, from start to finish, typically takes just one to two hours. Patients should expect to feel mild to moderate pain and tenderness around the incision for several days. Since the generator lies just beneath the surface of the skin, most individuals can clearly feel the outline of the pacemaker once the incision site has healed. Some patients end up with mild scarring or a small deformity of the skin near the generator, due to the fact that it is not seated deep within the body. More serious complications are rare (occurring in just 1-2% of patients) and may include severe bleeding, blood clots, puncturing of the heart or lung, heart attack, stroke, or a pacemaker malfunction. Since pacemaker batteries run from five to ten years, it is necessary to replace the generator every few years to ensure that it is running properly. Routine monitoring of the pacemaker ensures that is it operating as designed until such time that a replacement is needed.