Dual chamber pacing system malfunction: Evaluation and management
- David L Hayes, MD
David L Hayes, MD
- Professor of Medicine
- Mayo Medical School
Periodic evaluations are required to maintain optimal pacemaker programming as well as to identify any system problems. A review of the common pacing system problems of dual chamber pacemakers and the methods of evaluation and therapy are reviewed here. The malfunctions presented will be limited to those that are manifest on the electrocardiogram. Other complications, such as infections, venous thrombosis and emboli, pacemaker syndrome, and tricuspid regurgitation are discussed elsewhere. (See "Infections involving cardiac implantable electronic devices" and "Cardiac implantable electronic devices: Long-term complications", section on 'Tricuspid regurgitation'.)
A more general review of the evaluation and management of single and dual chamber pacemakers and of the modes of cardiac pacing and indications for pacemaker therapy are presented separately. (See "Pacing system malfunction: Evaluation and management" and "Modes of cardiac pacing: Nomenclature and selection" and "Permanent cardiac pacing: Overview of devices and indications".)
PACING SYSTEM COMPONENTS
The pacing system is comprised of the pulse generator (picture 1), also called the pacemaker, and the lead or leads that connect the pulse generator to the heart . Either component may be the source of a clinical malfunction. (See "Permanent cardiac pacing: Overview of devices and indications", section on 'Types of permanent pacemaker systems'.)
The phrase "pacing system malfunction" includes problems that might arise from any of the components of the system. Inappropriately programmed pacemaker parameters, although not representing abnormal pacing system function, may yield suboptimal results for the patient. The normal characteristics and unique timing systems and algorithms of a given pacemaker should be examined, as they may be interpreted as malfunction by a clinician who is unfamiliar with the specific pulse generator. Recording system artifacts must always be considered in the differential diagnosis of a pacing system malfunction.
DUAL CHAMBER PACING MODES
A pacemaker programmed to the DDD mode is capable of pacing and sensing in both the right atrium and right ventricle. Virtually all of the dual-chamber rate-modulated pacing systems can also be programmed to any of the available modes, including DDI, DVI, VDD, and all of the single-chamber modes (table 1). A review of the normal pacing modes is presented in detail separately. (See "Modes of cardiac pacing: Nomenclature and selection".)
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- PACING SYSTEM COMPONENTS
- DUAL CHAMBER PACING MODES
- LIMITING THE MAXIMAL PACED RATE
- Total atrial refractory period
- Maximum tracking rate timer
- Other techniques
- RATE MODULATED (RESPONSIVE) PACEMAKERS
- TRUE DUAL CHAMBER SYSTEM MALFUNCTION
- Loss of atrial capture
- Loss of atrial sensing
- Loss of ventricular capture
- Loss of ventricular sensing
- Ventricular oversensing
- Atrial oversensing
- BIVENTRICULAR PACEMAKERS
- Pacing system components and pacing mode
- CRT malfunction
- - Loss of capture
- - Oversensing
- - Mechanical lead failure
- PACING SYSTEM EVALUATION
- PACEMAKER DIAGNOSTICS
- SUMMARY AND RECOMMENDATIONS