Pacing system malfunction: Evaluation and management
- David L Hayes, MD
David L Hayes, MD
- Professor of Medicine
- Mayo Medical School
Periodic evaluations of an implanted pacemaker are required to maintain optimal programming and to identify any system problem that should be corrected. Common pacing system problems of single and dual chamber pacemakers and the methods of evaluation and therapy will be reviewed here. The malfunctions discussed will be limited to those that are manifest on an ECG rhythm strip.
Complications not related to pacing system malfunction — Other complications not related to pacing are presented separately. These include infections, venous thrombosis and emboli, pacemaker syndrome, tricuspid regurgitation, and specific problems associated with dual-chamber pacemakers. (See "Infections involving cardiac implantable electronic devices" and "Implantable cardioverter-defibrillators: Complications", section on 'Tricuspid regurgitation' and "Dual chamber pacing system malfunction: Evaluation and management".)
The incidence of pacing system malfunction is difficult to determine due to inconsistent definitions and the lack of any comprehensive reporting mechanism or registry [1,2]. Overall, device hardware is highly reliable . In terms of comparative reliability, there is a higher incidence of complications of leads compared with pulse generators. In terms of lead malfunction, more complex ICD leads have a higher incidence of failure than simpler pacemaker leads. As a result of a series of lead malfunctions, a policy was published by Heart Rhythm Society with lead performance guidelines .
PACING SYSTEM COMPONENTS
The pacing system is comprised of the pulse generator (picture 1), also called the pacemaker, and the lead or leads which connect the pulse generator to the heart.
The phrase "pacing system malfunction" includes problems that might arise from any of the components of the system. Inappropriately programmed pacemaker parameters, although they do not represent abnormal pacing system function, may be suboptimal for the patient. The normal characteristics and unique timing systems and algorithms of a given pacemaker are also an issue, as they may be interpreted as a malfunction by a clinician who is not familiar with the specific pulse generator. Recording system artifacts must always be considered in the differential diagnosis of a pacing system malfunction.
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- Complications not related to pacing system malfunction
- PACING SYSTEM COMPONENTS
- PACING STIMULI PRESENT WITH LOSS OF CAPTURE
- Causes of loss of capture
- - Lead dislodgement or malposition
- - Inflammation and fibrosis at the electrode/myocardial interface
- - Increase in capture threshold
- - Sub-threshold pacemaker output programming
- - Lead failure
- - Battery depletion
- - Recording system artifact
- PACING STIMULUS PRESENT WITH FAILURE TO SENSE
- Causes of undersensing
- - Inadequate signal
- - Pacemaker programmed to a value insufficient to sense intrinsic activity
- - Change in native signal
- - Ectopic beats
- - Lead maturation
- - Lead failure
- - Pulse generator failure
- - Environmental electrical fields
- - Magnet application
- - Noise detection
- Management of undersensing
- ELECTROMAGNETIC INTERFERENCE
- Therapeutic radiation
- Therapeutic electrical current
- - External cardioversion/defibrillation
- - Electrocautery
- Magnetic resonance imaging
- Computed tomography
- Extracorporeal shock wave lithotripsy
- PACING STIMULI ABSENT
- - Management
- Open circuit
- Short circuit due to loss of insulation integrity
- - Lead impedance measurements
- - Management
- Recording system artifact
- RECORDING SYSTEM ARTIFACTS
- LEAD EXTRACTION