eMedicine Specialties > Cardiology > Electrophysiology Procedures

Pacemaker Malfunction: Differential Diagnoses & Workup

Author: Chakri Yarlagadda, MD, FACC, FASNC, Consulting Cardiologist, St Elizabeth Hospital, Youngstown, OH
Contributor Information and Disclosures

Updated: Feb 18, 2009

Differential Diagnoses

Sudden Cardiac Death
Syncope

Other Problems to Be Considered

Pseudomalfunction

In pseudomalfunction of the pacemaker, although an apparent pacing system malfunction is suggested clinically, the apparent malfunction is a normal programmed pacer function. This is partly due to new algorithms to preserve intrinsic conduction and more physiologic pacing.

Examples of pseudomalfunction include the following:

  • Functional undersense with magnet application, safety pacing, triggered mode, fusion and pseudofusion beats, and blanking period
  • Functional oversense with short ventricular blanking period
  • Inappropriate rate with rate hysteresis, rate-drop response, rate smoothing, rate-responsive mode, programmed rest/sleep rate, and mode switch
  • Inappropriate mode with magnet application and mode switch

Manufacturers' advisories: Manufacturer recall or advisories due to unanticipated device malfunction after its release may require replacement of pulse generator, lead, or both. A decision analysis model by Amin et al warrant device replacement in pacemaker-dependent patients if a manufacturer advisory device failure rate is >0.3%.4

Workup

Laboratory Studies

  • Creatine kinase (CK) and isoenzymes - Elevated in myocardial injury and cardiac trauma
  • Coagulation panel - Required to prevent bleeding complications during invasive procedures
  • Electrolytes - To exclude electrolyte abnormalities that may affect pacing thresholds
  • Drug levels - For drugs, such as digoxin and antiarrhythmics (particularly flecainide), that may alter pacing thresholds

Imaging Studies

  • Chest radiography: Overpenetrated film helps to evaluate lead position, fracture, and the set-screws. Specific markers on pulse generator are useful for identification.
  • Fluoroscopy: To evaluate common sites of lead fracture such as an area of acute angulation or compression by real-time imaging while applying gentle traction on the lead.
  • Echocardiogram: It has limited use in the diagnosis of pacing system malfunction. Inappropriate lead position (ie, left ventricle, left atrium, or pericardial space), pericardial effusion/tamponade, or lead fracture may be observed on 2-dimensional echocardiogram.
  • Computed tomography: CT of the chest helps to evaluate lead position, especially in patients with suboptimal radiograph and echocardiogram results.

Other Tests

  • Pacemaker interrogation: Evaluation of thresholds, lead impedance, and battery voltage, as well as review of histograms, mode switch episodes, and stored electrograms.
  • Magnet application: After magnet application, pacemaker goes to asynchronous pacing mode at a programmed rate that is unique to that model. This is helpful in the diagnosis of loss of capture and battery depletion.
  • 12-lead electrocardiogram: This simple bedside test is useful to diagnose undersensing, oversensing, and capture loss. 
  • Telemetry monitoring: This is useful in early recognition of loss of sensing and capture from lead dislodgement in the immediate postimplant period.
  • Holter monitoring: This 24-48-hour simple test is helpful in the diagnosis of atrial and ventricular arrhythmias and abnormal sensing or capture. Sometimes an event monitoring may be required to diagnose intermittent pacemaker dysfunction.
  • Transtelephonic monitoring: Periodic transtelephonic monitoring is very useful in early recognition of battery depletion based on the magnet rate, which is unique to each pacemaker model.

Procedures

  • Fluoroscopy is useful to evaluate lead fracture, especially during provocative maneuvers.

More on Pacemaker Malfunction

Overview: Pacemaker Malfunction
Differential Diagnoses & Workup: Pacemaker Malfunction
Treatment & Medication: Pacemaker Malfunction
Follow-up: Pacemaker Malfunction
Multimedia: Pacemaker Malfunction
References
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References

  1. Maisel WH, Moynahan M, Zuckerman BD, Gross TP, Tovar OH, Tillman DB. Pacemaker and ICD generator malfunctions: analysis of Food and Drug Administration annual reports. JAMA. Apr 26 2006;295(16):1901-6. [Medline].

  2. Maisel WH. Pacemaker and ICD generator reliability: meta-analysis of device registries. JAMA. Apr 26 2006;295(16):1929-34. [Medline].

  3. Hauser RG, Hayes DL, Kallinen LM, Cannom DS, Epstein AE, Almquist AK, et al. Clinical experience with pacemaker pulse generators and transvenous leads: an 8-year prospective multicenter study. Heart Rhythm. Feb 2007;4(2):154-60. [Medline].

  4. Amin MS, Matchar DB, Wood MA, Ellenbogen KA. Management of recalled pacemakers and implantable cardioverter-defibrillators: a decision analysis model. JAMA. Jul 26 2006;296(4):412-20. [Medline].

  5. Erickson S, Sweesy M, Forney R. Complications and Corrections in Pacing systems. Pacing Clin Electrophysiol. 1995;18:99-1004.

  6. Földesi C, Hegedüs Z, Simon J, Pap I, Rudas L. [Pacemaker syndrome without a pacemaker]. Orv Hetil. Aug 30 1998;139(35):2081-2. [Medline].

  7. Goldman DS, Levine PA. Pacemaker-mediated polymorphic ventricular tachycardia. Pacing Clin Electrophysiol. Oct 1998;21(10):1993-5. [Medline].

  8. Heldman D, Mulvihill D, Nguyen H, Messenger JC, Rylaarsdam A, Evans K. True incidence of pacemaker syndrome. Pacing Clin Electrophysiol. Dec 1990;13(12 Pt 2):1742-50. [Medline].

  9. Levine PA, Love CJ. Pacemaker diagnostics and evaluation of pacing system malfunction. In: Clinical Cardiac Pacing and Defibrillation. 2nd ed. Philadelphia, Pa: WB Saunders; 2000:827-875.

  10. Pinski SL, Trohman RG. Interference with cardiac pacing. Cardiol Clin. Feb 2000;18(1):219-39, x. [Medline].

  11. Sweesy MW, Holland JL. Pseudomalfunction. In: Cardiac Device and Basic EP-Self Assessment. Simpsonville, SC: Cardiac Device Consultants, Inc; 2000:60-86.

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Further Reading

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Keywords

pacemaker malfunction, pacing system malfunction, heart pacing malfunction, pacemaker complication, pacemaker syndrome, pacemaker-mediated tachycardia, twiddler's syndrome, cardiac pacing, heart pacing, broken pacemaker, failed pacemaker, malfunctioning pacemaker, runaway pacemaker

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Contributor Information and Disclosures

Author

Chakri Yarlagadda, MD, FACC, FASNC, Consulting Cardiologist, St Elizabeth Hospital, Youngstown, OH
Chakri Yarlagadda, MD, FACC, FASNC is a member of the following medical societies: American College of Cardiology, American Society of Echocardiography, American Society of Nuclear Cardiology, and Heart Rhythm Society
Disclosure: Nothing to disclose.

Medical Editor

Hanumant Deshmukh, MD †, Former Chief of Cardiology, Veterans Affairs Medical Center; Former Associate Professor, Department of Medicine, Rosalind Franklin University of Medicine and Science
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Brian Olshansky, MD, Professor of Medicine, Department of Internal Medicine, University of Iowa College of Medicine
Brian Olshansky, MD is a member of the following medical societies: American Autonomic Society, American College of Cardiology, American College of Chest Physicians, American College of Physicians, American College of Sports Medicine, American Federation for Clinical Research, American Heart Association, Cardiac Electrophysiology Society, Heart Rhythm Society, and New York Academy of Sciences
Disclosure: Guidant/Boston Scientific Honoraria Speaking and teaching; Medtronic Honoraria Speaking and teaching; Guidant/Boston Scientific Consulting fee Consulting; Reliant Grant/research funds Other; Novartis Honoraria Speaking and teaching; Novartis Consulting fee Consulting

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

J Paul Mounsey, MD, PhD, MRCP, Professor of Medicine, Director, Cardiac Electrophysiology Service, Division of Cardiology, University of North Carolina at Chapel Hill School of Medicine
J Paul Mounsey, MD, PhD, MRCP is a member of the following medical societies: American College of Cardiology, American Heart Association, Heart Rhythm Society, and Royal College of Physicians of the United Kingdom
Disclosure: Medtronic Honoraria Speaking and teaching; St Jude Honoraria Speaking and teaching; Boston Scientific Honoraria Speaking and teaching

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