Pacemaker Malfunction Differential Diagnoses

  • Author: Chakri Yarlagadda, MD, FACC, FASNC, FSCAI; Chief Editor: Jeffrey N Rottman, MD   more...
 
Updated: Sep 7, 2011
 
 

Diagnostic Considerations

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]

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Chakri Yarlagadda, MD, FACC, FASNC, FSCAI  Director of Non-Invasive Cardiology, St Joseph Health Center; Invasive Cardiologist, Ohio Heart Institute

Chakri Yarlagadda, MD, FACC, FASNC, FSCAI is a member of the following medical societies: American College of Cardiology, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, and Society for Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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; Novartis Honoraria Speaking and teaching; Novartis Consulting fee Consulting

Amer Suleman, MD  Private Practice

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

Jeffrey N Rottman, MD  Professor of Medicine and Pharmacology, Vanderbilt University School of Medicine; Chief, Department of Cardiology, Nashville Veterans Affairs Medical Center

Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association and North American Society of Pacing and Electrophysiology (NASPE)

Disclosure: Nothing to disclose.

Additional Contributors

Terry Carle, PAC (Johnson City, Tennessee); Atef S. Labib, MD (Youngstown, Ohio)

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. Johansen JB, Jorgensen OD, Moller M, et al. Infection after pacemaker implantation: infection rates and risk factors associated with infection in a population-based cohort study of 46299 consecutive patients. Eur Heart J. Apr 2011;32(8):991-8. [Medline]. [Full Text].

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

  7. 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].

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

  9. 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].

  10. 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.

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

  12. 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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Atrial undersensing. Rhythm strip showing an atrial pacing artifact after the intrinsic P wave.
Ventricular undersensing. Rhythm strip showing ventricular pacing artifacts despite normal underlying ventricular activity.
Atrial lead dislodgement. Chest radiograph film detail showing dislodged atrial lead with tip in the right ventricular cavity.
Ventricular noncapture. Rhythm strip showing atrial (P wave) sensing followed by ventricular spike, which failed to capture the ventricle.
Loss of atrial capture. Rhythm strip showing intermittent loss of atrial capture.
Pacemaker-mediated tachycardia. Rhythm strip showing ventricular pacing at 110 beats per minute (programmed maximal track rate).
Termination of pacemaker-mediated tachycardia. Automatic postventricular atrial refractory period (PVARP) extension terminated the PMT.
This is an artifact due to monitor malfunction or loose limb lead connection. An abrupt loss of a portion of the QRS complex followed by a flat line can be observed. If R-R intervals are matched, 2 QRS complexes are missing during the pause. If it is due to a dislodged lead, a pacing artifact with no capture should be observed.
This is a typical example of ventricular oversensing with inhibition of ventricular pacing. In ventricular noncapture, a ventricular pacing artifact should be present after the third P wave.
 
 
 
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