Pacemaker Malfunction Workup
- Author: Chakri Yarlagadda, MD, FACC, FASNC, FSCAI; Chief Editor: Jeffrey N Rottman, MD more...
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.
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].
Maisel WH. Pacemaker and ICD generator reliability: meta-analysis of device registries. JAMA. Apr 26 2006;295(16):1929-34. [Medline].
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].
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].
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].
Erickson S, Sweesy M, Forney R. Complications and Corrections in Pacing systems. Pacing Clin Electrophysiol. 1995;18:99-1004.
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].
Goldman DS, Levine PA. Pacemaker-mediated polymorphic ventricular tachycardia. Pacing Clin Electrophysiol. Oct 1998;21(10):1993-5. [Medline].
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].
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.
Pinski SL, Trohman RG. Interference with cardiac pacing. Cardiol Clin. Feb 2000;18(1):219-39, x. [Medline].
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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