Pacemaker Syndrome Follow-up

  • Author: Daniel M Beyerbach, MD, PhD; Chief Editor: Jeffrey N Rottman, MD   more...
 
Updated: Jan 4, 2012
 

Further Inpatient Care

Patients with ventricular pacemakers and pacemaker syndrome may need placement of an additional pacemaker lead. Hospitalize and monitor patients undergoing device or lead implantation for 24 hours after placement surgery.

  • Administer intravenous antibiotics (cefazolin, or vancomycin in patients with beta-lactam allergy) for prophylaxis against skin wound infections.
  • Do not continue intravenous antibiotic therapy for more than 24 hours. If infection develops around the device, it is better detected early in the course in case device explantation is necessary.
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Further Outpatient Care

Schedule visits after device or lead implantation as follows: 1-2 weeks for wound check, 1 month for pacemaker interrogation, 3 months for pacemaker interrogation, and every 6 months thereafter for pacemaker interrogation.

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Transfer

  • Because diagnosis and treatment require interrogation and reprogramming of pacemaker, patients must be seen in either a clinical or hospital setting in which the appropriate interrogation equipment is available. Each pacemaker manufacturer produces an interrogation computer for its own devices. A major institution will have interrogation computers from several different manufacturers available for use.
  • Some pacemaker manufacturers provide courtesy interrogation services involving site visits for rural populations without easy access to functional facilities.
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Deterrence/Prevention

  • Because most cases of pacemaker syndrome occur in the setting of ventricular pacing, institute atrial pacing whenever it is not contraindicated. This includes AAI pacing for most cases of sinus node disease with intact AV nodal conduction. Alternatively, a dual-chamber system can be programmed to a long AV interval to promote intrinsic conduction, provided that the PR interval is not markedly prolonged.
  • Baseline studies by echocardiogram can assess change in cardiac output, stroke volume, and left atrial total emptying fraction in response to ventricular pacing. Examination of these parameters may guide the decision to institute dual-chamber pacing.
  • At time of device implantation, optimize pacing parameters, such as AV delay, PVARP, and rate response slope, for physiologic timing of atrial and ventricular contractions.
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Complications

  • Complications of AV dyssynchrony include atrial fibrillation, thromboembolic events, and heart failure.
  • Pacemaker syndrome also can be complicated by syncope or near syncope. Individuals may develop a subjectively worse quality of life with ventricular pacing than they had prior to pacemaker implantation, or they may endure a persistently degraded quality of life, as suggested by Sulke's study of subclinical pacemaker syndrome.
  • Complications of treatment may include the same complications of pacemaker implantation if reimplantation, additional lead placement, or explantation is involved. These complications include infection (4%), pneumothorax (1%), cardiac perforation and tamponade, bleeding, and pain.
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Prognosis

Prognosis is excellent with correction of pacing mode.

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Patient Education

Educate as in cases of pacemaker implantation in general.

  • Avoid strong electric and magnetic fields. Specifically avoid welding, MRI studies, and proximity to large motors or generators.
  • Use cell phones in ear contralateral to side of device implantation.
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Contributor Information and Disclosures
Author

Daniel M Beyerbach, MD, PhD  Medical Director, Cardiac Rhythm Program, The Christ Hospital; Affiliate Clinical Assistant Professor of Biomedical Science, Florida Atlantic University

Daniel M Beyerbach, MD, PhD is a member of the following medical societies: American College of Cardiology

Disclosure: Nothing to disclose.

Coauthor(s)

Christopher Cadman, MD  Director of Arrhythmia Service, Assistant Professor, Department of Internal Medicine, Division of Cardiology, University of New Mexico

Christopher Cadman, MD is a member of the following medical societies: American College of Cardiology and Phi Beta Kappa

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.

References

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Pronounced PR interval prolongation. The effect of this PR interval prolongation on AV dyssynchrony is demonstrated in this ECG image.
AV dyssynchrony resulting from severe PR interval prolongation in the setting of sinus rhythm. In this ECG, the PR interval is prolonged to the point that the P wave occurs coincident with the peak of the T wave. Compare to the prior image of the same patient with a slower sinus rate.
Accelerated idioventricular rhythm with retrogradely conducted P waves. This ECG demonstrates a mechanism of AV dyssynchrony that might lead to pseudopacemaker syndrome.
Junctional rhythm with retrogradely conducted P waves. If symptoms of pacemaker syndrome develop, increasing the lower rate limit for pacing may help to restore AV synchrony.
Retrogradely conducted P waves are visible directly following each ventricular-paced complex.
This is an ECG tracing of a patient with continuous atrioventricular synchronous (DDD) pacing prior to development of symptoms. Atrial stimulation (open arrows) is followed by visible P waves. Wide QRS complexes follow ventricular stimulation (solid arrows).
This is an ECG tracing of a patient with atrioventricular (AV) dissociation and resultant pacemaker syndrome. Native atrial depolarizations (arrows) move progressively closer to pacemaker-stimulated ventricular depolarizations. Ventricular pacemaker stimuli (arrowheads) are greater in amplitude than those visible in the previous image, consistent with mode reversion from AV synchronous (DDD) to ventricular inhibited (VVI), which includes a switch from bipolar pacing (low amplitude) to unipolar pacing (higher amplitude).
Table. Incidence of Atrial Fibrillation in Patients with Pacemakers
Study Patients



(number)



Total Incidence



(%)



Follow-up



(years)



Annual Incidence



(%)



VVI AAI DDD VVI AAI DDD
Frielingsdorf[25] 1838 18-47 0-17* 3.75 4.8-12.5 0-4.5*
Sutton and Kenny[26] 1061 22 3.9 AAI: 2.75



VVI: 3.25



6.77 1.42
Hesselson[27] 8827 14-57 0-23 AAI: 1-8



VVI: 3-8



Cannot be determined
Hesselson[27] 950 38 7 7 5.43 1.00
Santini[28] 339 48 3.7 13 5 9.6 0.74 2.6
Sasaki[29] 75 41 2* AAI: 3.25



VVI: 5.17



7.9 0.62*
Rosenqvist[30] 168 47 6.7 4 11.8 1.68
*Combined AAI and DDD
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