History and Physical Examination

History

Clinical symptoms of pacemaker malfunction are variable and include syncope, dizziness, palpitations, and slow or fast heart rate. Extracardiac stimulation or hiccup may be present. Obtain as much information as possible regarding the pulse generator, leads, and programmed values. Information on time of initial device placement, indication for pacemaker implant, special programming features particular to that model or patient, any recent surgeries, and knowledge of any manufacturer recalls or alerts on pacing systems may provide clues to the underlying malfunction.

Physical examination

Look for the following signs in patients with pacing system malfunction:

Pocket stimulation
Erosion of pocket
Diaphragmatic stimulation
Cannon A waves during atrioventricular dyssynchrony
Bradycardia
Tachycardia
Hypotension

Differential Diagnoses

Liaquat MT, Ahmed I, Alzahrani T. Pacemaker malfunction. StatPearls [Internet]. 2022 Jan. [QxMD MEDLINE Link]. [Full Text].
Khatiwala RV, Mullins E, Fan D, Srivatsa UN, Dhruva SS, Oesterle A. Electrical abnormalities with St. Jude/Abbott pacing leads: a systematic review and meta-analysis. Heart Rhythm. 2021 Dec. 18 (12):2061-9. [QxMD MEDLINE Link].
Prasitlumkum N, Ding K, Doyle K, Pai RG, Lo R. An unprecedented cause of cardiac resynchronization with defibrillator (CRT-D) malfunction "A beheaded generator assembly". J Cardiovasc Electrophysiol. 2022 Apr. 33 (4):769-72. [QxMD MEDLINE Link].
Sabbagh E, Abdelfattah T, Karim MM, Farah A, Grubb B, Karim S. Causes of failure to capture in pacemakers and implantable cardioverter-defibrillators. J Innov Card Rhythm Manag. 2020 Feb. 11(2):4013-7. [QxMD MEDLINE Link]. [Full Text].
Maisel WH, Moynahan M, Zuckerman BD, et al. Pacemaker and ICD generator malfunctions: analysis of Food and Drug Administration annual reports. JAMA. 2006 Apr 26. 295(16):1901-6. [QxMD MEDLINE Link]. [Full Text].
Maisel WH. Pacemaker and ICD generator reliability: meta-analysis of device registries. JAMA. 2006 Apr 26. 295(16):1929-34. [QxMD MEDLINE Link].
Hauser RG, Hayes DL, Kallinen LM, et al. Clinical experience with pacemaker pulse generators and transvenous leads: an 8-year prospective multicenter study. Heart Rhythm. 2007 Feb. 4(2):154-60. [QxMD MEDLINE Link].
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. 2011 Apr. 32(8):991-8. [QxMD MEDLINE Link]. [Full Text].
Managed ventricular pacing: cardiac device features. Medtronic. February 2017. Available at https://www.medtronic.com/us-en/healthcare-professionals/therapies-procedures/cardiac-rhythm/cardiac-device-features/pacemaker-features/managed-ventricular-pacing.html. Accessed: September 22, 2021.
Amin MS, Matchar DB, Wood MA, Ellenbogen KA. Management of recalled pacemakers and implantable cardioverter-defibrillators: a decision analysis model. JAMA. 2006 Jul 26. 296(4):412-20. [QxMD MEDLINE Link].
Lewis RK, Pokorney SD, Greenfield RA, et al. Preprocedural ECG-gated computed tomography for prevention of complications during lead extraction. Pacing Clin Electrophysiol. 2014 Oct. 37(10):1297-305. [QxMD MEDLINE Link].
[Guideline] Epstein AE, DiMarco JP, Ellenbogen KA, et al. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2013 Jan 22. 61(3):e6-75. [QxMD MEDLINE Link].
Grazia Bongiorni M, Dagres N, Estner H, Pison L, Todd D, Blomstrom-Lundqvist C. Management of malfunctioning and recalled pacemaker and defibrillator leads: results of the European Heart Rhythm Association survey. Europace. 2014 Nov. 16(11):1674-8. [QxMD MEDLINE Link].
Huang XM, Fu H, Osborn MJ, et al. Extraction of superfluous device leads: A comparison with removal of infected leads. Heart Rhythm. 2015 Jun. 12(6):1177-82. [QxMD MEDLINE Link].

Media Gallery

Pacemaker Malfunction. Atrial undersensing. The rhythm strip shows an atrial pacing artifact after the intrinsic P wave.
Pacemaker Malfunction. Ventricular undersensing. The rhythm strip shows ventricular pacing artifacts despite normal underlying ventricular activity.
Pacemaker Malfunction. Atrial lead dislodgment. The chest radiograph film detail shows a dislodged atrial lead with the tip in the right ventricular cavity.
Pacemaker Malfunction. Ventricular noncapture. The rhythm strip shows atrial (P wave) sensing followed by a ventricular spike, which failed to capture the ventricle.
Pacemaker Malfunction. Loss of atrial capture. The rhythm strip shows intermittent loss of atrial capture.
Pacemaker Malfunction. Pacemaker-mediated tachycardia. The rhythm strip shows ventricular pacing at 110 beats per minute (programmed maximal track rate).
Pacemaker Malfunction. Termination of pacemaker-mediated tachycardia (PMT). Automatic postventricular atrial refractory period (PVARP) extension terminated the PMT.
Pacemaker Malfunction. This image shows an artifact due to monitor malfunction or a 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, two QRS complexes are missing during the pause. If the artifact is due to a dislodged lead, a pacing artifact with no capture should be observed.
Pacemaker Malfunction. 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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Author

Priyanka Ghosh, DO Fellow in Cardiovascular Disease, Guthrie Robert Packer Hospital

Priyanka Ghosh, DO is a member of the following medical societies: Alliance for Academic Internal Medicine, American College of Cardiology, American College of Physicians, American Heart Association, Pennsylvania Chapter of American College of Cardiology, Women in Cardiology, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Saurabh Sharma, MD, FACC, FACP, FASE, RPVI Associate Non-Invasive Cardiologist, Director, Cardiovascular Prevention and Lipid Clinic, Program Director, Internal Medicine Residency Program, Guthrie Medical Group, Guthrie Robert Packer Hospital; Clinical Assistant Professor of Cardiology, Geisinger Commonwealth School of Medicine

Saurabh Sharma, MD, FACC, FACP, FASE, RPVI is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Geriatrics Society, American Medical Association, American Society for Preventive Cardiology, National Lipid Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Brian Olshansky, MD, FESC, FAHA, FACC, FHRS Professor Emeritus of Medicine, Department of Internal Medicine, University of Iowa College of Medicine

Brian Olshansky, MD, FESC, FAHA, FACC, FHRS is a member of the following medical societies: American College of Cardiology, American Heart Association, Cardiac Electrophysiology Society, European Society of Cardiology, Heart Rhythm Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Astra Zeneca, Artivion<br/>DSMB.

Chief Editor

Jose M Dizon, MD Professor of Clinical Medicine, Clinical Electrophysiology Laboratory, Division of Cardiology, Columbia University College of Physicians and Surgeons; Attending Physician, Department of Medicine, New York-Presbyterian/Columbia University Medical Center

Jose M Dizon, MD is a member of the following medical societies: American College of Cardiology, Heart Rhythm Society

Disclosure: Nothing to disclose.

Additional Contributors

Chakri Yarlagadda, MD, FACC, FSCAI, FASNC, CCDS Director of Cardiac Rehabilitation, St Elizabeth Youngstown Hospital; Radiation Safety Officer, Mercy Health Cardiology

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

Disclosure: Nothing to disclose.

Acknowledgements

Terry Carle, PAC (Johnson City, Tennessee) for his exemplary teaching during fellowship.