Medical Care
Medical therapy has a limited role in pacemaker malfunction. In case of abnormal thresholds, correct electrolyte and metabolic abnormalities (eg, hypokalemia, hyperkalemia, or hypomagnesemia), and adjust medication doses or withhold the medication as needed. Also, note the following:
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Apply transcutaneous pacing pads if external pacing is necessary
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Administer intravenous fluids and inotropic support if symptomatic hypotension
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Reprogram the pulse generator based on underlying pacing malfunction
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Any sign of hemodynamic instability should prompt intensive care and close monitoring
Additional inpatient care may include the following:
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Device interrogation
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Chest radiography for lead position and any complications such as pneumothorax
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Wound care after pulse generator change or lead implant
Activity
To minimize risk of lead dislodgment, advise patients not to raise the ipsilateral arm over and above the shoulder for approximately 2 weeks after implantation of the lead.
Consultations
Consider consultations with the following specialists:
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Cardiologist and/or electrophysiologist, to reprogram the pacemaker to prevent, eliminate, or minimize the pacing system malfunction; for pulse generator change or lead insertion or extraction
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Cardiovascular surgeon, if thoracotomy is needed
Surgical Care
Surgical care depends on underlying cause for pacing malfunction. Note the following:
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Exploration of pacemaker pocket, lead, connectors, and set-screws
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Repair, reposition, extraction, or replacement of lead
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Removal of air from dry-pocket
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Upgrading single chamber to dual chamber generator in pacemaker syndrome
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Tightening of loose set-screws
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Replacement of pulse generator
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Uncoiling the lead, new lead implant, or repositioning of the pulse generator in twiddler syndrome
In 2013, the American College of Cardiology Foundation/American Heart Association and the Heart Rhythm Society jointly issued guidelines for device-based therapy of cardiac rhythm abnormalities. [12]
In the multicenter European Heart Rhythm Association survey which used a questionnaire to evaluate management strategies for malfunctioning and recalled pacemaker and defibrillator leads across Europe, investigators found 85% of responding centers performed lead extraction. [13] Primary factors in decision making were the patient's age, the presence of damaged leads, and the lead dwelling time.
In a study that retrospectively reviewed the outcomes of the transvenous extraction of superfluous leads of cardiovascular implantable electronic devices, Huang et al found that this procedure is highly successful. They reviewed transvenous lead extraction procedures performed at the Mayo Clinic, including 123 procedures to remove 167 superfluous functional or nonfunctional leads. The procedural complete-success rate for the removal of superfluous leads was 97%. [14]
Long-Term Monitoring
Most cases of pacemaker malfunction require only follow-up device interrogation and chest radiography. Encourage patients to regularly follow-up with their cardiologist and/or electrophysiologist for device monitoring. If applicable, patients should participate in remote-device monitoring in set time intervals.
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Pacemaker Malfunction. Atrial undersensing. The rhythm strip shows an atrial pacing artifact after the intrinsic P wave.
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Pacemaker Malfunction. Ventricular undersensing. The rhythm strip shows ventricular pacing artifacts despite normal underlying ventricular activity.
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Pacemaker Malfunction. Atrial lead dislodgment. The chest radiograph film detail shows a dislodged atrial lead with the tip in the right ventricular cavity.
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Pacemaker Malfunction. Ventricular noncapture. The rhythm strip shows atrial (P wave) sensing followed by a ventricular spike, which failed to capture the ventricle.
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Pacemaker Malfunction. Loss of atrial capture. The rhythm strip shows intermittent loss of atrial capture.
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Pacemaker Malfunction. Pacemaker-mediated tachycardia. The rhythm strip shows ventricular pacing at 110 beats per minute (programmed maximal track rate).
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Pacemaker Malfunction. Termination of pacemaker-mediated tachycardia (PMT). Automatic postventricular atrial refractory period (PVARP) extension terminated the PMT.
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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.
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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.
