Pacemaker Malfunction Treatment & Management

Updated: Sep 19, 2016
  • Author: Chakri Yarlagadda, MD, FACC, FSCAI, FASNC, CCDS; Chief Editor: Jeffrey N Rottman, MD  more...
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Medical Care

Medical therapy has a limited role in pacemaker malfunction. Note the following:

  • Correction of electrolyte and metabolic abnormalities

  • Apply transcutaneous pacing pads if external pacing is necessary.

  • Intravenous fluids and inotropic support if symptomatic hypotension

  • Adjust the dose or withhold the medication.

  • Pulse generator reprogramming based on underlying pacing malfunction.


Surgical Care

Surgical care depends on underlying cause for pacing malfunction. Note the following:

  • Exploration of pacemaker pocket, lead, connectors, and set-screws

  • Repair, reposition, extraction, or replacement of lead

  • Removal of air from dry-pocket

  • Upgrading single chamber to dual chamber generator in pacemaker syndrome

  • Tightening of loose set-screws

  • Replacement of pulse generator

  • 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. [6]

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. [7] 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%. [8]



Consider consultations with the following:

  • Cardiologist - To reprogram the pacemaker to prevent, eliminate, or minimize the pacing system malfunction; for pulse generator change or lead insertion or extraction

  • Cardiovascular surgeon - If thoracotomy is needed



To minimize risk of lead dislodgement, advise patient not to raise ipsilateral arm over and above the shoulder for approximately 2 weeks after lead implant.