Approach Considerations
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.
Consultation with an electrophysiologist determines the possible need for additional pacemaker lead placement and the care related to the pacemaker and for procedures to aid in diagnosis and treatment of pacemaker syndrome.
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.
Medical Care
For ventricularly paced patients, addition of an atrial lead and institution of AV synchronous pacing usually resolves symptoms.
In patients with other pacing modes, symptoms usually resolve after interrogation and reprogramming of pacemaker parameters, such as AV delay, postventricular atrial refractory period, sensing level, and pacing threshold voltage. In many cases, optimal parameter values may be obtained experimentally with successive reprogramming and measurement of pertinent parameters, such as blood pressure, cardiac output (see the Cardiac Output calculator), and total peripheral resistance, as well as observations of symptomatology.
In rare instances, using hysteresis to help maintain AV synchrony can help alleviate symptoms in patients with VVI pacemakers and intact sinus node function. For example, if pacing rate is 60 beats per minute (bpm), the hysteresis rate can be programmed to be 50 bpm; in this way, pacing is not instituted until the native ventricular rate falls below 50 bpm, but when pacing is instituted, the pacemaker rate is 60 bpm. Hysteresis effects a reduction in the amount of time spent in pacing mode, which can alleviate symptoms, particularly when the pacing mode, such as VVI, is generating AV dyssynchrony.
Additional treatment modalities include replacing the pacemaker pulse generator and revision of medication regimen.
Medical care includes supportive care in relation to possible heart failure, hypotension, tachycardia, tachypnea, and oxygenation deficit.
Diet and Activity
A low-salt diet is indicated for patients with heart failure.
For patients with autonomic insufficiency, a high-salt diet may be appropriate.
For patients with dehydration, oral fluid rehydration is needed.
Patients may engage in activities as tolerated.
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 the time of device implantation, optimize pacing parameters, such as AV delay, PVARP, and rate response slope, for physiologic timing of atrial and ventricular contractions.
Long-Term Monitoring
Schedule follow-up visits after device or lead implantation as follows:
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1-2 weeks for wound check
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1 month for pacemaker interrogation
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3 months for pacemaker interrogation
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Every 6 months thereafter for pacemaker interrogation
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Pacemaker Syndrome. Pacemaker syndrome without pacemaker participation. Displayed are stored data from a dual-chamber pacemaker. The intracardiac tracings reveal atrial tachycardia with second-degree AV block that together created continuous atrioventricular (AV) dyssynchrony, leading to symptoms of pacemaker syndrome, including fatigue, lightheadedness, and exertional dyspnea. Notice that the pacemaker does not participate in creation of AV dyssynchrony. There are no paced events. Top tracing: atrial electrogram. Middle tracing: ventricular electrogram. Bottom tracing: channel markers. Ab = atrial sensed event in postventricular blanking period, AR = atrial sensed event in postventricular refractory period; VS – Ventricular sensed event.
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Pacemaker Syndrome. Pronounced PR interval prolongation. The effect of this PR interval prolongation on AV dyssynchrony is demonstrated in this ECG image.
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Pacemaker Syndrome. 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.
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Pacemaker Syndrome. Accelerated idioventricular rhythm with retrogradely conducted P waves. This ECG demonstrates a mechanism of AV dyssynchrony that might lead to pseudopacemaker syndrome.
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Pacemaker 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.
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Pacemaker Syndrome. Retrogradely conducted P waves are visible directly following each ventricular-paced complex.
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Pacemaker Syndrome. 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).
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Pacemaker Syndrome. 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).
Tables
Study |
Patients (number) |
Total Incidence (%) |
Follow-up (years) |
Annual Incidence (%) |
||||
|
|
VVI |
AAI |
DDD |
|
VVI |
AAI |
DDD |
Frielingsdorf [34] |
1838 |
18-47 |
0-17* |
3.75 |
4.8-12.5 |
0-4.5* |
||
Sutton and Kenny [35] |
1061 |
22 |
3.9 |
|
AAI: 2.75 VVI: 3.25 |
6.77 |
1.42 |
|
Hesselson [36] |
8827 |
14-57 |
0-23 |
|
AAI: 1-8 VVI: 3-8 |
Cannot be determined |
||
Hesselson [36] |
950 |
38 |
7 |
|
7 |
5.43 |
1.00 |
|
Santini [37] |
339 |
48 |
3.7 |
13 |
5 |
9.6 |
0.74 |
2.6 |
Sasaki [38] |
75 |
41 |
2* |
AAI: 3.25 VVI: 5.17 |
7.9 |
0.62* |
||
Rosenqvist [39] |
168 |
47 |
6.7 |
|
4 |
11.8 |
1.68 |
|
*Combined AAI and DDD |
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