January 2007 ■ EMN 11
Cases in Diagnosis: Pacemaker Failure to Capture
Electrocardiography
By Theodore Chan, MD,
William Brady, MD, &
Richard Harrigan, MD
T he 12-lead ECG demonstrates atrial
fibrillation with a narrow QRS com-
plex rhythm at a rate of 55 beats/minute
with intermittent irregularity. More
importantly, there are small pacer spikes
seen throughout the 12-lead ECG that
have no clear or consistent association
with the QRS complexes. (Fig. 2: circles.)
This finding, along with the fact that her
rate is bradycardic and below most pro-
grammed pacing thresholds is consistent
with pacemaker failure to capture.
Implantable cardiac pacemakers
were first used to prevent Adams-Stokes
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attacks. Since then, indications for pace-
makers have grown remarkably and now
include atrioventricular (AV) node and
sinus node dysfunction, hypersensitive
carotid sinus syndrome and neurally-
mediated syncope (vasovagal syncope),
prevention of tachycardia with long QT
syndrome, hypertrophic cardiomyopa-
thy, certain cases of congestive heart fail-
ure, and prevention of atrial fibrillation.
(Circulation 1998;97:1325.) Advances in
technology, expanding indications, and
the aging population ensure that EPs will
encounter more patients with cardiac
pacemakers on a regular basis.
A five-position code has been devel-
oped to describe pacemakers. (Pacing
Clin Electrophysiol 1993;16:1776.) Posi-
tion I indicates the chambers being
paced, atrium (A), ventricle (V), both (D,
dual), or none (0). Position II gives the
location where the pacemaker senses
native cardiac electrical activity (A, V, D,
or O). Position III indicates the pacemak-
er’s response to sensing: triggering (T),
inhibition (I), both (D), or none (O). Posi-
tion IV indicates the programmability of
the pacemaker and the capability to adap-
tively control rate; position V identifies
the presence of antitachydysrhythmia
functions. Pacemakers are commonly
classified to the first three position codes.
Most patients will have a card in their
wallet identifying the make and model of
pacemaker. Manufacturers also place an
identification number in the generator
that is sometimes visible on chest x-ray.
The most commonly encountered
pacer is the DDD pacemaker, where
both the atria and the ventricles are
sensed and either paced or inhibited
depending on the native cardiac activity
sensed. VVI pacing is useful in those
with chronically ineffective atria, such
as chronic atrial fibrillation or atrial flut-
ter. In this mode, the ventricle is sensed
and paced. If the native ventricular activ-
ity is sensed, then pacing is inhibited.
Because the ventricular pacing lead is
placed in the right ventricle, the ventricles
depolarize from right to left rather than by
the regular conduction system, producing
an overall QRS morphology similar to a left
bundle branch block with QRS interval
prolongation (occasionally, intracardiac
pacemaker leads may be placed over the
Continued from p. 8
Figure 2. Initial 12-lead ECG. Note the low amplitude pacing spikes (circles) with no consistent capture or association with
ventricular activity.
to slow the rate with carotid massage or
adenosine can be helpful, but should be
performed with extreme caution in the
pacemaker patient. Finally, if routine
evaluation yields no abnormalities, the
pacemaker should be interrogated.
The cause of this patient’s pacemaker
malfunction and failure to capture were
seen on the chest radiograph, which
demonstrated a fracture in the pacing
wire. (Fig. 3: circle.) This wire fracture not
only caused the failure to capture, but also
failure to sense native ventricular activity
as well as some aspect of failure to pace
with low amplitude pacer spikes. The
patient was admitted to the electrophysi-
ology service, at which time the fractured
right ventricular pacing lead as well as
Figure 3. Chest radiograph demonstrating implantable pacemaker with fractured
pacemaker generator were replaced. After
lead (circle).
left ventricle, resulting in a right
bundle branch block pattern).
(Emerg Med Clinics NA
2006;24[1]:179.) Because of the
abnormal ventricular depolariza-
tion seen in paced rhythms,
repolarization also occurs abnor-
mally, and ST segments and T
waves should typically be discor-
dant with the QRS complex.
(Acad Emerg Med 1998;5:52.)
Pacemaker malfunction
includes failure to pace, failure
to capture, undersensing, and Figure 4. Repeat 12-lead ECG after replacement of fractured pacing wire and generator. Note
pacemaker-mediated dysrhyth- the higher amplitude ventricular pacing spikes. There is sensing of native ventricular activity
mias. Failure to pace occurs (thin arrow), as well as normal pacing with good ventricular capture (wide arrow).
when the pacemaker does not
fire when pacing should occur. On the a pacemaker fails to sense or detect native the procedure, the patient’s symptoms
ECG, there are no visible pacing spikes cardiac activity. Pacing spikes will be seen resolved. A follow-up12-lead ECG demon-
where they should have occurred. Caus- when none should occur. strates normal ventricular pacing. (Fig. 4.)
es include oversensing, pacing lead Patients with pacemaker malfunction
problems (dislodgement or fracture), often have vague and nonspecific symp- Dr. Chan is a professor of clinical med-
battery or component failure, and elec- toms. Beyond the 12-lead ECG, cautious icine and the medical director of emer-
tromagnetic interference. use of a magnet can assist in evaluating gency medicine at the University of
Failure to capture occurs when a pac- pacer function. For example, if there is California, San Diego School of Medi-
ing stimulus is generated, but fails to trig- no pacemaker activity on the ECG, plac- cine. Dr. Harrigan is an associate pro-
ger myocardial depolarization. On the ing a magnet over the pacer will switch fessor of emergency medicine at Temple
ECG, failure to capture is identified by the the pacemaker to asynchronous pacing University School of Medicine in
presence of pacing spikes without associ- and allow for assessment of capture. Philadelphia. Dr. Brady is a professor
ated myocardial depolarization. Causes Appropriate experience with this diag- of emergency medicine and internal
include pacing lead problems, battery or nostic approach is urged prior to its use, medicine and the vice chairman of
component failure, low pacing voltage or however. Similarly, if the patient’s native emergency medicine at the University
elevated myocardial pacing thresholds, cardiac rhythm is above the lower rate of Virginia School of Medicine in
and exit block. Undersensing occurs when threshold for pacing, cautious attempts Charlottesville.