Pacemaker Malfunction

ECG Signs of Pacemaker

Malfunction

• Failure to output

• Failure to capture

• Undersensing

• Inappropriate pacemaker rate

true malfunctions / pseudomalfunctions

 Failure to Output
• Causes :
– Oversensing
– Battery depletion (% of time pacing is required, thresholds
necessary, single- or dual-chamber pacing, rate-modulation and
other features)
– Circuit failure (Lead fracture, disconnection of lead from the PM)
– Random component failure (rare)

• Pseudomalfunction
– Crosstalk (dual-chamber PM)
– when the monitor system does not display the pacemaker stimulus
artifact when it is really present (frequently with bipolar pacing)
 Oversensing
• Unexpected sensing of an intracardiac or extracardiac signal.

• Intermittent or constant

• Electrical signals that may cause oversensing include myopotentials, T waves, and P
waves.

• Oversensing of myopotentials in a single-chamber PM may result in pauses,

whereas oversensing of myopotentials by the atrial-sensing circuit of a dual-
chamber PM may result in rapid paced rhythms.

• Corrected by reprogramming the sensitivity or by reprogramming the refractory

period of the channel on which oversensing is occurring

• Oversensing of extracardiac events occurs much less commonly with bipolar

sensing.
dual-chamber bipolar PM. Paced ventricular activity is absent after the third
paced atrial beat because of oversensing

PM programmed to unipolar sensing. Sensing of myopotentials led to

symptomatic pauses. Reprogramming the pacemaker to a bipolar sensing
prevented myopotential oversensing
 Cross talk
• Not a true malfunction

• In a dual-chamber PM, the PM stimulus in one chamber is sensed in

the other chamber.

• For the PM-dependent patient, inhibition could result in ventricular

asystole.

• Most PMs have two methods of protection

– Interposition of a short 'blanking period' of refractoriness in the
ventricular channel simultaneous with the atrial output stimulus.
– Ventricular "safety pacing," whereby any event sensed on the
ventricular sensing circuit within a defined early portion of the AV
delay initiates the delivery of a ventricular pacing stimulus.
DDD pacemaker. After the third atrial pacing artifact, there is evidence of
atrial depolarization, but there is no ventricular pacing output. Failure to
deliver the ventricular pacing artifact is due to crosstalk
 Failure to Capture
• Cause :
– Dislodgment of the PM lead from the endocardial surface (usually in the first
few weeks)
– Break in the insulation of the PM catheter allows some of the current from the
electrode to escape into the surrounding tissues.
– Impending battery depletion
– If the pacing threshold required to depolarize the myocardium is greater
than the programmed voltage amplitude and pulse duration (Poor lead position,
exit block etc.)
– Marked metabolic abnormalities, such as hyperkalemia, and some cardioactive
drugs, such as flecainide.

• Pseudomalfunction –
– Inappropriately low voltage-amplitude and pulse-duration settings
– A PM artifact occurring within the myocardial refractory period
Intermittent ventricular failure to capture in a patient with a dual-chamber
pacemaker

DDDR pacemaker. All but one ventricular pacing artifact fail to result in
ventricular depolarization, that is, failure to capture
 Undersensing
• Intermittent or total

• Rarely an urgent problem

• Results in PM output that is undesirably competitive with the intrinsic rhythm.

• Can result in an unwanted rhythm (eg. atrial pacing that competes with NSR may
result in AF).

• Competition in the ventricle is possible but is almost never a problem except when
the fibrillation threshold has been altered by ischemia, electrolyte imbalance, or
some other metabolic abnormality.

• Undersensing can frequently be corrected by reprogramming the sensitivity

• Causes :
– Lead dislodgment
– Poor lead position at the time of implantation
– Interruption in the insulation of the pacing catheter.
– Delivery of a low-amplitude P wave or QRS complex to a normally functioning
pacing system. (eg. concomitant drug therapy, body position, MI, and
cardiomyopathy)

• Pseudomalfunction
– Magnet application
– Environmental electrical noise
– When a P wave or QRS complex falls within the RP of PM
– Monitor artifact

• In dual-chamber PMs, apparent undersensing may occur during the initial portion of
the AV interval (blanking period).
During this interval, the ventricular channel of the pacemaker is refractory to avoid
sensing of the atrial stimulus and depolarization. If an intrinsic ventricular event
occurs during the blanking period, it is not sensed.
This problem can be corrected by shortening the blanking period.
 ventricular PM programmed to 50 bpm. The second and third pacing artifacts
occur inappropriately close to the preceding QRS complex (that is, at less than
1200 ms the programmed rate of the PM)

Functional undersensing. ventricular PM programmed to 70 bpm. There is failure to

capture with the second and third pacing artifacts. The third pacing stimulus occurs 850
ms after the preceding intrinsic QRS (normal sensing). The fourth pacing stimulus
occurs 640 ms after the preceding intrinsic QRS, indicating that the preceding QRS
complex was not sensed because it occurred during the pacemaker's ventricular RP
 Inappropriate Pacing Rates
• Runaway pacemaker
– May be lethal for both PM-dependent and non-dependent patients.
– Pacing rates may be very rapid and cause hemodynamic instability and collapse.
– Result from battery failure, random component failure, or component failure
induced by therapeutic radiation.
– Treatment is disabling the faulty pacemaker output

• Pseudomalfunction
Sensing abnormalities
– Tracking of atrial fibrillatory or flutter waves
– PM re-entrant tachycardia (seen in dual-chamber PMs; occurs when sensing of a
retrograde atrial depolarization initiates ventricular pacing, which in turn leads
to retrograde conduction and repetition of the cycle).

– Electromagnetic interference from the patient's environment may cause the

generator to be reset to a rate different from that programmed.

– Many PMs operate at a slower rate when battery depletion is imminent.

 Pacemaker re-entrant tachycardia with a dual-chamber PM. Atrial
and ventricular pacing stimuli precede the first three paced complexes at
a rate of 80 bpm. A PVC follows the third paced ventricular complex and
is conducted in a retrograde to the atria. The atrial activation is sensed by
the PM and initiates ventricular pacing. The pacing rate is limited to the
programmed upper rate limit of 110 bpm
 Environmental Causes of Pacemaker
Malfunction
• Electrocautery
Causes temporary sensing problems or reprogramming (rarely permanent alteration)

• Transthoracic Defibrillation
– Can cause reversion to back-up mode, transient increases in capture threshold
and loss of capture as well as destruction of the PM generator and circuitry
– Damage is minimized by positioning paddles anteroposteriorly and as far from
the pacemaker or lead as possible (ideally 15cm).

• Extracorporeal Shock-Wave Lithotripsy

– Usually synchronized to the patient's ventricular depolarization or to the output
stimulus of the PM.
– In dual-chamber PMs, synchronization of the lithotriptor with the atrial output
can result in inhibition of ventricular output.
– In patients with an rate-adaptive PM, sensing of the shock waves can result in
increased pacing rates and damage to the piezoelectric crystal.
– The following guidelines should be followed : 1) Program the PM to the VVI or
VOO mode 2) keep the focal point of the lithotriptor at least 6 inches away
• Magnetic Resonance Imaging

– All pacemakers to revert to asynchronous mode because of reed-switch closure.

– Investigations have shown that MRI does not permanently damage the reed
switch or other pulse generator components.
– The radiofrequency does not alter the acutely programmed variables, change the
normal magnet rate, or induce pacing in most pacemakers tested.

– A study by Vahlhaus et al. of 32 patients with PM exposed to MRI at 0.5 Tesla.

– Lead impedance, sensing and stimulation thresholds did not change, battery
current and impedance tended to increase, no change in programmed data or the
ability to interrogate and program. No irreversible changes in PM systems
PACE 2001; 24: 489-95

– In general, MRI should be avoided in a patient with an implanted PM.

– MRI may be attempted in non-PM-dependent patients if the device can be
programmed to an output at which there is failure to capture or OOO mode.
– Low magnetic field (0.5 Tesla) is preferable.
– The patient should be monitored by pulse oximetry, blood pressure and ECG
– If the body area to be imaged is in close proximity to the PM site, the PM-
induced artifact on MRI may obscure the images.
• Transcutaneous Electrical Nerve Stimulation
– Appears to be safe in most patients with permanent PMs.
– It is not known how close to the PM the stimulator can be placed, and it is best
to avoid applying the stimulator to a vector or path that would be parallel to the
pacing lead.
– In patients with VD or DDD PMs, it may result in an increased ventricular rate.

• Therapeutic Radiation
– Failure of various battery components or accelerated battery depletion
– Changes in sensing capability, failure of telemetry function, runaway function
and complete shut down may all occur
– No specific prediction relative to dose can be made.
– Particularly patients undergoing radiation for thoracic / chest wall malignancy.
– Precautions - Position the field of radiation at an angle oblique to the PM, total
accumulated dosage limit of 2 rad, shielding of the PM with a 1cm margin may
be required.
– If this is not possible, the PM should be explanted and moved to another site .
• RFA
– PM should be checked before and after ablation.
– Rate response function should be turned off.
– RF applications should be as brief as possible and remote from the electrode tip.
– If the patient is not dependent, the pacemaker can be programmed to OOO or
VVI at a lower rate than the intrinsic heart rate.
– If the patient is dependent, the PM should be programmed to VOO mode

• Uncommon sources of EMI

– dental instruments, including ultrasound scalers and cleaners, and
electrosurgical instruments can cause transient inhibition of PM output
– Certain cardiac monitoring systems can cause inappropriate rate changes in
patients with rate adaptive pacing systems that use a minute ventilation sensor.
– Antitheft devices may cause EMI with pacemakers.
– Acoustomagnetic systems may cause reversion to asynchronous pacing and
rapid ventricular pacing.
Nonmedical Equipment and Devices
• Cellular phones
– May interact with PM function by inhibiting the pacing output, asynchronous
pacing and ventricular triggering.
– Hayes DL et al in a multicenter study studied 980 patients.
• The incidence of all types of interference was 20%.
• Ventricular tracking of signals sensed on the atrial channel, noise reversion and
inhibition of ventricular output were the most commonly observed.
• The incidence of overall clinical significant interference was 6.6 %.
• Interference that was definitely clinically significant occurred in only 1.7 % of
tests and only when the phone was held over the pacemaker.
• Interference was more common in dual chamber systems (25.3 %) than in single
chamber systems (6.8 %) and in digital telephones (24%) compared to analog
telephones (3 %).

– Patients who are PM dependent should use an analog type cellular phone
system. Carrying the phone on the same side of the body as the implanted
PM may cause interference. When using the phone, it should be held at
least 15 cm away from the PM and on the opposite ear.
N Eng J Med 1997; 336: 1473-9
• Potentially significant restrictions exist for a small subset of patients
who work in environments with equipment capable of causing
significant electromagnetic interference— eg. internal combustion
engines, arc welding equipment, degaussing equipment and induction
ovens.
The use of bipolar leads can minimize or eliminate the problem.

• Microwaves should not cause any problem. Metal detectors could

theoretically cause inhibition of a single beat, but significant clinical
sequelae should not result.
 Triboelectric simulation
• Static electricity or triboelectric phenomena occur more commonly during
very cold weather and very low relative humidity.

• Triboelectric signals are usually wider and more irregular than pacemaker
stimuli

• Relatively prolonged overshoot is typical of electrostatic discharge

THANK YOU
 Pacemaker Syndrome
• First described in 1969 by Mitsui et al.

• Incidence ranges from 2% to 83%.

• Defined as the symptoms associated with right ventricular pacing relieved with the
return of A-V and V-V synchrony.

• The symptoms include DOE, PND, orthopnea, hypotension, pre-syncope, and

syncope.

• Additional symptoms include easy fatigability, malaise, headache, and the sensation
of fullness and pulsations in the head and neck

• Symptoms are most severe when intact V-A conduction is intact.

• Signs of congestive heart failure, cannon A-waves.