Pacemaker Malfunction Overview
- Pacemaker malfunction can occur for a wide variety of reasons, ranging from equipment failure to changes in underlying native rhythm.
- Diagnosis of pacemaker malfunction is challenging and often associated with non-specific clinical symptoms while ECG changes can be subtle or absent.
Note: Normal pacemaker function is discussed extensively in a seperate post.
Problems with Sensing
- Undersensing occurs when the pacemaker fails to sense native cardiac activity.
- Results in asynchronous pacing.
- Causes include increased stimulation threshold at electrode site (exit block), poor lead contact, new bundle branch block or programming problems.
- ECG findings may be minimal, although presence of pacing spikes within QRS complexes is suggestive of undersensing.
- Oversensing occurs when electrical signal are inappropriately recognised as native cardiac activity and pacing is inhibited.
- These inappropriate signals may be large P or T waves, skeletal muscle activity or lead contact problems.
- Abnormal signals may not be evident on ECG.
- Reduced pacemaker output / output failure may be seen on ECG monitoring if the patient stimulates their rectus or pectoral muscles (due to oversensing of muscle activity).
Problems with Pacing
- Output failure occurs when a paced stimulus is not generated in a situation where expected.
- Results in decreased or absent pacemaker function.
- Multiple causes including oversensing, wire fracture, lead displacement, or interference.
Failure to capture
- Failure to capture occurs when paced stimulus does not result in myocardial depolarisation.
- Multiple causes including electrode displacement, wire fracture, electrolyte disturbance, MI or exit block.
NB. If the patient’s native heart rate is above the pacemaker threshold, no pacemaker activity is expected and therefore output failure and capture failure cannot be recognised on the ECG.
Pacemaker Associated Dysrhythmias
Several types of pacemaker associated dysrhythmias can occur including pacemaker-mediated tachycardia (PMT), sensor-induced tachycardia, runaway pacemaker, pacemaker-mediated Wenckebach AV block and lead dislodgement dysrhythmia.
Pacemaker-mediated tachycardia (PMT)
- Also known as endless-loop tachycardia or pacemaker circus movement tachycardia.
- PMT is a re-entry tachycardia in which the pacemaker forms the antegrade pathway with retrograde conduction occurring via the AV node.
- Caused by retrograde p waves being sensed as native atrial activity with subsequent ventricular pacing.
- The paced ventricular complex results in further retrograde conduction with retrograde p wave generation thus forming a continuous cycle.
- Results in a paced tachycardia with the maximum rate limited by the pacemaker programming.
- Can be terminated by slowing AV conduction e.g. adenosine or activation of magnet mode.
- Newer pacemakers contain programmed algorithms designed to terminate PMT.
- May result in rate related ischaemia in the presences of IHD.
- Modern pacemakers are programmed to allow increased heart rates in response to physiological stimuli such as exercise, tachypnoea, hypercapnia or acidaemia.
- Sensors may “misfire” in the presence of distracting stimuli such as vibrations, loud noises, fever, limb movement, hyperventilation or electrocautery (e.g. during surgery).
- This misfiring leads to pacing at an inappropriately fast rate.
- The ventricular rate cannot exceed the pacemaker’s upper rate limit (usually 160-180 bpm).
- These will also usually terminate with application of a magnet.
- This potentially life-threatening malfunction of older-generation pacemakers is related to low battery voltage (e.g. overdue pacemaker replacement).
- The pacemaker delivers paroxysms of pacing spikes at 200 bpm, which may provoke ventricular fibrillation.
- Paradoxically, there may be failure to capture — causing bradycardia — because the pacing spikes are very low in amplitude (due to the depleted battery voltage) and because at very high rates the ventricle may become refractory to stimulation.
- Application of a magnet can be life saving but definitive treatment requires replacement of the pacemaker.
- Some great cases of runaway pacemaker are discussed here.
Lead displacement dysrhythmia
- A dislodged pacing lead may float around inside the right ventricle, intermittently “tickling” the myocardium and causing ventricular ectopics or runs of VT (in much the same way as the guide wire of a central line!), alternating with failure of capture.
- If the paced QRS morphology changes from a LBBB pattern (indicating RV placement) to a RBBB pattern (indicating LV placement), this suggests that the electrode has eroded through the interventricular septum.
- A chest x-ray will usually help to confirm the diagnosis.
- Caused by improper timing of atrial and ventricular contractions resulting in AV dyssynchrony and loss of atrial “kick”.
- Variety of clinical symptoms including fatigue, dizziness, palpations, pre-syncope.
- Associated decrease in systolic blood pressure > 20 mmHg during change from native rhythm to paced rhythm.
- Patient manipulation of the pulse generator (accidentally or deliberately).
- The pacemaker rotates on its long axis, resulting in dislodgement of pacing leads.
- Can result in diaphragmatic or brachial plexus pacing (e.g. arm twitching) depending on extent of lead migration.
ECG in Pacemaker Malfunction
- Normal pacemaker rhythms can result in absent pacing activity, irregular pacing and absence of pacing spikes.
- Diagnosis of pacemaker malfunction on the ECG is very difficult and may be impossible depending on the underlying native rhythm.
- If pacemaker malfunction is suspected cardiology review is required to facilitate pacemaker interrogation and testing.
Pacing failure:This ECG shows a ventricular paced rhythm with intermittent failure to capture:
- Atrial sensing appears to be intact — ventricular pacing spikes follow each P wave, most easily seen in V3-6 (tiny pacing spikes are also visible in I, aVR and V1).
- There is presumably an underlying complete heart block or high-grade 2nd degree AV block, as the native P waves do not capture the ventricles.
Rapid ventricular pacing
There is a rapid ventricular-paced rhythm (120 bpm) with no evidence of preceding atrial activity (except for the first complex). The differential diagnosis of this rhythm would include:
- Pacemaker-mediated tachycardia (with retrograde P waves buried in the QRS complexes /T waves).
- Sensor-induced tachycardia.
- Could potentially be normal in the presence of an appropriate physiological stimulus (e.g. exercise).
Example 3 – Runaway pacemaker
- Paroxysms of rapid pacing spikes at 2000 bpm with decreasing amplitude and rate — this fails to excite the ventricles due to the low amplitude spikes.
- The underlying rhythm is atrial flutter with 3rd degree AV block and ventricular escape rhythm at 30 bpm.
- In the middle, three pacing spikes are seen at 60 ppm in VOO mode: the first is ventricular refractory (failed capture).
This ECG and interpretation is reproduced from Ortega et al. (2005).
- Nicholson WJ, Tuohy KA, Tilkemeier P. Twiddler’s Syndrome N Engl J Med 2003; 348:1726-1727.
- Ortega DF, Sammartino MV, Pellegrino GM, Barja LD, Albina G, Segura EV, Balado R, Laiño R, Giniger AG. Runaway pacemaker: a forgotten phenomenon? Europace. 2005 Nov;7(6):592-7. Epub 2005 Sep 8. PubMed PMID: 16216762
- Wiesbauer F, Kühn P. ECG Yellow Belt online course: Become an ECG expert. Medmastery
- Wiesbauer F, Kühn P. ECG Blue Belt online course: Learn to diagnose any rhythm problem. Medmastery
- Rawshani A. Clinical ECG Interpretation ECG Waves
- Smith SW. Dr Smith’s ECG blog.
- Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical Care. 2e, 2019
- Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine. 1e, 2020
- Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
- Hampton J. The ECG Made Practical 7e, 2019
- Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
- Brady WJ, Truwit JD. Critical Decisions in Emergency and Acute Care Electrocardiography 1e, 2009
- Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric 6e, 2008
- Mattu A, Brady W. ECG’s for the Emergency Physician Part I 1e, 2003 and Part II
- Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004
LITFL Further Reading
- ECG Library Basics – Waves, Intervals, Segments and Clinical Interpretation
- ECG A to Z by diagnosis – ECG interpretation in clinical context
- ECG Exigency and Cardiovascular Curveball – ECG Clinical Cases
- 100 ECG Quiz – Self-assessment tool for examination practice
- ECG Reference SITES and BOOKS – the best of the rest