History and Physical Examination

History

Clinical symptoms of pacemaker malfunction are variable and include syncope, dizziness, palpitations, and slow or fast heart rate. Extracardiac stimulation or hiccup may be present. Obtain as much information as possible regarding the pulse generator, leads, and programmed values. Information on time of initial device placement, indication for pacemaker implant, special programming features particular to that model or patient, any recent surgeries, and knowledge of any manufacturer recalls or alerts on pacing systems may provide clues to the underlying malfunction.

Physical examination

Look for the following signs in patients with pacing system malfunction:

Pocket stimulation
Erosion of pocket
Diaphragmatic stimulation
Cannon A waves during atrioventricular dyssynchrony
Bradycardia
Tachycardia
Hypotension

Differential Diagnoses

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Media Gallery

Pacemaker Malfunction. Atrial undersensing. The rhythm strip shows an atrial pacing artifact after the intrinsic P wave.
Pacemaker Malfunction. Ventricular undersensing. The rhythm strip shows ventricular pacing artifacts despite normal underlying ventricular activity.
Pacemaker Malfunction. Atrial lead dislodgment. The chest radiograph film detail shows a dislodged atrial lead with the tip in the right ventricular cavity.
Pacemaker Malfunction. Ventricular noncapture. The rhythm strip shows atrial (P wave) sensing followed by a ventricular spike, which failed to capture the ventricle.
Pacemaker Malfunction. Loss of atrial capture. The rhythm strip shows intermittent loss of atrial capture.
Pacemaker Malfunction. Pacemaker-mediated tachycardia. The rhythm strip shows ventricular pacing at 110 beats per minute (programmed maximal track rate).
Pacemaker Malfunction. Termination of pacemaker-mediated tachycardia (PMT). Automatic postventricular atrial refractory period (PVARP) extension terminated the PMT.
Pacemaker Malfunction. This image shows an artifact due to monitor malfunction or a loose limb lead connection. An abrupt loss of a portion of the QRS complex followed by a flat line can be observed. If R-R intervals are matched, two QRS complexes are missing during the pause. If the artifact is due to a dislodged lead, a pacing artifact with no capture should be observed.
Pacemaker Malfunction. This is a typical example of ventricular oversensing with inhibition of ventricular pacing. In ventricular noncapture, a ventricular pacing artifact should be present after the third P wave.

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#author-disclosures{display:block}#author-disclosures.modal-layer{position:relative}#author-disclosures .modal-content{max-height:none}#author-disclosures .close-modal{display:none}

Author

Priyanka Ghosh, DO Fellow in Cardiovascular Disease, Guthrie Robert Packer Hospital

Priyanka Ghosh, DO is a member of the following medical societies: Alliance for Academic Internal Medicine, American College of Cardiology, American College of Physicians, American Heart Association, Pennsylvania Chapter of American College of Cardiology, Women in Cardiology, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Saurabh Sharma, MD, FACC, FACP, FASE, RPVI Associate Non-Invasive Cardiologist, Director, Cardiovascular Prevention and Lipid Clinic, Program Director, Internal Medicine Residency Program, Guthrie Medical Group, Guthrie Robert Packer Hospital; Clinical Assistant Professor of Cardiology, Geisinger Commonwealth School of Medicine

Saurabh Sharma, MD, FACC, FACP, FASE, RPVI is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Geriatrics Society, American Medical Association, American Society for Preventive Cardiology, National Lipid Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Brian Olshansky, MD, FESC, FAHA, FACC, FHRS Professor Emeritus of Medicine, Department of Internal Medicine, University of Iowa College of Medicine

Brian Olshansky, MD, FESC, FAHA, FACC, FHRS is a member of the following medical societies: American College of Cardiology, American Heart Association, Cardiac Electrophysiology Society, European Society of Cardiology, Heart Rhythm Society

Disclosure: Nothing to disclose.

Chief Editor

Jose M Dizon, MD Professor of Clinical Medicine, Clinical Electrophysiology Laboratory, Division of Cardiology, Columbia University College of Physicians and Surgeons; Attending Physician, Department of Medicine, New York-Presbyterian/Columbia University Medical Center

Jose M Dizon, MD is a member of the following medical societies: American College of Cardiology, Heart Rhythm Society

Disclosure: Nothing to disclose.

Additional Contributors

Chakri Yarlagadda, MD, FACC, FSCAI, FASNC, CCDS Director of Cardiac Rehabilitation, St Elizabeth Youngstown Hospital; Radiation Safety Officer, Mercy Health Cardiology

Chakri Yarlagadda, MD, FACC, FSCAI, FASNC, CCDS is a member of the following medical societies: American College of Cardiology, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Acknowledgements

Terry Carle, PAC (Johnson City, Tennessee) for his exemplary teaching during fellowship.

Pacemaker Malfunction Clinical Presentation

History and Physical Examination

History

Physical examination

References

Tables

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