Pacemaker failure

Pacemaker failure is the inability of an

implanted artificial pacemaker to perform
its intended function of regulating the
beating of the heart. A pacemaker uses
electrical impulses delivered by electrodes
in order to contract the heart muscles.[1]
Failure of a pacemaker is defined by the
requirement of repeat surgical pacemaker-
related procedures after the initial
implantation. Most implanted pacemakers
are dual chambered and have two leads,
causing the implantation time to take
longer because of this more complicated
pacemaker system. These factors can
contribute to an increased rate of
complications which can lead to
pacemaker failure.[2]

Approximately 2.25 million pacemakers

were implanted in the United States
between 1990 and 2002, and of those
pacemakers, about 8,834 were removed
from patients because of device
malfunction most commonly connected to
generator abnormalities.[3] In the 1970s,
results of an Oregon study indicated that
10% of implanted pacemakers failed
within the first month.[4] Another study
found that more than half of pacemaker
complications occurred during the first 3
months after implantation.[2] Causes of
pacemaker failure include lead related
failure, unit malfunction, problems at the
insertion site, failures related to exposure
to high voltage electricity or high intensity
microwaves, and a miscellaneous
category (one patient had ventricular
tachycardia when using his electric razor
and another patient had persistent pacing
of the diaphragm muscle).[4] Pacemaker
malfunction has the ability to cause
serious injury or death, but if detected
early enough, patients can continue with
their needed therapy once complications
are resolved.[3]

Symptoms[5]
Moderate dizziness or lightheadedness
Syncope
Slow or fast heart rate
Discomfort in chest area
Palpitations
Hiccups 

Causes
Direct factors

Lead dislodgement
A Macro-dislodgement is
radiographically visible.[5]
A Micro-dislodgement is a minimal
displacement in the lead that is not
visible in a chest X-ray, but has the
ability to increase the capture
threshold and eventually cause a
loss of capture.[5]
Lead dislodgement can cause
sensing failure, which occurs when
proper atrial or ventricular sensing
is not achieved by the programming
of the pacemaker. Ventricular lead
dislodgement is less common
compared to atrial lead
dislodgement.[2]
Causes
Twiddler's Syndrome
The patient's constant
manipulation of the pulse
generator within its skin
pocket can lead to a
dislodgement of the
device.[6] The generator is
rotated on its longitudinal
axis, which causes traction
and results in a lead
dislodgement.[5]
Reel's Syndrome
 Like Twiddler's Syndrome,
it is the manipulation of
the pulse generator, but
instead the generator is
rotated on its transverse
axis, which rolls the lead
around the generator,
creating dislodgement.[5]
Direct trauma over the
system.[5]
Lead fracture[2]
Unit malfunction
Battery failure, component
malfunction, or generator failure[4]
Problems at the insertion site
 Infection of the insertion site can
cause local inflammation or the
formation of an abscess in the
pulse generator pocket.[2]
Infection can cause the erosion of
part of the pacing system that is in
the skin.[2]
Failures related to exposure to high
voltage electricity or high intensity
microwaves[4]

Indirect factors

Power-generating equipment, arc

welding equipment and powerful
magnets (as in medical devices, heavy
equipment or motors) can inhibit pulse
generators. Patients who work with or
near such equipment should know that
their pacemakers may not work properly
in those conditions.[7]
With the advances of technology,
Federal Communications Commission
(FCC) is making new frequencies
available. Cellphones using these new
frequencies might make pacemakers
less reliable. A group of cellphone
companies is studying that possibility.[7]
Equipment used by doctors and dentists
can affect pacemakers.[7]
Magnetic resonance imaging (MRI) uses
a powerful magnet to produce images
of internal organs and their functions.
Metal objects are attracted to the
magnet and are normally not allowed
near MRI machines. The magnet can
interrupt the pacing and inhibit the
output of pacemakers. If MRI must be
done, the pacemaker output in some
models can be reprogrammed.[7] In
February 2011, the FDA approved an
MRI-safe pacemaker.[8]
Extracorporeal shock-wave lithotripsy
(ESWL) procedure is safe for most
pacemaker patients, with some
reprogramming of the pacing. Careful
follow-up after the procedure is
required. Patients with certain kinds of
pacemakers implanted in the abdomen
should avoid ESWL.[7]
Diagnostic radiation (such as screening
X-ray) appears to have no effect on
pacemaker pulse generators. However,
therapeutic radiation (such as for
treating cancerous tumors) may
damage the pacemaker's circuits. The
degree of damage is unpredictable and
may vary with different systems.
However, the risk is significant and
builds up as the radiation dose
increases. The American Heart
Association recommends that the
 pacemaker be shielded as much as
possible, and moved if it lies directly in
the radiation field.[7]
Short-wave or microwave diathermy
uses high-frequency, high-intensity
signals. These may bypass pacemaker's
noise protection and interfere with or
permanently damage the pulse
generator.[7]

Prevention[5]
Lead displacement
Adequate surgical implantation.
Usage of active fixation leads.
 Verification of lead position 24–48
hours implantation.

Treatment[5]
Lead displacement
Early displacements: surgical
repositioning of the lead or lead
repositioning via percutaneous
access.
Late displacements: implanting a
new lead in the chamber where
displacement has occurred.

See also
Pacemaker crosstalk

References
1. McWilliam, John A. (1889-02-16).
"Electrical Stimulation of the Heart in Man" .
Br Med J. 1 (1468): 348–350.
doi:10.1136/bmj.1.1468.348 . ISSN 0007-
1447 .
2. Kiviniemi, Mikko S.; Pirnes, Markku A.;
Eränen, H. Jaakko K.; Kettunen, Raimo V.j.;
Hartikainen, Juha E.k. (1999-05-01).
"Complications Related to Permanent
Pacemaker Therapy" . Pacing and Clinical
Electrophysiology. 22 (5): 711–720.
doi:10.1111/j.1540-8159.1999.tb00534.x .
ISSN 1540-8159 .
3. "Pacemakers malfunction less often than
defibrillators". AORN Journal. 82: 862. 2005
– via Gale Health Reference Center
Academic.
4. Reinhart, Steven; McAnulty J; Dobbs J
(April 1981). "Type and timing of permanent
pacemaker failure" . Chest. Portland,
Oregon. 81 (4): 433–5.
doi:10.1378/chest.81.4.433 .
PMID 7067508 . Retrieved 2009-09-08.
5. Fuertes, Beatriz; Toquero, Jorge; Arroyo-
Espliguero, Ramon; Lozano, Ignacio F
(2003-10-01). "Pacemaker Lead
Displacement: Mechanisms And
Management" . Indian Pacing and
Electrophysiology Journal. 3 (4): 231–238.
ISSN 0972-6292 . PMC 1513524 .
PMID 16943923 .
6. Salahuddin, Mohammad; Cader, Fathima
Aaysha; Nasrin, Sahela; Chowdhury,
Mashhud Zia (2016-01-01). "The
pacemaker-twiddler's syndrome: an
infrequent cause of pacemaker failure" .
BMC Research Notes. 9: 32.
doi:10.1186/s13104-015-1818-0 .
ISSN 1756-0500 . PMC 4721019 .
PMID 26790626 .
7. "Pacemakers" . American Heart
Association. Retrieved 6 April 2011.
8. Miller, Reed (9 February 2011). "FDA
approves first "MRI-safe" pacemaker" .
theheart.org. Retrieved 4 April 2011.

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