17th Symposium

on Cardiac
Pacemaker
Arrhythmias Troubleshooting:
Common Clinical Scenarios

A
Payam Safavi-Naeini, MD pacemaker is a device that provides electrical stimuli to maintain or restore
Mohammad Saeed, MD, a normal heartbeat. Pacing systems are made of 2 implantable cardiac com-
FACC
ponents (the pacemaker pulse generator and the intracardiac leads), and
can be interrogated by using a wireless, telemetered, external programming device.1
Pacemakers can be dual- or single-chamber. Single-chamber pacemakers have a single
lead, which is placed either into the right atrium or, more often, into the right ventricle.
Dual-chamber pacemakers have 2 leads, with one in the right atrium and the other
in the right ventricle.2

Causes of Pacemaker Malfunction

Patients with pacemakers generally face problems that can be grouped into the fol-
lowing categories3:

1) Failure to pace the appropriate cardiac chamber:

CME Credit Output failure
Capture failure
Presented at the 17th
Symposium on Cardiac
Arrhythmias in Honor of
2) Problem with detecting intracardiac signals:
Dr. Ali Massumi, Houston, Undersensing
20 February 2016. Oversensing

Section Editor: 3) Pseudomalfunction:

Mohammad Saeed, MD Crosstalk with resultant safety pacing
Pacemaker-mediated tachycardia
Key words: Arrhythmias, Sensor-induced tachycardia
cardiac/therapy; cardiac pac- Runaway pacemaker
ing, artificial/instrumentation;
cardiac resynchronization/
Lead-displacement dysrhythmia
instrumentation; electrocar- Twiddler syndrome
diography; equipment failure
Output Failure
From: Department of Car- A failure of output is suspected if the heart rate is below the programmed lower rate
diology (Drs. Saeed and of the pacemaker and no pacer electrical output is noted on the electrocardiogram
Safavi-Naeini), Texas Heart
Institute; and Section of
(ECG)—that is, pacing spikes are absent. Causes of output failure are generally lead
Cardiology, Department of failure (lead fracture, lead displacement), generator failure, battery failure, crosstalk
Medicine (Dr. Saeed), inhibition, or oversensing (Fig. 1).4
Baylor College of Medicine;
Houston, Texas 77030
Capture Failure
Capture failure occurs when the generated pacing stimulus does not initiate myocar-
Address for reprints:
Mohammad Saeed, MD,
dial depolarization. On the surface ECG, pacing spikes are present, but they are not
FACC, 6624 Fannin St., followed by a QRS complex in the event of ventricular noncapture or by the lack of P
Houston, TX 77030 waves in the event of atrial noncapture (Fig. 2). The main causes of this failure are lead
dislodgment, low output, lead maturation, and lead or pacer failure (fibrosis, fracture,
E-mail: low pacing voltage, or elevated myocardial pacing thresholds).5
mohammas@[Link]
What Affects the Pacing Threshold?
© 2016 by the Texas Heart ® The pacing threshold is the minimum required energy that consistently triggers a de-
Institute, Houston polarization of the paced chamber. Multiple factors—including antiarrhythmic drug

Texas Heart Institute Journal • Oct. 2016, Vol. 43, No. 5 [Link] 415
 Ventricular Fusion and Pseudofusion
“Ventricular fusion” is the electrical summation of a
heart’s intrinsic beat and a depolarization from a pac-
ing stimulus. The hallmark of this phenomenon is that
its morphology lies between a fully paced beat and a
complete intrinsic beat. On the other hand, when the
pacemaker spikes fall directly on top of an intrinsic beat,
without contributing to the actual depolarization, this
Fig. 1 Output failure. Surface electrocardiogram from a patient event is called “pseudofusion” beat.7 Fusion and pseudo-
with a single-chamber pacemaker shows underlying atrial fusion beats are both consistent with normal pacemaker
fibrillation and ventricular pacing at a rate of 70 beats/min. There behavior (Fig. 5).
is no pacing spike at the expected interval at the beginning of the
tracing (circle), which suggests a failure of pacing output from the
pacemaker. At the bottom of the tracing, the expected pacing Pseudomalfunction
intervals are marked. Pseudomalfunctions are unusual and unexpected ECG
findings that appear to be pacemaker malfunctions
but actually are normal pacemaker behavior. Pseudo-
malfunctions are classified under 3 categories: 1) rate-
related, 2) atrioventricular (AV) interval/refractory
period-related, and 3) model-related.
Most common are the rate-related pseudomalfunc-
tions. Rate changes in the presence of normal pace-
maker function can occur because of magnet operation,
Fig. 2 Ventricular noncapture. Surface electrocardiogram from timing variations (A-A vs V-V), upper-rate behavior
a patient with a single-chamber pacemaker shows sinus rhythm (Wenckebach or 2:1 block), pacemaker-mediated tachy-
with first-degree atrioventricular block. Pacing spikes are visible
cardia (PMT), or rate response.7
at a rate of 65 beats/min and are marching through without cap-
ture, even though the ventricular myocardium is not expected to The following paragraphs cover some of the typical
be refractory at those times. clinical situations presenting as pseudomalfunctions.

use, physical activity level, posture, time of day, and

comorbidity—could all affect the pacing threshold.6

Undersensing
Undersensing occurs when the pacemaker fails to detect
spontaneous myocardial depolarization, which results
in asynchronous pacing. Atrial or ventricular pacing Fig. 3 Ventricular undersensing. Surface electrocardiogram
spikes arise regardless of P waves or QRS complex. This shows sinus rhythm with first-degree atrioventricular block and
typically results in the appearance of too many pacing bundle branch block in a patient with a pacemaker. Ventricular
spikes, as seen on ECG (Fig. 3). The main causes of pacing spikes are visible and not only fail to capture the myocar-
dium but show evidence of undersensing: note the inappropriate
undersensing are pacemaker programming problems pacing soon after a QRS complex, after the 3rd beat.
(improper sensing threshold), insufficient myocardial
voltage signal, lead or pacer failure (fibrosis, fracture,
etc.), or an electrolyte abnormality.7

Oversensing
Oversensing occurs when the pacemaker senses electri-
cal signals that it should not normally encounter, which
results in inappropriate inhibition of the pacing stimu-
lus. In addition to the native cardiac depolarization
signals (P or R waves), any electrical signal with suffi-
cient amplitude and frequent occurrence can be sensed
and can inhibit the pacemaker when pacing is needed. Fig. 4 Ventricular oversensing. Surface electrocardiogram
shows sinus rhythm with ventricular pacing. After the 3rd sinus
Oversensing can be caused by physiologic signals like T P wave, the pacing spike is absent—which suggests oversens-
waves or by myopotential (and nonphysiologic) signals ing by the pacemaker, with inappropriate inhibition of pacing and
like electromagnetic interference or a lead failure (an an asystolic pause in a pacemaker-dependent patient.
insulation break or a lead fracture) (Fig. 4).7

416 Pacemaker Troubleshooting Oct. 2016, Vol. 43, No. 5

Fig. 5 Ventricular fusion and pseudofusion. Intracardiac atrial and right ventricular (RV) electrograms (EGMs), along with a surface
electrocardiogram (ECG), in a patient with atrial fibrillation and congestive heart failure. The patient is being treated with cardiac
resynchronization therapy, and the tracing shows QRS complexes of various morphologies and durations. Some resemble intrinsic
QRS and represent pseudofusion, whereas others show a morphology between intrinsic beats and paced beats and thereby represent
true fusion between conducted impulses and paced beats.

Ventricular Safety Pacing. Ventricular safety pacing Surface

(SP) prevents ventricular asystole due to crosstalk. Pace- ECG

maker crosstalk in a dual-chamber pacemaker refers to

the detection of a paced signal in one chamber by the Atrial
EGM
lead in another chamber, and to the misrepresentation
of the paced signal as a cardiac depolarization signal.
This, in turn, results in inappropriate inhibition of pac-
ing in the 2nd chamber.8 Ventricular
EGM
Ventricular safety pacing delivers a ventricular pac-
ing stimulus after detecting a ventricular “sense event”
shortly after an atrial paced event (SP algorithms differ Fig. 6 Surface electrocardiogram (ECG) with intracardiac atrial
among pacemaker manufacturers).9 Ventricular safety and ventricular electrograms (EGMs). This is an example of
pacing typically results in the appearance of 2 very crosstalk wherein the pacing signal from one channel (in this
case, the atrium) is sensed on the other channel (in this case,
closely spaced atrial and ventricular paced events on the ventricle). In this example, the cross-sensed signal is ignored
ECG (Fig. 6). and no action is taken by the pacemaker. In other situations,
Pacemaker-Mediated Tachycardia. Pacemaker- the cross-sensed signal can be misconstrued as a pacemaker
mediated tachycardia is an endless-loop tachycardia, malfunction and can trigger ventricular safety pacing.
sustained, in part, by the presence of the pacemaker.
Pacemaker-mediated tachycardia requires the presence
of retrograde ventriculo-atrial conduction and a trig-
gering event like premature ventricular contraction or
loss of AV synchrony. Pacemaker-mediated tachycar-
dia is similar to a re-entrant tachycardia, except that
the pacemaker forms part of the re-entrant circuit; the
tachycardia could therefore be avoided by programming
a sufficiently long postventricular atrial refractory pe-
Fig. 7 Surface electrocardiogram shows an example of
riod (PVARP).10 Placing a magnet on the device during
pacemaker-mediated tachycardia. Ventricular pacing spikes are
the PMT will change the pacemaker’s mode to dual- visible at a rate of 120 beats/min, along with appropriate capture.
chamber pacing mode (in DOO, intrinsic P waves and Pacemaker is pacing at the upper rate as it tracks the retro-
R waves are ignored), which results in the termination gradely conducted P waves in this dual-chamber pacemaker.
of tachycardia by suspending the pacemaker’s sensing
function (Fig. 7).4,10
Upper-Rate Behavior. Upper-rate behavior refers to the the rate at which the ventricle can pace in the presence
pacing characteristics seen in dual-chambered pacemak- of high atrial rates. This limit is called the maximum
ers programmed to an atrial tracking mode as the atrial tracking rate (MTR) and is a programmable value. The
rate increases and approaches a certain upper thresh- upper-rate behavior depends upon MTR and total atrial
old. In dual-chambered devices, it is necessary to limit refractory period (TARP). The TARP is equal to AV

Texas Heart Institute Journal Pacemaker Troubleshooting 417

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634-8.
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418 Pacemaker Troubleshooting Oct. 2016, Vol. 43, No. 5