C a rd i a c Pa c e m a k e r s

Eleanor Paglia, MD, Jill Carter, MPA, PA-C

KEYWORDS
 Cardiac Pacemaker  Pacemaker indications  Pacemaker Complications
 Pacing Modes  Pacemaker Interrogation

HOSPITAL MEDICINE CLINICS CHECKLIST

1. Pacemaker insertion in the setting of sinus node dysfunction requires both

symptoms and irreversibility.
2. First-degree atrioventricular block and type I second-degree atrioventricular
block do not typically progress to advanced block, and therefore do not
require a pacemaker.
3. Type II second-degree and third-degree atrioventricular block pose a signifi-
cant risk of complications and therefore permanent pacemaker is indicated ir-
respective of symptoms.
4. Chest radiography is helpful in confirming type of pacemaker, placement of
leads and presence of ICD shock coils, as well as device and manufacturer
identification.
5. The North American Society of Pacing and Electrophysiology (NASPE) and the
British Pacing and Electrophysiology Group (BPEG) published the NBG pace-
maker code, last revised in 2002. It describes the 5-letter code for operation of
implantable pacemakers and is the common language used to communicate
device pacing modes. There are 5 positions, although position V is rarely used.
6. Atrial pacing, when possible, is preferred given that it avoids the complications
associated with long term right ventricular pacing (heart failure death and atrial
fibrillation).
7. Managed Ventricular Pacing and Mode Switching are pacing programs that
minimize dependency on right ventricular pacing.
8. Cardiac resynchronization therapy (CRT), also referred to as biventricular pac-
ing, is used in systolic heart failure to improve ventricular synchrony, resulting
in improved outcomes.

CONTINUED

Internal Medicine, Newton-Wellesley Hospital, 2014 Washington Street, Newton, MA

02462, USA
E-mail address: epaglia@partners.org

Hosp Med Clin 6 (2017) 374–396

http://dx.doi.org/10.1016/j.ehmc.2017.04.007
2211-5943/17/ª 2017 Elsevier Inc. All rights reserved.
 Cardiac Pacemakers 375

CONTINUED
9. Implantable cardioverter defibrillators (ICDs) are devices used for treatment of
tachyarrhythmias. ICDs are equipped with both demand pacing functionality
as well as the ability to deliver high-voltage shock. They might also be pro-
grammed to provide specialized therapeutic intervention such as anti-tachy-
cardia pacing (ATP).
10. A pacemaker magnet moves a programmable switch in the pacemaker which will
change the pacemaker mode, commonly DOO at a predetermined high rate.
Magnets will also turn off ICD therapy so that it will not be able to deliver a shock.

When should pacemaker implantation be considered?

In a community hospital, it is important to have a basic understanding of the indica-
tions for implantation of a permanent pacemaker. The most recent guidelines were
published in 2012 as an update to the 2008 American College of Cardiology

Fig. 1. Applying classification of recommendations and level of evidence. (From Epstein

AE, DiMarco JP, Ellenbogen KA, et al. 2012 ACCF/AHA/HRS focused update incorporated
into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm ab-
normalities: a report of the American College of Cardiology Foundation/American Heart
Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Car-
diol 2013;61(3):e6–75; with permission.)
376 Paglia & Carter

Foundation/American Heart Association/Heart Rhythm Society (ACCF/AHA/HRS)

Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities.1 Fig. 1 re-
views classification of recommendations and level of evidence that can be applied
to the listed indications below.

SINUS NODE DYSFUNCTION

Pacemaker insertion in the setting of sinus node dysfunction requires both symptoms
and irreversibility. Asymptomatic sinus bradycardia is not an indication for a pace-
maker, so it is important to distinguish this from pathologic bradycardia. Similarly,
permanent pacemaker insertion should be avoided in the setting of reversible causes
of bradycardia as can be seen with electrolye disturbances, toxins, and medications.
The following guidelines, with corresponding certainty and magnitude of treatment
based on AHA evidence classification, apply (for full list, see Epstein and col-
leagues2):

 Sinus node dysfunction with documented symptomatic bradycardia or pauses,

including those that result from a required drug therapy that cannot be
discontinued
 Symptomatic chronotropic incompetence (ie, the inability of the heart to increase
its rate commensurate with increased activity or demand).3

 Heart rate less than 40 beats per minute when association between symptoms
and bradycardia has not been established
 Unexplained syncope if sinus node abnormalities are discovered or provoked in
electrophysiologic studies

 Minimally symptomatic patients with heart rate persistently less than 40 bpm
while awake.

ATRIOVENTRICULAR BLOCK/FASCICULAR BLOCK

Similar to sinus node dysfunction, a pacemaker is not indicated in the setting of

asymptomatic first-degree atrioventricular (AV) block or type I second-degree AV
block, because these conditions do not typically progress to advanced AV block. He-
modynamic compromise can occasionally be seen in patients with markedly pro-
longed PR (>300 ms) when atrial systole occurs too close to the previous
ventricular systole. In this situation there may be some benefit to pacemaker inser-
tion. Again, reversible or temporary causes (such as hyperkalemia, thyroid dysfunc-
tion, and Lyme disease) should be ruled out, but further diagnostics or pacemaker
 Cardiac Pacemakers 377

placement is not usually required in first-degree or type I second-degree blocks.

Alternatively, in the setting of type II second-degree or third-degree AV block, pacing
is indicated irrespective of symptoms, given the concern for severe and progressive
conduction disease. The following guidelines apply:

 Advanced second-degree (defined as non-conduction of two or more consecu-

tive P waves) or third-degree AV block if associated with symptomatic brady-
cardia or ventricular arrhythmia
 Advanced second degree or third degree, without symptoms, if documented ep-
isodes of (1) asystole greater than or equal to 3 seconds, (2) escape rhythm either
less than 40 bpm or below AV node, (3) atrial fibrillation (AF) with pauses greater
than or equal to 5 seconds, (4) block during exercise in absence of ischemia
 Alternating bundle-branch block

 Neuromuscular disease with associated advanced second-degree or third-

degree AV block (with or without symptoms)
 Any second-degree AV block if associated with symptomatic bradycardia
 Asymptomatic third-degree AV block, no matter the rate, when cardiomegaly or
LV dysfunction is present or block is below AV node

 First-degree or second-degree AV block with symptoms attributable to pace-

maker syndrome
 Asymptomatic type II second-degree block with a narrow QRS complex (a wide
QRS complex would be a Class I indication)
 Asymptomatic second-degree block at or below bundle of His
 Syncope in the setting of chronic bifascicular block, not due to AV block and with
other causes excluded

C
 Asymptomatic third-degree block with escape rate greater than 40 bpm without
cardiomegaly
It is important for hospitalists to be familiar with the conditions in which pacemakers
are not recommended.
Pacemakers are not indicated for:
 Sinus node dysfunction in asymptomatic patients
 Sinus node dysfunction when the concerning symptoms are documented to
occur in the absence of bradycardia
 Sinus bradycardia due to medications that can safely be discontinued
378 Paglia & Carter

 Asymptomatic first-degree AV block

 Asymptomatic type I second-degree AV block above the Bundle of His
 AV block expected to resolve
 Fascicular block without AV block or symptoms
 Fascicular block plus first-degree AV block without symptoms
 Hypersensitive cardioinhibitory response without symptoms
 Situational vasovagal syncope

How is a pacemaker implanted?

A pacemaker consists of two main parts: (1) a pulse generator (or ”can”), which con-
tains technology that can sense and stimulate cardiac electrical activity and (2) leads,
which are wires that travel from the pulse generator to the myocardium.
Pacemaker implantation is usually performed in a cardiac catheterization laboratory
or operating room. It is typically inserted under local anesthesia, although rarely gen-
eral anesthesia may be used. To start, a 1.5-in to 2-in incision is made in the infracla-
vicular area parallel to the middle third of the clavicle. A subcutaneous pocket is
created with sharp and blunt dissection where the pacemaker eventually is implanted.
The endocardial leads are inserted transvenously by a variety of possible approaches,
with the most common either the subclavian vein or the cephalic vein (cut-down tech-
nique). Other options, although rarely used, include the internal jugular vein, femoral
vein, or axillary vein. Pacemaker leads are advanced to the appropriate location under
fluoroscopic guidance and are secured either via tines (anchors that passively fix to
the trabeculae) or an active screw at the tip. The pulse generator is attached to the
leads and placed in the subcutaneous pocket and the incision is closed. An arm immo-
bilizer, such as a sling, is typically applied for 12 hours to 24 hours post-procedure.

What information can be obtained on plain films?

Chest radiography (both posterior-anterior and lateral views) is always obtained post-
implantation to confirm appropriate lead position and rule out a pneumothorax. The

Fig. 2. Chest radiography revealing dual-chamber pacemaker with appropriate lead place-
ment. (A) PA view and (B) lateral view.
 Cardiac Pacemakers 379

pulse generator typically is visible in the upper left or right chest. The right atrial lead is
inferiorly directed, with a terminal anterior curve known as the J loop, which suggests
the tip is at the right atrial appendage. The RV lead is directed inferiorly through the
right atrium. It crosses the tricuspid valve and terminates at the RV apex. Appropriate
placement is indicated by the lead tip appearing to the left of the spine on posteroan-
terior (PA) view and by a lateral view revealing an anteriorly oriented lead. In single-
chamber pacemakers, only one of the leads is present. See Fig. 2 for an example
of chest radiography revealing dual-chamber pacemaker with appropriate lead place-
ment—PA view on the left and lateral view on the right.
Biventricular pacemakers, also referred to as CRT, are used as treatment of heart fail-
ure with concurrent ventricular dyssynchrony. Biventricular pacemakers have leads
pacing both the RV and LV and occasionally have a right atrial lead. The right-sided
lead positions should look similar to a standard dual-chamber pacemaker, as discussed
previously. Through a transvenous approach, the LV lead is guided from the right atrium
to the posterolateral epicardial vein of the LV wall via the coronary sinus. See Fig. 3 for
an illustration of lead placement in a biventricular pacemaker. Correct positioning of the
LV lead would be confirmed on a lateral chest radiograph, with posterior orientation of
the LV lead.

Fig. 3. Cardiac resynchronization therapy (CRT) or biventricular pacemaker (BiV). (1) Pacemaker
generator. (2) Right atrial pacer wire. (3) RV pacer wire. (4) Coronary sinus (LV) pacer wire.
(Courtesy of Medtronic, Minneapolis, Minnesota; with permission.)

On chest radiography, the presence of an ICD is confirmed by one or two metal

shock coils placed at the superior vena cava (SVC) junction and the RV. Biventricular
pacemakers are often combined with ICDs.
See Fig. 4 for an example of an appropriately positioned biventricular pacemaker.
Note that this is a combination biventricular pacemaker/ICD, as evidenced by SVC
and RV shock coils (blue arrow). Right atrial lead can be seen making a J loop (green
arrow). LV lead can be seen to the left of the spine, just above the RV lead (red
arrow).
380 Paglia & Carter

Fig. 4. Example of an appropriately positioned biventricular pacemaker. Note that this is a

combination biventricular pacemaker/ICD, as evidenced by the SVC and RV shock coils (blue
arrows). Right atrial lead can be seen making a J loop (green arrow). LV lead can be seen to
the left of the spine, just above the RV lead (red arrow).

DEVICE IDENTIFICATION

Optimal care of patients with cardiovascular implantable electronic devices (CIEDs)

requires accurate identification of the patient’s device, particularly when device
interrogation is required. Performing a device interrogation requires the manufac-
turer-specific hardware and software. If the device manufacturer is unable to be
identified from the patient or medical record, it is useful to know that there is a
device-specific radioopaque alphanumeric code (ANC). The ANC is unique to
each manufacturer and may be visualized on chest radiography depending on im-
age quality. Additionally, the pulse generator often has a distinctive silhouette and
configuration, depending on device manufacturer, which can help lead to identifica-
tion.4 This is helpful because many patients do not always realize which device they
have or may not carry their ID card. Device companies are available 24/7 and
should be contacted for identification and device interrogation (Table 1).

Table 1
Device company contact information

Medtronic 1-800-MEDTRONIC

St Jude 1-800-722-3774

Boston Scientific 1-800-CARDIAC

 Cardiac Pacemakers 381

Fig. 5 is a zoomed-in radiograph of a pacemaker. The letters PVX are noted on the
device, indicating that this is an Ensura or Advisa (Medtronic) generator. The wavy line
symbol w indicates an MRI conditional pacemaker.

Fig. 5. Inserted pacemaker on chest radiograph. Red arrow identifies ANC location. The let-
ters PVX are noted on the device, indicating that this is an Ensura or Advisa (Medtronic)
generator. The wavy line symbol w indicates an MRI conditional pacemaker.

What are the most common periprocedural issues and concerns?

It is common for patients to be observed on the medical floor overnight. It is important
for hospitalists to be aware of the potential complications that can occur immediately
after the procedure, once a patient is on the medical floor. Post-procedure care in-
cludes a chest radiograph (verify lead position and evaluate for pneumothorax/hemo-
thorax), telemetry monitoring (traditionally overnight to rule out arrhythmia), and 12-
lead electrocardiogram (ECG) evaluation.
Incidence of pacemaker complications is difficult to pinpoint because there is no
specific database or required reporting; in addition, definitions for each complication
vary. Most acute, procedure-related complications are from transvenous access and
lead placement.

ACCESS-RELATED COMPLICATIONS
Pneumothorax (0.5%–2%)
Access via subclavian venous puncture is associated with increased rate of pneumo-
thorax when compared to cephalic vein cut-down or axillary vein puncture, which is
associated with lower rate of pneumothorax.5–8

Hemothorax (Less Than 1%)

Hemothorax is caused by complications during vascular access, including damage to
subclavian or axillary vein as well as the damage to vena cava.9 Postprocedure chest
radiograph should be obtained. Any new effusion should be considered a procedure-
related hemothorax until proven otherwise, with appropriate thoracic surgery
consultation.
382 Paglia & Carter

LEAD-RELATED COMPLICATIONS
Myocardial Perforation (0.1%–0.98%)
Myocardial perforation is classified as acute (developing during the first 24 hours after
implantation), subacute (up to 1 month), or chronic (greater than 1 month).10 Perfora-
tion is more likely to be seen at the site of an atrial lead due to the thinner (2 mm) wall or
with a ventricular lead in the setting of a thin, dilated ventricular wall. Risk factors for
cardiac perforation include steroid use, low body mass index, older age, female
gender, and anticoagulation.7 Red-flag symptoms of perforation depend on the site
of perforation and might include chest or abdominal pain, dyspnea, or hiccups. Hos-
pitalists should be vigilant for any significant down-trending blood pressure sugges-
tive of associated complications such as pericardial effusion or cardiac tamponade
to screen for any evidence of perforation.
A chronic perforation may be walled off by muscle and fibrous tissue and, therefore,
may be asymptomatic. Discussion of treatment of this long-term complication is
beyond the scope of this article.

Lead Failure or Dislodgement (3%–4% Atrial, 1%–2% Ventricular)

Lead disruption is typically seen as a result of mechanical stress and shoulder move-
ment.7 Lead failure or a dislodged lead can lead to a variety of electrical complications,
including undersensing, loss of capture or increased frequency of ectopy. Formal
interrogation is typically required and should be arranged if these findings are noted
on telemetry.

POCKET SITE–RELATED COMPLICATIONS

Pocket Hematoma
The risk of pocket hematoma varies depending on peri-procedure anticoagulation
management. Risk of hematoma is higher for those patients requiring a lead addition
or device upgrade compared with those who are undergoing first time insertions.
When possible, anticoagulation and antiplatelets are held in preparation for the pro-
cedure. In one study looking at the bleeding complications in patients receiving CIEDs,
the risk for pocket hematoma was higher when patients were taking antiplatelets/anti-
coagulation: no anticoagulation 1.6%, aspirin alone 3.9%, dual antiplatelet treatment
(DAPT) 7.2%, and heparin bridge 14.3%.11 Although the risk of pocket hematoma is
only slightly higher when patients are on aspirin therapy, most providers hold aspirin
when possible. Given the high risk of bleeding on DAPT, cardiologists will hold them
when possible (typically a period of 3–5 days prior to procedure). Careful thought,
however, is required if a patient has had a drug-eluting stent during the previous
6 months. Warfarin in low-risk individuals can be stopped for 3 days to 5 days both
pre and post-procedure. For high-risk individuals (ie, those who normally require
bridge therapy), warfarin should be continued without interruption. The Bridge or
Continue Coumadin for Device Surgery Randomized Controlled Trial (BRUISE CON-
TROL) demonstrated that continuation of warfarin at the time of pacemaker implanta-
tion is associated with lower incidence of pocket hematoma compared with heparin
bridge (3.5% vs 16%).12 There is variation on how the direct oral anticoagulants
(DOACs) are handled periprocedurally. Most cardiologists hold the DOAC for 24 to
48 hours prior to and 48 hours post-procedure. The BRUISE CONTROL-2 is an
ongoing randomized trial evaluating the best strategy to manage novel oral anticoag-
ulants at the time of device surgery (estimated study completion date December
2018).13
 Cardiac Pacemakers 383

Pacemaker Infections
Pacemaker-associated infections can occur at any site, including pocket, leads, and
valves. Risk of infection is significantly higher in those patients whose device implan-
tation was complicated by hematoma.14 It has also been observed that pacemaker
infection is associated with early reintervention for complication (ie, hematoma or dis-
lodged lead) as well as comorbid congestive heart failure, diabetes mellitus, and renal
insufficiency.15,16 The incidence of early infection is minimized by the use of perioper-
ative antibiotics at the time of pacemaker insertion.17,18

What are the common pacemaker devices and modes?

A pacemaker may be a single-chamber, dual-chamber, or triple-chamber system. A

single-chamber system paces either the right atrium (RA) or the right ventricle (RV). It
is always best to pace the right atrium and use the heart’s own intrinsic conduction sys-
tem when possible. Revising a single-chamber system to a dual-chamber system is
challenging and associated with some risk, so it is common to place a dual-chamber
system even when right atrial pacing is the goal. Dual-chamber systems consist of
two leads, one in the atrium the other in the ventricle. A dual system is often used in sce-
narios with a dysfunctional AV node; however, it may also be used in cases of sinus node
dysfunction without AV block, in case the extra lead be needed in the future. This ad-
dresses concerns regarding the possibility of progressive conduction disease that
may later require dual-chamber pacing (ie, avoiding a difficult revision procedure).
The pacemaker is a computer that requires programming. These programmed
modes are selected based on a patient’s underlying rhythm and intrinsic conduction.
The NASPE and BPEG published the NBG pacemaker code, last revised in 2002.19
It describes the 5-letter code for operation of implantable pacemakers and is the com-
mon language used to communicate device pacing modes. There are five positions,
although position V is rarely used (Table 2).

Position I
Position I indicates the chamber paced. “A” indicates pacing in the atrium, “V” indi-
cates pacing in the ventricle, and “D” indicates dual pacing (both atrium and ventricle).

Position II
Position II indicates chamber sensed (ie, the detection of spontaneous cardiac depo-
larizations). “A” indicates the ability to sense depolarization in the atrium, “V” indicates
the ability to sense depolarizations in the ventricle, and “D” indicates sensing in both
atria and ventricle (dual). “O” indicates the absence of sensing.

Position III
Position III indicates how the pacemaker responds to a sensed discharge. The pace-
maker may inhibit (I) pacing or trigger (T) pacing. A dual mode (D) indicates that after a
sensed atrial event, ventricular output is triggered but only if no intrinsic ventricular
event is sensed (after specified delay). “O” indicates the absence of any response.

Position IV
Position IV indicates whether or not rate modulation (R) is present or absent (O). That
is, the ability to adjust the programmed rate based on activity (determined by sen-
sors—vibration, minute ventilation).
384 Paglia & Carter

Table 2
NASPE/BPEG pacemaker code

I II III IV V
Chamber paced Chamber sensed Response to Rate modulation Mutisite pacing
sensed beat
O 5 none O 5 none O 5 none O 5 none O 5 none
A 5 atrium A 5 atrium T 5 triggered R 5 rate A 5 atrium
V 5 ventricle V 5 ventricle I 5 inhibited modulation V 5 ventricle
D 5 dual (A 1 V) D 5 dual (A 1 V) D 5 dual (T 1 I) D 5 dual (A 1 V)

From Bernstein A, Daubert J, Fletcher R, et al. The revised NASPE/BPEG generic code for antibradycar-
dia, adaptive-rate, and multisite pacing. Pacing Clin Electrophysiol 2002;25(2):260–4; with permission.

Position V
Position V indicates the presence or absence of multisite pacing (stimulation of both
atria or both ventricles or more than one stimulation site in any single chamber).
This position is rarely used.

APPEARANCE ON ELECTROCARDIOGRAM

The electrical discharge from a pacemaker manifests as a narrow spike on ECG

known as a pacing stimulus or spike. A pacing spike followed by a P wave represents
atrial pacing. A pacing spike followed by a wide complex (typically left bundle
morphology) represents ventricular pacing.
See Fig. 6 for an example of an atrial paced rhythm. This is the ECG of a patient who
received a pacemaker for sinoatrial (SA) node dysfunction. The patient has intact AV
conduction as evidenced by spontaneous conduction of ventricular depolarization
(narrow complex QRS not preceded by a pacing spike).

Fig. 6. Example of an atrial paced rhythm. This is an ECG of a patient who received a pace-
maker for SA node dysfunction.

See Fig. 7 for an example of a ventricular paced rhythm. This is the ECG of a patient
who received a pacemaker for third-degree AV block (complete heart block).

Fig. 7. Example of a ventricular paced rhythm. This is an ECG of a patient who received a
pacemaker for third-degree AV block (complete heart block).

See Fig. 8 for an example of AV sequential pacing, as evidenced by pacing spikes

preceding both the P wave (atrial pacing) and the wide, bizarre QRS complex (ventric-
ular pacing).
 Cardiac Pacemakers 385

Fig. 8. Example of AV sequential pacing, as evidenced by pacing spikes preceding both the
P wave (atrial pacing) and the wide, bizarre QRS complex (ventricular pacing).

Pacemakers with unipolar leads result in much larger pacing spikes than those pro-
duced by bipolar leads. Bipolar pacemaker spikes can be very small and difficult to
see, particularly on a telemetry monitor. Monitors have different settings and
commonly are not set to maximize the identification of pacing spikes. Additionally,
with newer pacemaker models and rate-responsive functions it can be challenging
on an ECG or telemetry to confirm that the pacemaker is both sensing and pacing
appropriately. This can lead to provider confusion and subsequent requests for
interrogation.

COMMON PACING MODES

DDD
DDD mode is the most commonly programmed mode of a dual-chamber or triple-
chamber pacemaker. It ensures AV synchronization with sensed or paced atrial
rhythms (atrial contraction followed by ventricular contraction). Additionally, intrinsic
or spontaneous atrial or ventricular activity occurring outside the refractory periods in-
hibits pacing. Benefits of this mode include preservation of the atrial kick and use of
the native conduction system when possible. The DDD mode may result in one of
four possible ECG rhythms:
 Normal sinus rhythm (A sensed, V sensed) (Fig. 9)

Fig. 9. Normal sinus rhythm (A sensed, V sensed).

386 Paglia & Carter

 Ventricular paced rhythm (A sensed, V paced – also called P wave tracking)

(Fig. 10)

Fig. 10. Ventricular paced rhythm (A sensed, V paced—also called P wave tracking).

 Atrial paced rhythm (A paced, V sensed), seen with sinus node dysfunction with
intact conduction (Fig. 11)

Fig. 11. Atrial paced rhythm (A paced, V sensed). Seen with sinus node dysfunction with
intact conduction.
 Cardiac Pacemakers 387

 Both atrial and ventricular paced rhythm (A paced, V paced) (Fig. 12)

Fig. 12. Both atrial and ventricular paced rhythm (A paced, V paced).

VVI
VVI mode is a single-ventricular pacing mode. The RV is paced at a preprogrammed
interval called the lower rate interval, the longest amount of time allowed before the
delivery of a pacing pulse. A sensed ventricular event (within the lower rate interval)
inhibits pacing the ventricle. If native ventricular electrical activity is sensed, the pace-
maker does not discharge. If native ventricular activity is not sensed, pacing of the
ventricle occurs at the preprogrammed rate. VVIR mode adds the rate modulation (in-
creases rate based on increased minute ventilation or activity).

AAI
AAI mode is a single-chamber atrial pacing mode. The right atrium is paced at a pro-
grammed rate unless inhibited by a sensed event. Because there is no ventricular lead,
and thus no ventricular pacing, the mode is best suited for pure sinus node dysfunc-
tion with preservation of normal cardiac conduction.

VOO
VOO mode is a single-chamber pacing mode that paces the ventricle at a fixed rate.
There is no sensing and, therefore, no coordination with intrinsic, spontaneous
rhythm. Because this program does not synchronize with intrinsic electrical activity
it can be referred to as an “asynchronous mode”. Pacemakers are not normally pro-
grammed to this setting; however, they may be used temporarily in specific situa-
tions. For example, this mode might be used in the operating room to avoid the
risk of inhibition from electrosurgical interference. The other asynchronous modes
are AOO and DOO.
388 Paglia & Carter

Managed Ventricular Pacing

RV pacing over the long term is associated with several adverse outcomes, including
increased mortality from heart failure and increased incidence of AF.20 For this reason,
it is preferred to use the heart’s intrinsic conduction system via atrial based pacing
whenever possible. Managed ventricular pacing (MVP) has both a primary mode
(AAI/AAIR) and a secondary mode (DDD/DDDR). If AV conduction is lost, the device
is designed to switch from primary mode to secondary mode. If AV conduction re-
sumes, pacing again resumes atrial pacing (AAI/AAIR).21 MVP reduces the depen-
dency on RV pacing, using atrial pacing as the preferred mode and, therefore,
maintaining AV synchrony whenever possible. This allows for a more efficient beat
and helps minimize complications that can arise from long-term RV pacing.

Mode Switching
Rapid tracking of atrial tachyarrhythmias is a concern for patients who are prone to
paroxysmal AF, atrial flutter, or other supraventricular tachycardias. With the advent
of mode-switching algorithms, dual-chamber pacemakers programmed to DDD
mode may now be used in this population. In the setting of an atrial tachyarrhythmia,
the device no longer attempts to track each atrial depolarization; rather, it mode
switches and paces the ventricle at a predetermined rate (with ongoing atrial sensing).
DDD mode and atrial tracking resume once the tachyarrhythmia resolves. In addition
to minimizing RV pacing and AV dyssynchrony, symptom surveys reveal that patients
prefer DDD mode with mode switching compared with VVI mode.22

What does it mean to interrogate? Who does it? What information is obtained?
In conjunction with a complete patient history, a pacemaker interrogation can provide
useful information regarding potential pacemaker malfunction and/or underlying
arrhythmia. The most common symptoms suggesting pacemaker malfunction include
near syncope, syncope, or sudden decrease in exercise tolerance.23 Pacemaker interro-
gations are often performed by a specialized nurse, physician assistant, nurse practi-
tioner, or clinical pacemaker specialist/technician but can also be performed by
physicians trained to perform interrogation. Clinical services, such as device interroga-
tion, are typically available around the clock by major device manufacturers and can be
requested by calling the toll-free technical support number specific to each manufacturer.
Basic information obtained during pacemaker interrogation may include:
 Battery status and expected remaining longevity (in years or months)
 The estimate of longevity is based on the remaining voltage of the battery,
pacemaker settings, and percentage of time pacing is used.24
 Elective replacement indicator (ERI) indicates 90 days of reliable function
remains.
 End of life indicates the battery is depleted to the point that function is
unreliable.9
 Pacing mode (ie, AAI, VVI, DDD, etc)
 Upper and lower rate limits (in beats per minute)
 Sensing thresholds
 Sensing is the ability of the pacemaker to detect intrinsic electrical activity and
is measured in millivolts. Higher values imply lower sensitivity.
 Pacing thresholds
 Pacing thresholds, or capture thresholds, are the measurements (in volts and
duration) of the energy required to reliably depolarize the myocardium. Devices
 Cardiac Pacemakers 389

should typically be programmed to double the output of the capture threshold

to ensure consistent myocardial depolarization.25
 Lead impedance
 Impedance is the sum of factors that inhibit electrical current and is measured
in ohms.
 Changes in impedance are more important than the value.
 Very elevated lead impedance implies lead fracture, whereas very low lead
impedance implies lead insulation failure.25
 Stored events26
 Percentage of beats sensed and/or paced in the atrium and ventricle
 High atrial or ventricular rate episodes
 AF burden (in percentage of time)
 Mode-switch episodes

What do patients need to know after getting a pacemaker?

It is important that patients recognize the need for longitudinal care related to their
pacemaker. Although the frequency of follow-up checks varies depending on patient,
pacemaker type, and age of the device, patients are typically recommended to un-
dergo in-person evaluation at least once per year and to enroll in remote monitoring
to allow for automated transmission of data related to important clinical events and
to assess the device’s performance.27
Patients should be aware of the potential for electromagnetic interference (EMI)
related to environmental exposures. This includes limiting the period of time exposed
to such systems as metal detectors for security and antitheft systems near store or busi-
ness entrances. Cell phones do not seem to damage pacemakers but occasionally pro-
viders recommend using them on the opposite side of the device out of an abundance of
caution. Most MP3 player headphones contain a magnetic substance, and thus recom-
mendations are to avoid placing the headphones within 3 cm of the pacemaker.28
Patients should be advised to carry their pacemaker identification card with them at
all times.

What are the other considerations with which hospitalists should be familiar?

MAGNETS

A pacemaker magnet moves a programmable switch in the pacemaker, causing the

pacemaker mode to change to asynchronous pacing at a fixed rate. It is critical that
users know basic device details (ie, ICD vs permanent pacemaker, manufacturer,
and model) and know the current pacing mode setting as well as the magnet mode
setting. The magnet mode depends on the make or brand of pacemaker, the type
of device, and the programming. A magnet moves a switch and users must under-
stand what that switch does or risk adverse events.29
It is common for a magnet to switch a pacemaker mode to DOO at a predeter-
mined high rate (80–100); however, this is not universal. Additionally, if a magnet is
placed over an ICD, it will turn off device therapy (ie, the device will not be able to
deliver a shock). Almost all pacemakers revert to preprogrammed mode and rate af-
ter the magnet is removed (and ICD therapy will turn back on once the magnet is
removed), although it is important to interrogate the device after magnet removal,
particularly if a user is not familiar with the manufacturer programming.
390 Paglia & Carter

Common scenarios requiring magnet application include high-risk surgical proced-

ures (discussed later), radiofrequency ablation, radiation therapy, electrical nerve
stimulation, pacemaker interrogation, and battery testing. Because the magnet pacing
rate for each manufacturer is slightly different, the magnet mode can also be used for
pacemaker identification if other identification attempts have failed. See Fig. 13 for an
example of a pacemaker magnet.

SURGERY

Electrosurgery is the use of electrical current to cut or coagulate. It requires that elec-
trical current travel through tissue in a complete, closed, electrical circuit. A bipolar
electrosurgical unit uses a forceps-style mechanism with the electrical current traveling
from one tip to the other with the tissue in between (more commonly used in neurosur-
gery). A monopolar or unipolar electrosurgical unit uses a grounding plate to direct the
current (often placed on the leg or buttock). Electrosurgery can cause electromagnetic
interference (EMI) and result in bradyarrhythmia or asystole (if EMI leads to pacemaker
inhibition) as well as other complications, including but not limited to:
 Misinterpretation of EMI as atrial signal (P wave) and causing ventricular pacing
(P wave tracking) and subsequent tachycardia.
 Misinterpretation of EMI as ventricular tachycardia (VT) or ventricular fibrillation
(VF), resulting in inappropriate ICD shock.
 Direct damage to the battery or generator.
EMI can be minimized by the following:
 Use of bipolar electrosurgery (keeping electrical circuit between forceps tips,
thus grounding pad not required)
 In monopolar electrosurgery, placing grounding as close as possible to the
surgery site
Surgical sites closest to the generator are at highest risk (chest or neck). For high-
risk surgical procedures, the pacemaker should be programmed to VOO/DOO, which
would eliminate the possibility of misinterpreting the EMI (ie, pacemaker no longer able
to sense). In this situation, it is important to monitor continuous ECG intraoperatively
and be prepared for urgent cardioversion or pacing. Modes, such as DOO/VOO,
require the anesthesiologist to monitor for R-on-T phenomenon (because the pace-
maker is in an asynchronous mode and no longer sensing).

Fig. 13. Example of pacemaker magnet. (Reproduced with permission of Medtronic, Inc.)
 Cardiac Pacemakers 391

The following information is necessary prior to any operative procedure:

 Pacemaker brand and model
 Pacemaker mode
 Indication for the pacemaker (ie, patient’s intrinsic rhythm) and whether or not the
patient is pacemaker dependent
 Magnet mode
 Who is available to interrogate and program the device
This information can be easily obtained by referencing a patient’s ID card or calling
the company (see chest radiograph identification, discussed previously).

Note: electrocautery refers to small, battery-operated devices, which heat a wire tip
(often used by dermatologists and ophthalmologists) and is not synonymous with
electrosurgery.

CARDIAC ARREST

In the event of cardiac arrest, cardiopulmonary resuscitation (CPR) should be per-

formed with the usual technique. In patients with an ICD or a permanent pacemaker,
the placement of paddles/pads should be at least 8 cm from the generator. The
anterior-posterior and anterior-lateral paddle/pad placements on the chest are
acceptable in patients with a permanent pacemaker or ICD. If a patient has an implant-
able defibrillator that delivers a shock during CPR, it is recommended that any external
defibrillation be delayed for 30 seconds to 60 seconds.30

RADIATION THERAPY

Radiation treatment presents unique challenges for patients with CIEDs. Exposure of
the CIEDs to radiation may cause any of several malfunctions, including:
1. Device-related clinical events—pacemaker may inappropriately sense radiation as
intrinsic cardiac activity leading to pauses in pacing therapy (or inappropriate dis-
charges in patients with ICDs)
2. Device-related (nonclinical) malfunctions, such as parameter resets or memory er-
rors/memory wipe-outs
3. Permanent device damage
Theoretically, the device should be relocated if it is directly within a radiation treat-
ment field. In one study,31 malfunction of CIED attributable to radiation occurred in 7%
of the cases reviewed, with 2.5% experiencing clinical symptoms. All cases of mal-
function occurred in the setting of neutron-producing radiation therapy (with no events
noted in electron or proton-producing radiation). For this reason, highest concern is
with high-energy, high neutron production radiation therapy. Algorithms vary from
site to site, although it is typical to have pacemaker-dependent patients secure a mag-
net over the device during therapy (ie, convert to asynchronous mode) followed by
postradiation interrogation. Nondependent patients do not usually require magnet
mode and may be monitored with regular interrogation. Electrophysiology consult is
usually obtained prior to initiation of any radiation treatment regimen.

What is pacemaker syndrome?

“Pacemaker syndrome represents the clinical consequences of AV dyssynchrony or

suboptimal AV synchrony, regardless of pacing mode.”32 Symptoms of pacemaker
392 Paglia & Carter

syndrome include those associated with diminished cardiac output, such as fatigue,
lightheadedness, and lethargy as well as symptoms that can be associated with
congestion, such as shortness of breath, dyspnea on exertion, orthopnea, or neck pul-
sations.33 All these symptoms are more commonly seen with ventricular pacing
modes, such as VVI, particularly when the patient is in sinus rhythm.34 Some of the
symptoms are attributed to the occurrence of atrial kick against closed valves,
although the pathophysiology seems more complicated, including diminished stroke
volume, loss of systemic vascular resistance, and sympathetic activation.31 On exam-
ination, elevated neck veins, pulmonary and hepatic congestion, or lower extremity
edema may be observed. Occasionally, due to these complex autonomic and vascular
changes, hypotension can occur and may lead to syncope and presyncope.35

What is cardiac resynchronization therapy?

Cardiac resynchronization therapy (CRT), also referred to as biventricular pacing, is
used in systolic heart failure to address ventricular dyssynchrony, defined as a delay
in the left ventricular conduction. Most traditional pacemakers pace the RV, which
causes RV contraction prior to the electrical impulse reaching the septum and stimu-
lating the LV. This ventricular dyssynchrony is thought to exacerbate heart failure and
can worsen AF.20 Pacing both ventricles simultaneously can lead to improved hemo-
dynamics (stroke volume and ejection fraction) and improved LV contractility. Meta-
analyses of CRT have revealed a reduction in hospitalizations by 30% and a mortality
benefit ranging from 24% to 36%.36
Class I indications for CRT include: LVEF less than or equal to 35%, sinus rhythm,
LBBB with QRS duration greater than or equal to 150 ms, and New York Heart Asso-
ciation (NYHA) class II, III, or IV symptoms on guideline-directed medical therapy.1

What are the indications for implantable cardioverter defibrillators?

Implantable cardioverter defibrillators (ICDs) are devices used for treatment of tachy-
arrhythmias. ICDs are equipped with both demand pacing functionality as well as the
ability to defibrillate. If a patient develops a tachyarrhythmia, the ICD can sense the
elevated ventricular rate. Dependent on a device’s programming, the ICD may be
able to administer antitachycardia pacing (ATP) with the goal of terminating the ven-
tricular arrhythmia. If ATP is enabled, there is usually a predetermined number of at-
tempts or a prespecified period of time during which ATP can be undertaken. If ATP
fails to terminate the arrhythmia, or the ventricular rate is higher than a particular
rate (such as in VF), then the ICD delivers a shock (defibrillate) in an attempt to restore
normal electrical activity.

Class I indications for ICD placement include:

 Patients who are survivors of cardiac arrest due to VF or hemodynamically unsta-
ble sustained VT, after evaluation to define the cause of the event and to exclude
any completely reversible causes
 Patients with structural heart disease AND spontaneous sustained VT, whether
hemodynamically stable or unstable
 Patients with syncope of undetermined origin AND with clinically relevant, hemo-
dynamically significant sustained VT or VF induced at electrophysiologic study
 Patients with LV ejection fraction (LVEF) less than or equal to 35% due to prior
myocardial infarction (MI) AND who are at least 40 days post-MI AND are in
NYHA functional class II or III
 Cardiac Pacemakers 393

 Patients with nonischemic dilated cardiomyopathy AND who have an LVEF less
than or equal to 35% AND who are in NYHA functional class II or III
 Patients with LV dysfunction due to prior MI AND who are at least 40 days
post-MI, AND have an LVEF less than or equal to 30%, AND are in NYHA functional
class I
 Patients with nonsustained VT due to prior MI, AND LVEF less than or equal to
40%, AND inducible VF or sustained VT at electrophysiologic study

How does an Implantable Cardioverter Defibrillator (ICD) detect an arrhythmia? What

are ICD detection zones?
The programming of an ICD determines its ability to distinguish between a normal
rhythm versus an arrhythmia that requires monitoring or treatment. ICDs are pro-
grammed to have several detection zones programmed. These zones are usually
referred to as VT (ventricular tachycardia) or VF (ventricular fibrillation) zones. Every
patient who has an ICD implanted will have a VF zone established at the time of
implant. This is a programmed zone, set at a particular lower rate limit (for example,
a patient’s VF zone could be set at  190 bpm).
When an ICD senses a high ventricular rate that is sustained and is above the
threshold of the rate set for the “VF zone”, capacitors charge and deliver a shock.
The amount of charge time is dependent on the manufacturer as well as the type
and condition of the battery and capacitor. If the rhythm has not corrected itself by
the end of the charge time, the ICD will check once more for persistent arrhythmia,
and then deliver a high-voltage shock.
ICDs can be programmed with one or two VT zones in addition to the VF zone.
These can be monitoring zones (zones in which the device can detect an arrhythmia
but does not provide therapy), or alternatively, they may be set to allow for specialized
therapeutic intervention (ie, anti-tachycardia pacing or shock therapy).
As an example, the following hypothetical ICD has three separate detection zones,
with their respective interventions:
 VT Zone #1 (Slow VT): 150 to 170 beats per minute: Monitor
 VT Zone #2 (Fast VT): 170 to 190 beats per minute: ATP/Shock
 VF Zone: Greater than 190 beats per minute: Shock
In the case of this sample patient, the ICD would be able to detect high ventricular
rates starting at 150 bpm, but would not provide any therapy until the arrhythmia
reached 170 bpm. At a rate of 170–190 bpm, antitachycardic pacing (ATP) would
be initiated, and if unsuccessful, a shock would eventually be delivered. For rates
over 190 beats per minute, ATP would be bypassed and shock would be delivered.
It is important to note that if this particular patient had a slow ventricular tachycardia
(ie, 125 bpm), the device would not necessarily detect it, as it is slower than the lower
rate limit of VT Zone #1.

Can/should pacemakers be deactivated?

Pacemaker deactivation has the potential to make clinicians feel uncomfortable for
several reasons: (1) pacemaker deactivation in a pacemaker-dependent patient may
lead to immediate death, (2) a patient’s right to refuse treatment typically applies to
new or ongoing treatment decisions (and not undoing treatments that were previously
administered), and (3) an implanted permanent pacemaker could be viewed as part of
the patient’s “self” (much like a transplanted kidney, for example, which would not be
394 Paglia & Carter

“deactivated” at patient’s request). Given this, the deactivation of a pacemaker might

be controversial—perceived not so much as withdrawal of unwanted treatment but
rather as actively hastening or facilitating end of life.
In 2010, the American Heart Rhythm Society (AHRS) released a consensus state-
ment reviewing the ethical and legal concerns associated with device deactivation.
HRS stated that withdrawal of life-sustaining treatment (ie, pacemaker) is neither
physician-assisted suicide nor euthanasia. Furthermore, a patient need not have a ter-
minal condition to have the device deactivated. Pacemaker deactivation is considered
removal of unwanted therapy.37

HRS consensus statement: A patient with decision-making capacity has the legal
right to refuse or request the withdrawal of any medical treatment or intervention,
regardless of whether s/he is terminally ill, and regardless of whether the treat-
ment prolongs life and its withdrawal results in death. When a patient lacks ca-
pacity, his/her legally-defined surrogate decision-maker has the same right to
refuse or request the withdrawal of treatment as the patient would have if the pa-
tient had decision-making capacity.37

The HRS, in its 2010 publication, recommends thoughtful conversation and docu-
mentation of advance directives prior to implantation, which should include
 Clear discussion of benefits and burdens of the device
 Discussion of potential future limitations or burdensome aspects of device
therapy
 Encouraging patients to have some form of advance directive
 Informing of option to deactivate in the future

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