Living with a permanent cardiac pacemaker

Responses of 30 cardiac pacemaker recipients showed that 90 per cent were aware of warning signs and symptoms prior to pacemaker implantation, but only 37 per cent sought medical attention when the initial warning signs were evident. The group which sought care experienced more symptoms per patient than the other groups which did not seek early treatment. The most commonly occurring symptoms experienced by the patients prior to pacemaker insertion were blackouts and slow regarding pacemaker implantation were made by the physician alone. Patients took inventory after implantation, and 60 per cent reported that they were fortunate to have received a pacemaker. During the inventory and long-term recovery stages, patients who thought they had experienced few life-style changes after receiving a cardiac pacemaker reported positive feelings about living with a cardiac pacemaker. Many of the patients' problems in adjusting to a permanently implanted cardiac pacemaker and participating in its maintenance were related to a lack of accurate information about what to expect or how to assure normal functioning of the pacemaker.     

Pacemaker update 1984. Part IV. DDD pacemaker--electrocardiographic assessment and problem solving

Knowledge of the programmed parameters of an artificial pacemaker is critical to the accurate assessment of pacemaker function, especially with the use of an AV universal (DDD) pacemaker. In addition, each manufacturer's idiosyncrasies regarding pacemaker function have to be appreciated to intelligently monitor the rhythm of a state-of-the-art pacemaker.     

Pacemaker infection due to Aspergillus: report of two cases and literature review

BACKGROUND: Aspergillus infections of pacing systems are extremely uncommon, and most cases reported are characterized by an aggressive behavior that may lead to death of the patient. HYPOTHESIS: The study was undertaken to assess the incidence of pacemaker infection due to Aspergillus in a defined population. METHODS: A retrospective review of the case histories of all patients who underwent pacemaker implantation in the reference center for a defined population over a 13-year period was undertaken. A literature review of pacemaker infections due to Aspergillus was conducted. RESULTS: Of the 1,321 patients who required pacemaker implantation at Hospital Xeral-Calde in the Lugo region of northwestern Spain, 38 suffered a pacemaker infection. A pacemaker pocket infection due to Aspergillus fumigatus was found in two patients. Both patients had a previous history of diabetes mellitus. Cultures from pacemaker pocket inflammatory fluid yielded positive results. Following pacemaker explantation and antifungal therapy, clinical improvement was achieved. A literature review showed another five cases of pacemaker infection due to Aspergillus. However, two peculiarities were found in our patients: In both cases an etiological diagnosis was achieved prior to surgery and, to the best of our knowledge, they also constitute the first cases of pacemaker pocket infection due to Aspergillus. CONCLUSION: Although pacemaker infections due to Aspergillus species are uncommon, they should be considered in immunocompromised patients.     

频率适应性起搏器的研究进展

频率适应性起搏器是起搏器发展史上的重大进展。现对频率适应性起搏器作简要介绍,并对近年来频率适应性起搏器传感器(特别是双感受器传感器)、算式和适应证的研究进展进行简要综述。     

Usefulness of Holter Recordings in the Evaluation of Pacemaker Function: Standard Techniques and Intracardiac Recordings

A dedicated pacemaker Holter system facilitates recognition of the pacemaker stimulus by amplifying and displaying it in an ECG channel without any other data. Such a Holter pacemaker channel may occasionally generate electrostatic charges that produce deflections resembling pacemaker stimuli (pseudopacemaker spikes) arising from a loose ECG electrode, crushed tape, or a dirty recording head. False-positive spikes or spurious marker deflections in Holter pacemaker channels and occasional failure to detect tiny bipolar stimuli can present challenging problems in the interpretation of pacemaker function. In multiple-channel recorders, skewing of the recording heads may lead to timing errors and puzzling recordings when one of the ECG or pacemaker channels lags behind others producing asynchrony or malalignment in simultaneously recorded tracings. The interpretation of Holter recordings from contemporary complex pacemakers requires knowledge of pacemaker timing cycles and their interrelationships, a large variety of programmable parameters or functions, behavior of the nonatrial sensor or sensors in rate-adaptive systems, device-specific responses to protect the system from a variety of undesirable situations, and an appreciation of pacemaker eccentricities. There are a few prospective studies on the value of routine Holter recordings in pacemaker patients. The real value of Holter recordings lies with symptomatic patients when symptoms occur during the recording period. Correlation between symptoms and occasional abnormality of pacemaker function during Holter monitoring remains poorly characterized. The cause of the symptoms is frequently unrelated to the pacemaker system and may not be related to coexisting arrhythmias. In asymptomatic patients, Holter recordings are particularly useful to uncover a lead problem after an unrevealing thorough investigation in the pacemaker clinic. Special instrumentation was recently developed to register telemetry data from implanted pacemakers simultaneously with ambulatory electrocardiography. In this way, diagnostic marker signals and/or intracardiac electrograms transmitted from the pacemaker can be recorded continuously for 24 hours by a Holter recorder. Advanced technology involving the memory capability of pacemakers will transform the pacemaker itself into a 24-hour Holter recorder, probably in 4 to 5 years. At present, the memory for storage of intracardiac electrograms is limited from a few seconds to less than a minute according to the manufacturer, but even such mini-Holter recordings can be diagnostically important.     

Permanent left ventricular pacing from the great cardiac vein of a patient with artificial tricuspid and mitral valves--a case report

Transvenous placement of a right ventricular pacemaker lead through the artificial tricuspid valve is a known contraindication, and in this situation, epicardial pacemaker implantation is the procedure of choice. However, permanent pacemaker implantation is a subject for debate when the use of the epicardial route is impossible. This report describes alternate transvenous routes for a pacemaker lead in a patient with an artificial tricuspid valve and mitral valve in whom the epicardial lead and pacemaker generator must be removed because of resistant infection.     

Reel syndrome and pulsatile liver in a patient with a two-chamber pacemaker

Twiddler's syndrome is characterized by coiling of the pacemaker lead due to the rotation of the pacemaker generator on its long axis. Reel syndrome is another form of Twiddler's syndrome. It occurs due to the rotation of the pacemaker generator on its transverse axis with subsequent coiling of the pacemaker leads around the pulse generator. In this article we describe a patient with a two-chamber pacemaker who presented with sudden onset of abdominal pulsation and was subsequently diagnosed as Reel syndrome. To the best of our knowledge, this case is the first case of Reel syndrome that developed in a patient with a two-chamber pacemaker.     

Aspergillus fumigatus pacemaker lead endocarditis: a case report and review of the literature

The diagnosis of fungal endocarditis requires a high index of clinical suspicion. Rarely, pacemaker implantation may be a risk factor for the development of fungal endocarditis. A 71-year-old man with a history of multiple transvenous pacemaker manipulations and fever of an uncertain source is described. A diagnosis of culture-negative pacemaker endocarditis was established only after repeat transthoracic echocardiography. Amphotericin B was instituted; however, the patient developed a cerebral infarct and died. Postmortem examination demonstrated Aspergillus fumigatus within a large pacemaker lead thrombus, tricuspid and aortic valve vegetations, and septic pulmonary and renal emboli. The present report describes the clinical and pathological features of a rare case of Aspergillus fumigatus pacemaker lead endocarditis and suggests that serial echocardiograms may be effective in the early detection of pacemaker lead vegetations. The diagnostic features and therapeutic management of pacemaker lead endocarditis are reviewed.     

A prospective trial of new versus refurbished cardiac pacemakers: a Canadian experience

Pacemaker reimplantation in the same patient is common, and pacemaker transplantation or reuse in a second patient has been reported. No report prospectively compares the long term costs, the impact of reuse on the number of pacemakers implanted, the pacemaker related complications, the types of patients selected and the patient survival of those who receive new versus a refurbished pacemaker. The authors implanted 70 pacemakers of which 75% (52) were new and 25% (18) were refurbished. The refurbished pacemakers were implanted in older patients (P less than 0.02), with a mean +/- SD of 77 +/- 8 versus 69 +/- 13 years of age. During a follow-up period of 36 months, the rate of pacemaker related complications was the same in both groups, with no unusual or unexpected problems arising in the refurbished group. There were 12 (23%) complications in the new pacemaker group and four (22%) complications in the refurbished pacemaker group. There were no major pacemaker related complications, no pacemaker battery depletions and no pacemaker related deaths. The refurbished pacemakers saved $33,000. After three years the cumulative probability of survival in the new group tended to be higher (P = 0.08) with a mean (SE) of 0.62 (0.12) versus 0.44 (0.15). New and refurbished pacemakers are similar with respect to pacemaker related survival and complications. Refurbished pacemakers effect a major reduction in pacemaker costs while maintaining health care standards.     

False inhibition of a demand pacemaker by inactive myocardial electrodes

A 14-year-old girl has been implanted a cardiac pacemaker with a myocardial electrode since 8 years old. As the first myocardial electrode fractured near its tip, the second one was added. Thus, patient had two pairs of myocardial electrode systems with one demand pacemaker implanted. When she was readmitted to hospital because of light-headedness, ECG monitor revealed the frequent suppression of pacemaker emission on transcutaneous waving of pacemaker unit. Application of the magnet over the generator resulted in no inhibition even on moving the unit. The pacemaker pocket was reopened. Waving the active myocardial electrode or pacemaker unit did not inhibit the demand pacemaker, but manipulation of the inactive lead induced suppression of pacemaker emission. Such manipulation produced high interference waves, which were created probably by motion of the cut end of inactive leads against patient's abdominal muscle. The exchange of the demand pulse generator to a fixed mode was followed by complete disappearance of light-headedness in this case.     

Ventricular tachycardia initiated solely by reduced pacing rate during routine pacemaker follow-up

Ventricular arrhythmias during a pacemaker follow-up have been previously reported, usually in conjunction with temporary asynchronous stimulation of a demand pacemaker through magnet application or by increased myocardial excitability, for example, following a myocardial infarction. The subject of this report, an 82-year-old pacemaker patient, had been VVI-paced without problems for the past 11 years. As an aid in determining the sensing threshold, the pacemaker lower rate was reduced from 70 to 40 beats/min. A ventricular tachycardia of 240 beats/min was induced, most likely following short-long cycles; syncope resulted. To our knowledge, this is the first report of induction of a ventricular tachycardia during pacemaker follow-up solely by reduction of pacing rate and not by asynchronous pacing. This case demonstrates an additional potential risk associated with pacemaker rate manipulation during pacemaker follow-up.     

Utility of ambulatory electrocardiography in detecting pacemaker dysfunction in the early postimplantation period

The value of ambulatory electrocardiography (AECG) in detecting pacemaker dysfunction before hospital discharge was assessed in 100 patients a mean of 1.2 days after pacemaker implantation. The incidence of permanent pacemaker dysfunction detected by AECG in the early postimplantation period, the frequency that pacemaker dysfunction detected by AECG was not detected by telemetric monitoring and the frequency that results of AECG led to pacemaker reprogramming before hospital discharge were determined. AECG detected at least 1 type of pacemaker dysfunction in 35% of patients and routine telemetry identified the abnormality in only 8% (p < 0.001). Pacemaker dysfunction occurred in 42% of patients with dual-chamber devices and 27% of those with single-chamber devices (difference not significant). In the 35 patients who had pacemaker malfunction, a total of 50 instances of pacemaker dysfunction were detected. Failure of atrial capture occurred in 2% of patients, failure of atrial sensing in 9%, failure of atrial output in 1%, failure of ventricular capture in 8%, failure of ventricular sensing in 14%, failure of ventricular output due to myopotential inhibition in 11% and pacemaker-mediated tachycardia in 5%. The results of the AECG led to a clinical intervention in 22 patients (pacemaker reprogramming in 21 patients and lead repositioning in 1 patient) in whom no pacemaker dysfunction was suspected on the basis of telemetry or clinical symptoms. In conclusion, AECG provides additional benefit beyond that of routine telemetry monitoring in identifying pacemaker dysfunction in the early period after implantation.     

Runaway pacemaker. Unpredictable pacemaker failure.

The runaway pacemaker is an uncommon but very serious complication of permanent artificial pacemakers. Although the runaway pacemaker has been most frequently encountered in older (fixed rate) pacemakers, this problem has also been reported in various types of newer models manufactured by different companies. The most striking finding in our case is that the pacemaker was reported by a reliable pacemaker follow-up service to be working normally only one week before the development of the malfunction. The extremely rapid pacing rate (750 beats per minute) was a manifestation of a far-advanced runaway pacemaker. The manufacturer believes that this is the first reported incident of a runaway pacemaker in this model. This indicates that the runaway pacemaker is still a potential problem, even in newer pacemakers, and reemphasizes the unpredictable and serious nature of this medical emergency.     

High incidence of pacemaker syndrome in patients with sinus node dysfunction treated with ventricular-based pacing in the Mode Selection Trial (MOST)

OBJECTIVES: We evaluated the incidence, predictors, and treatment of pacemaker syndrome in patients with sinus node dysfunction treated with ventricular-based (VVIR) pacing in the Mode Selection Trial (MOST). BACKGROUND: Pacemaker syndrome, or intolerance to VVIR pacing, consists of cardiovascular signs and symptoms induced by VVIR pacing. METHODS: The definition of pacemaker syndrome required that a patient with single-chamber VVIR pacing develop either congestive signs and symptoms associated with retrograde conduction during VVIR pacing or a >or=20 mm Hg reduction of systolic blood pressure during VVIR pacing, associated with reproducible symptoms of weakness, lightheadedness, or syncope. RESULTS: Of 996 patients randomized to VVIR pacing, 182 (18.3%) met criteria for pacemaker syndrome in follow-up. Pacemaker syndrome occurred early in most patients (13.8% at 6 months, 16.0% at 1 year, increasing to 19.7% at 4 years). Baseline univariate predictors of pacemaker syndrome included a lower sinus rate and higher programmed pacemaker rate. Previous heart failure, ejection fraction, and drop in systolic blood pressure with VVIR pacing at implantation did not predict the development of pacemaker syndrome. Post-implantation predictors of pacemaker syndrome were a higher percentage of paced beats, higher programmed low rate, and slower underlying spontaneous sinus rate. Quality of life decreased at the time of diagnosis of pacemaker syndrome and improved with reprogramming to atrial-based pacing. CONCLUSIONS: Severe pacemaker syndrome developed in nearly 20% of VVIR-paced patients and improved with reprogramming to the dual-chamber pacing mode. Because prediction of pacemaker syndrome is difficult, the only way to prevent pacemaker syndrome is to implant atrial-based pacemakers in all patients.     

Transvenous pacemaker malposition in the systemic circulation and pacemaker infection: a case report and review of the literature

Transvenous pacemaker malposition in the systemic circulation is a rare complication of pacemaker implantation; the incidence is not well known. However, with the aid of two-dimensional echocardiography, the problem of pacemaker malposition can be identified earlier. After pacemaker insertion, an electrocardiogram and a posterior-anterior and lateral chest x-ray should be routinely performed. In difficult cases, transthoracic echocardiography and transesophageal echocardiography can be helpful for better visualization and confirmation of the malposition of the pacemaker lead(s). Pacemaker infection is another complication. A case of pacer lead malposition into the left ventricle through a sinus venosus atrial septal defect and superimposed infection is reported, and the management of endocardial lead malposition in the systemic circulation and pacemaker infection is reviewed.     

永久性心脏起搏器植入早期左心室重构的研究

目的分析起搏器植入后早期左心室重构特点.方法全组患者27例,其中,起搏心室感知心室R波抑制型(VVI)起搏器组15例,起搏双腔感知双腔P波/R波抑制型(DDD)起搏器组12例.采用双探头门控单光子发射计算机断层摄影系统(GSPECT)采集心肌显像资料,测定患者起搏器植入前及植入后随访时(随访期4.6±1.5个月)自身心律状态时下列左心室参数值:左心室射血分数(LVEF),左心室舒张末容积(EDV),左心室收缩末容积(ESV).EDV增加或降低10%及以上者,为重构.结果13例(48.1%)出现重构,VVI组10例(66.7%),DDD组3例(25%).其中,EDV增大7例(25.9%),VVI组5例(33.3%),DDD组2例(16.7%);EDV减少者6例(22.2%),VVI组5例(33.3%),DDD组1例(8.3%).结论起搏器植入后早期,即可出现左心室重构,表现在EDV增大或缩小.本研究提示,永久性心脏起搏器植入在获得电生理学益处的同时,可能对左心室结构带来某些不利影响.     

Unusual case of colonized pacemaker lead presenting with endocarditis, hemoptysis and tricuspid valve stenosis

The present report is the first to describe a case of hemoptysis caused by an endocardial pacemaker lead. In addition, the patient presented with endocarditis and tricuspid valve stenosis. Aggressive treatment consisted of surgical extraction of two pacemaker leads and one pacemaker battery, replacement of the tricuspid valve and implantation of a DDD-R epicardial pacemaker.     

起搏器电池耗竭的心电图表现及临床意义

目的探讨起搏器电池耗竭的心电图表现及其临床意义。方法对23例临床证实起搏器电池耗竭患者的临床资料及心电图进行回顾性分析。结果起搏频率减慢或起搏频率不均6例;起搏频率奔放1例;感知功能异常6例;起搏功能异常3例;感知及起搏功能均异常4例;起搏方式改变3例。结论起搏器电池耗竭可以有多种心电图表现,但必须结合临床,要除外起搏器系统的机械故障及起搏器参数设置不当引起类似的心电图改变,对于证实起搏器电池耗竭的患者要及时更换起搏器。     

Pacemaker recycling:A notion whose time has come

The purpose of this paper is to summarize the need,feasibility,safety,legality,and ethical perspectives of pacemaker reutilization in low-and middle-income countries(LMICs). It will also describe,in-depth,Project My Heart Your Heart(PMHYH) as a model for pacemaker reuse in LMICs. The primary source of the discussion points in this paper is a collection of 14 publications produced by the research team at the University of Michigan and its collaborative partners. The need for pacemaker reutilization in LMICs is evident. Numerous studies show that the concept of pacemaker reutilization in LMICs is feasible. Infection and device malfunction are the main concerns in regard to pacemaker reutilization,yet many studies have shown that pacemaker reuse is not associated with increased infection risk or higher mortality compared with new device implantation. Under the right circumstances,the ethical and legal bases for pacemaker reutilization are supported. PMHYH is a proof of concept pacemaker donation initiative that has allowed funeral home and crematory directors to send explanted devices to an academic center for evaluation and re-sterilization before donation to underserved patients in LMICs. The time is now to pursue large-scale studies and trials of pacemaker reuse for the betterment of society. PMHYH is leading the way in the effort and is poised to conduct a prospective randomized,non-inferiority,multicenter study to confirm the clinical efficacy and safety of pacemaker reuse,for clinical and legal support.     

Faulty design resulting in temporary pacemaker failure

A 77-year-old man became asystolic 3 days after aortic valve replacement and coronary artery bypass surgery. A dual-chamber temporary pacemaker generator was turned on but failed to discharge; instead, an obscure error message appeared on the liquid crystal display of the pacemaker. The intensive-care nurses and physicians were unable to activate the pacemaker. We describe the pacemaker design that led to this instance of pacemaker failure. This case is important because it illustrates how a medical equipment design flaw can turn a human error into a potentially catastrophic event.