Pacemaker Malfunction

Failure to pace occurs when the paced stimulus is not generated when expected. Pacemaker spikes are decreased or absent. It is usually caused by oversensing but can also be caused by lead fracture or insulation defect. Oversensing occurs when pacemaker activity is inhibited by inappropriately recognized non-cardiac activity (i.e., skeletal muscle).

Failure to sense occurs when the pacemaker fails to sense native cardiac activity which leads to asynchronous pacing. Pacing spikes can be seen within QRS complexes. This can be caused by a lead insulation break, new intrinsic bundle branch blocks, electrolyte abnormalities, and Class IC antiarrhythmics.

Failure to capture occurs when delivery of a pacing stimulus does not lead to myocardial depolarization. This can be caused by mechanical lead displacement or fracture, electrolyte abnormalities, and ischemia or infarct.

Failure to Pace

Failure to Sense

Failure to Capture

Examples

Failure to Capture

Failure to capture in a patient diagnosed with Twiddler's syndrome, a rare condition in which the pacemaker malfunctions due to coiling of the device in the skin pocket and resultant lead displacement. Pacemaker spikes (green) are seen without resultant complexes.

Failure to Sense

Failure to sense occurs when the pacemaker fails to sense native cardiac activity which leads to asynchronous pacing. Pacing spikes can be seen within QRS complexes. This case was caused by a temporary pacemaker that became mechanically dislodged during transport.

Pacemaker Mediated Tachycardia

This is pacemaker-mediated tachycardia (PMT), or endless loop tachycardia. This patient received amiodarone and the arrhythmia ceased.

References

Mulpuru SK, Madhavan M, McLeod CJ, Cha YM, Friedman PA. Cardiac Pacemakers: Function, Troubleshooting, and Management: Part 1 of a 2-Part Series. Journal of the American College of Cardiology. 2017;69(2):189-210.
Berberian JG, Levine BJ, Brady WJ. EMRA EKG Guide. 1st ed. Emergency Medicine Residents’ Association; 2017.