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Types of Pacemakers and their Complications

By DoRIs J. W. EsCHER, M.D.

T HE THREE TYPES of artificial cardiac choices in pacing rate, current amplitude, and mode
pacemaker systems in common clinical use of action. Several models are available (table 1).
are: Common features are that they are small in size
1. Implantable pulse generators with endo- (average 11.7 x 7.4 x 3.1 cm), are light in weight
cardial or myocardial electrodes for long-term or (average 3.0 g), can be strapped to the patient's
permanent use. chest or limbs, are designed to accept, directly or by
2. External, miniaturized, transistorized, patient- adapters, all or almost all electrodes likely to be
portable, battery-powered, pulse generators with utilized with them, are readily serviced for battery
exteriorized electrodes for temporary transvenous changes or cleaning, are capable of gas autoclaving
endocardial or transthoracic myocardial pacing. for sterilization or contamination control, and are of
3. Console battery- or AC-powered cardiovertors, increasingly dependable reliability.
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defibrillators, or monitors with high-current external These units operate in the asynchronous and R-
transcutaneous or low-current endocardial or myo- wave inhibited modes over a wide range of rates.
cardial circuits for temporary pacing in asynchro- Their low trigger sensitivity may allow for their use
nous or demand modes, with manual or triggered in atrial as well as ventricular noncompetitive
initiation of pacing. pacing. The Vitatron Triplextern offers the addi-
tional feature of ventricular synchronous pacing.
Console Pacemakers This has a very useful special application in
The simplest and fastest method of pacing is treatment of pacing failure of an implanted system
external transcutaneous stimulation by two elec- operating in the fixed-rate mode with intermittent
trode plates or subcutaneous needles applied to the stimulus output or with regular output but intermit-
skin of the chest.1 However, the high voltages tent capture. In these cases, where the implant
required (75-150 v) to penetrate to the heart result emission cannot be suppressed by external stimuli
in vigorous and painful contractions of the muscles and induces competition with asynchronous exter-
of the chest wall, tolerable only under sedation. nal pacing or suppression of R-wave inhibited
Capture is uncertain ill the obese or emphysema- external pacing, synchronous pacing locks to the
tous patient, and skin burns may occur as a result of timing of the implant emission and effects noncom-
insufficient electrode jelly or prolonged use. This petitive external supplemental pacing. It is not
route of pacing, therefore, is reserved for brief preferable to ventricular-inhibited pacing in routine
emergencies or where no other means are available. use, as the stimulus artifact in the absolute
The use of alternating current (AC) powered refractory period deforms the electrocardiogram
consoles for temporary endocardial or myocardial and may not be absolutely safe.3 The Triplextern
stimulation always carries the risk of malfunction also has a six-beat hysteresis in the R-wave
with the possibility, despite safeguards, of inducing inhibited node.
ventricular fibrillation by AC leakage into the The optional rate-doubler feature of the General
pacing wires.2 Electric External Standby is useful in the special
Battery-powered consoles eliminate this direct case of rapid supraventricular tachyeardias where it
risk, but as pacemakers they are bulky, limit permits capture and rate reduction by overriding
mobility and ambulation, and are less convenient pacing or the disruption of a rapid tachycardia or
and more expensive than miniaturized units. flutter by the blocking action of brief application of
External Pacemakers very high rates.4' 5 Rapid fixed rate pacing (to 400

External, patient portable, battery-powered pulse beats/min), atrial and ventricular synchronous or
generators are designed to provide a wide range of stimulus-inhibited pacing, and paired and coupled
pacing are otherwise available only in specialized
instruments, such as Medtronic Multiple Mode
From the Cardiology Service Medical Division, Montefiore
Hospital and Medical Center and the Albert Einstein Research Generator (5837) or the Cordis Syn-
College of Medicine, Bronx, New York. chrocor II.
Circulation, Volume XLVII, May 1973 1119
1120

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Circulation, Volume XLVlI, May 1973
TYPES OF PACEMAKERS 1121
Any unipolar or bipolar temporary or implantable and stiffer electrodes are more likely to stay in place
pacemaker electrode can be connected to any of if they are positioned visually as well as electrically.
these external generators. The routes and technics They are inserted in the jugular and brachial veins
of application and their special utilities or problems by direct cutdown, and similarly in the femoral
are: veins of children. In adults, they are passed
(1) Percutaneous transthoracic direct myocar- routinely by percutaneous needle in the femoral
dial puncture of the left ventricle by a needle vein and occasionally in all other veins. The
electrode or by a temporary needle inserter through semifloating electrodes are almost always inserted
which a fine-wire or coil-spring electrode is passed by percutaneous needle, usually by the subelavian
to the lumen.6 This technic, reserved for the acute or brachial veins, and occasionally by any other
emergency, can be lifesaving. Complications are vein. They can be monitored by electrocardiograph
potentially grave and include the possibility of or X-ray.
pneumothorax, damage to a coronary artery, tam- A number of complications relate specifically to
ponade, and, especially if used during closed-chest particulars of application. The brachial route is
massage, of unstable pacing or electrode displace- associated with an increased incidence of thrombo-
ment. phlebitis'1 and of motion displacement12 of any
(2) Myocardial wires inserted by thoracotomy electrode (especially if the arm is lifted over
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after pulmonary or cardiac surgery6' 7 In this shoulder level) with disruption of pacing'3 and
application, an exposed segment of an otherwise myocardial perforation.14 To a lesser degree, motion
insulated 0 or 00 braided-steel wire suture is displacement occurs with the femoral route when
stitched through the myocardium in such a fashion both knee and hip are flexed 90', but disruption of
that a light tug can remove it without difficulty. pacing is much less frequent (5-7%) and accidental
Two wires are applied to the chamber to be paced perforation of the artery during insertion (3%)
(atrium or ventricle) for bipolar pacing. In responds promptly and benignly to 5 min of local
unipolar pacing, one wire (the cathode) is applied pressure.9 15
to the myocardium, and the second "indifferent" The subelavian route is known to allow arterial
wire (anode) is applied to the skin. Common puncture (3%), pneumothorax (0.7%), and rarely an
difficulties are premature displacement of the extravascular, intrapleural electrode passage. The
loosely applied wires and/or marked increases in relatively high freouency of easilv corrected elec-
threshold to pace. Less frequently, failure to pace is trode malposition (17%) is not a function of route
caused by touching of exposed wires or their but of positioning by electrocardiography rather
approximation in fluid pools, with short circuit of than by direct vision. Bacteremia (1%) and gross
output or demand suppression of output by ectopic sinus infection (2%) are problems common to all
(wire motion or interference) signals. If the signals percutaneous insertions but fortunately of low
are rapid transients, they may not be seen on the incidence, especially with good skin hygiene, and
peripheral electrocardiogram or even on the myo- are promptly responsive to electrode withdrawal
cardial electrogram but should appear on an and antibiotic therapy.16
oscilliscope with an expanded time and amplitude Most of the operating complications are inherent
scale.8 in the situation: the external electrodes are
(3) Percutaneous transvenous endocardial cathe- temporarily connected; the pulse generators are
ter electrodes passed to the right ventricle or right subject to disruption and interference because they
atrium though the right or left subclavian vein by are exposed and mobile, with adjustable controls
the infra- or supraclavicular route and the right or
left femoral. brachial, and external or internal and short-life removable batteries; they are han-
jugular veins.9' 10 The electrodes commonly used are dled, mishandled, and serviced by various person-
the United States Catheter and Instrument Corpo- nel or even patients. Because they are exposed,
ration (5651, 5652) and the Electro-Catheter however, they can be inspected, tested, repaired, or
Company (Elecath 0501-2, 3501-2) 5F and 6F changed with no trauma to the patient unless an
bipolar catheter electrodes, usually passed under electrode has to be repositioned or replaced. The
direct observation by fluoroscopy, and the Cordis major problems are an increased incidence of
Corporation (370-110) and Elecath (561) semi- external damage, wetting, wire shorting, poor
floating 4F bipolar electrodes, usually passed by extermal electrode contact, gross electrode displace-
indirect electrocardiographic control. The heavier ment or internal electrode malposition, battery
Circulation, Volume XLVII, May 1973
1122 ESCHER
depletion, and the increased risk of AC interference petitive instruments. Implanted pacemakers are
or induced fibrillation.2' 8 further cross categorized by whether they are
Implanted Pacemakers
unipolar or bipolar, transvenous endocardial or
transthoracic myocardial systems and whether they
Implanted pacemakers are of two basic types: are pacing the ventricle or the atrium.
(1) fully implanted; (2) radiofrequency or electro-
magnetically coupled semiimplants. Asynchronous Pacemakers
In the semiimplanted group, the pulse generator, These are defined as "pulse generators in which
with replaceable batteries and variable rate and the repetition rate is independent of the electrical
current-amplitude controls, is carried externally. Its and/or mechanical activity of the heart."26 Their
pacing stimulus is released through a primary-coil stimulus repetition rate usually is set at 60-70
antenna taped to the patient's skin overlying an beats/min for adults and 80-100 beats/min for
implanted secondary-coil receiver. The implanted children, and they discharge at this rate regardless
unit is a subcutaneous secondary coil attached to a of the underlying rate or rhythm of the patient.
standard implantable myocardial or endocardial They have the simplest construction and are the
electrode.17-21 Surgery is not required for pulse most stable and long lasting of all implants. Without
generator replacement, and many threshold or a current-utilizing, continuously operating sensing
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rhythm problems can be handled by changes of rate circuit they have fewer components to fail, no
or current amplitude or the use of specially tailored nonpacing battery drain,27 28 and little or no
pulse generators.22 The very small size of the response to electromagnetic interference.29 They
receiving capsule can be accommodated in the even have a somewhat lower incidence of problems
limited subcutaneous tissue of infants or cachectic with their electrodes, because they exclude those
adults eliminating the tumescence and pressure related to failure to sense or to the delivery of false
necrosis that can result in these patients even with signals as may occur in triggered systems.27
"pediatric"-sized fully implantable pulse genera- The major defect of asynchronous pacing is
tors. The disadvantages are the bulk, constant competition if there are interpolated spontaneous
presence, and psychological pressure of the need to beats or tachyarrhythmias. Patients often find the
care for the external generator and relatively fragile resultant "palpitations" disquieting. Physician dis-
antennae, the risk of accidental displacement or quiet foresees competition-induced ventricular
fracture of the antennae (intrinsic to this system), fibrillation. The degree of risk of this occurring is
and the fact that these systems operate only in the disputed but is probably low in healthy patients
fixed-rate mode. In the United States the relatively and increases if there is tissue anoxia or injury,
carefree fully implanted pacemakers are preferred, electrolyte imbalance, or drug toxicity.30-32
and therefore the semiimplanted systems are very Atrial Synchronous Pacemaker
rarely used. Only one, the Cordis Corporation
Transicor, is available by special order. In Europe, Historically the first implantable triggered sys-
especially England, they are in more prevalent use, tem,33 it is "a ventricular stimulating pulse genera-
even where competition could be anticipated tor, the repetition rate of which is directly
because of their fixed-rate limitation.23-25 determined by the atrial rate"26 (table 3). It senses
Fully implanted pacemakers are now manufac- the atrial contraction voltage and, following a
tured in most nations with sophisticated technol- simulated P-R interval, emits a ventricular stimulus.
ogies. Tables 2 and 3 list most instruments made or It utilizes two electrodes, atrial sensing and
retailed in the United States. Established producers ventricular stimulating. These are usually sutured to
and new firms (e.g., in the U.S.A., Edwards the left atrium and ventricle, when implantation is
Laboratories) regularly introduce new models. by thoracotomy. The atrial potential to the sensor is
Fully implanted pacemakers are categorized 3.0-8.0 mv.34 Right-sided transvenous atrial synchro-
primarily on the basis of their pulse-generator nous pacing is much less reliable as atrial electrode
function as asynchronous, atrial synchronous, ven- stability is difficult to maintain and the atrial signal
tricular synchronous, and ventricular inhibited. The is only 0.5-3.0 mv.34 35 If the atrial signal is lost,
latter three, with sensing circuits, are also known as becomes subthreshold, or slows below the base rate
triggered pacemakers. The ventricular synchronous (lower escape rate), these pacemakers are pro-
and ventricular inhibited units, variously termed gramed to drop into asynchronous pacing at 60-70
demand or standby pacemakers, are both noncom- beats/min for adults, 70-90 for children. An upper
Circulation, Volume XLVII, May 1973
TYPES OF PACEMAKERS 1123

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Circulation, Volume XLVII, May 1973
TYPES OF PACEMAKERS 1125
escape limit protects the ventricle against direct Thoracotomy, which does provide stable position-
stimulation in anl atrial tachycardia by initiating a inig, is acceptable in the young, difficult for the old,
2:1, 3:1, or 4:1 block. A poststimulation refractory and obligates repeat thoracotomy if there are
period to sensing or pacing protects against initrathoracic electrode problems. With loss of atrial
reactivation of the pacemaker by its own electrode sensing, fixed-rate pacing supervenes, competitive if
capacitance and against an early atrial premature there is an underlying spontaneous rhythm. Occa-
contraction releasing a competitive stimulus on the sionally, the sensor responds to a ventricular instead
T wave of the preceding QRS. of an atrial signal, and the pacing stimulus is
The complicationis of atrial synchronous pacing emitted at the end of the QRS or start of the T wave.
iniclude the following: This is probably not dangerous as long as the
(1) Difficulty in positioning and maintaining impulse is delivered early enough in the S-T area to
transvenous atrial electrodes for stable sensing avoid the vulnerable zone (fig. la).
despite newly designed electrodes or special tech- (2) Heart failure or angina with stimulated
nics for transvenous36, 3 or mediastinal insertion.38 ventricular rates of 100-120 or 140-150 beats/min,
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S A Y V

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(a.) Atrial synchronous pacing (S) with an asynchronotus paced beat (A) and ventricular triggering (V).
(b.) Atrial synchronous pacing with intruding ventricular extrasysotles. This artifact may be ventric-
WzZar synchronized and triggered; if it were not sensed it would fall on the apex of the T wave asyn-
chronously. (c.) Rate acceleration of triggered pacemakers by external interference. (d.) Ventricular syn-
chronous pacing with late sensing (third and fifthQRS) and triplets (third and fifth beats and fifth to
seventh beats), because of early unsensed extrasystoles. (e.) Bifocal pacing with atrial and ventricular
stimulation with response to an extrasystole. (f.) Inadequate sensor signal. The difference between the
large distal and proximal intracardiac bipolar signal (left and middle complex, respectively) is so little
that the bipolar signal generated between them is barely 2 mw (right complex).
Circulation, Volume XLVII, May 1973
1126 ESCHER
in response to the sensed rapid atrial rates of sinus must be checked periodically by overdrive stimula-
tachyeardias, multiple atrial extrasystoles, or atrial tion or magnetic conversion to asynchronous
flutter or fibrillation with inadequate block. Digital- pacing.
is does not affect the blocking mechanism in these (2) Failure to sense (electrode malposition,
cases, and these upper escape rates, designed to battery depletion, or signal decrement) results in
accommodate to a sinus response to exercise, are fixed-rate pacing and, if the pacing threshold is sus-
too high for the patient with a diseased myocardi- tained, competition with spontaneous rhythms.4' 42
um, prothetic valve, or coronary narrowing. In a (3) The synchronous-pacer artifact consistently
coarse atrial fibrillation, signals of trigger amplitude distorts the electrocardiogram even during sinus
may result in irregular ventricular tachyarrhythmias rhythm. Magnetic mode pacing allows occasional
interspersed with fixed-rate pacing. Here, digitalis breakthrough of unpaced spontaneous beats if the
may convert a coarse fibrillation to a finer more rhythm is at or over the escape rate, but this
rapid action, less likely to elicit synchrony. engenders competition and is avoided when the
(3) Failure to sense or accommodate to ventricu- need to see a true complex is the highest, i.e.,
lar extrasystoles which produce an effective ventric- during an acute coronary.
ular tachycardia if they intrude between sinus (4) Extrasystoles that come within the refractory
paced beats and competition if the succeeding period of a paced beat are not sensed, and the next
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atrially triggered stimulus falls on the vulnerable paced beat, cycling at the escape rate from the
period of their T wave (fig. lb). previous paced beat, results in a tachyeardic triplet.
(4) Susceptibility to electrical or electromagnetic Prolongation of the refractory period enhances this
interference which in the physiologic rate range effect and allows the paced "escape" beat to come
trigger simulated atrial premature contractions uncomfortably close to the T wave of the "missed"
when the signals are discrete or drive the pulse spontaneous beat.41 43 These mixtures of spontane-
generator to its upper limit of performance if ous and ectopic beats, with synchronous and paced
repetitive. At supraphysiologic rates, including 50-60 beats, are difficult to interpret and often alarming to
cycle alternating current, the pulse generators block the uninitiated (fig. ld).
to asynchronous pacing usually at their lower (5) A wide variety of transient "interference"
escape rates (table 3). The risk of competition currents, including those produced by the magnetic
engendered is less than that of a sustained upper- or radiofrequency tripping of the magnetic switch,
limit tachycardia (fig. lc). wire breaks, faulty connections, short circuits,
Ventricular Synchronous Pacemaker
whipping catheter motions, and tall T waves, are
equated with QRS signals by the sensor circuit.44
This pacemaker is one with "a ventricular This results in an erratic, frequently competitive,
stimulating pulse generator delivering its output pacing output. With repetitive stimuli, however, the
synchronously with the natural ventricular activity response rate cannot exceed the top design output
and asynchronously in the absence of natural of the pacemaker (a fail-safe feature) (fig. lc) .45 A
ventricular activity"26 (table 3). Ventricular syn- positive effect of this interference sensitivity is that
chronous pacemakers are modifications of atrial these pulse generators may be externally triggered
synchronous pacemakers. They have a similar upper to overdrive rates (to their upper escape limits),
and lower safeguard escape rate, but utilize a single which is useful in the treatment of postimplantation
ventricular electrode for sensing and stimulation, multifocal extrasystoles or intermittent tachy-
have a lower trigger sensitivity, an almost immedi- arrhythmias.
ate response to a trigger stimulus, logic to (6) Late synchronization occasionally occurs
differentiate the QRS from the P and T waves, a with the stimulus late in the QRS. Rarely, it reaches
refractory period of about 400 msec, and a the vulnerable zone and initiates early or repetitive
magnetic-switch asynchronous mode. They are contractions.46 In right-sided transvenous pacing, it
noncompetitive with ventricular activity except in has been ascribed to origination of the contraction
very rare instances and insensitive to nontransmit- on the left with delayed conduction to the right
ted atrial activity.39 40 (RBBB). There may also be a specific latency, with
Special problems or deficits associated with their either ventricle, particularly in recent infarction
use include the following. (fig. Id).
(1) During sustained synchronous stimulation, (7) Impulses driven into the "absolute refrac-
the threshold to pace is uncertain, and its adequacy tory" period may sensitize to lesser, later impulses.
Circulation, Volume XLVII, May 1973
TYPES OF PACEMAKERS 1127
This suggests reexamination of the use of the by the length of one refractory period. Occasional-
ventricular synchronous mode and may be a source ly, stimulation is markedly delayed when a short
of problem in competition.3' 46 refractory period, a low trigger sensitivity, and a
(8) The ventricular synchronous pacemaker high pacer output or capacitance combine to
has the shortest mean longevity of battery life due recycle these pulse generators from one to four
to constant pacing, often above the escape rate, and times.27' 43
the additional current drain of the sensing (B) Partial sensing with incomplete inhibition
circuit.27 and rate irregularities from a marginal signal or
borderline reception of a normal signal in a narrow
Ventricular-Inhibited Pulse Generator zone between the refractory and alert period. These
This is "a ventricular stimulating pulse generator low signals, observed primarily in Medtronic 5841
which suppresses its output in response to natural and 5842 and American Optical pacemakers, cause
ventricular activity, and produces an output asyn- incomplete saturation of the output circuit and
chronously in the absence of natural ventricular partial, rather than complete, recycling.48 They may
activity"26 (table 3). It is a noncompetitive pace- occur with other equipment.
maker with an escape rate below which it paces (C) Recycling by large P or T waves (particu-
asynchronously (60-70 beats/min in the adult) and larly if superimposed), which may result in a
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above which stimulus output is suppressed, leaving bradycardia from T-wave sensitivity or asystole
the patient and electrocardiogram unaffected.47 The from repetitive P-wave stimuli.27' 41 49 These mar-
refractory times are foreshortened (75-325 msec) to ginal currents also may induce partial recycling.
allow early response to ectopic activity. All models (D) Inhibition by local nonpropagated ven-
have magnetic switches to convert conducted or tricular currents (concealed extrasystoles), which
other spontaneous rhythms to fixed pacing except trigger the sensor but not a contraction. They are
the discontinued Medtronic 5841. This enables unseen on a peripheral electrocardiogram, appear
testing for the ability to pace in a patient, normally as transients on an intracardiac electrogram, and
in the inhibited mode, and counting of the output may be suppressed by antiarrhythmic medication or
rate for battery follow-up. The General Electric, overdrive pacing.50
Medtronic 5843 and Vitatron have a rate-hysteresis (E) False signals (transient currents) from
capability. Several are cased in metal as a any type of incomplete wire break, sheath interrup-
radiofrequency interference deterrent and/or to tion, intermittent short circuit, wetting, loose
exclude moisture. connection, contact with an adjacent second elec-
Ventricular-inhibited pacing is the most popular trode (active or inactive), or whipping resistance
mode in use. The lack of artifact output during altering or catheter motion which may be the
spontaneous rhythm leaves the electrocardiogram source of erratic sensing. This is often associated
clear and also is battery sparing, with significant with intermittent failure to pace without evidence
improvement in longevity.27' 30 The inability to of battery depletion.51-53
accelerate rate by triggering (except in the General (F) Suppression by alternating currents, or
Electric A7072 and discontinued Medtronic 5841) is radiofrequency, electromagnetic, and magnetic in-
discounted. terference. Weak alternating current leaks from
Complications of use include the following: poorly grounded equipment have no direct route to
(1) The major problem of ectopic (non-QRS) fibrillate the heart. If of magnitude enough to affect
suppression of output, induced by a variety of the pacemaker, they will be sensed, and the contact
signals: is usually severed before serious effect. Radiofre-
(A) Self-inhibition, because the short refrac- quency and electromagnetic signals are silent. The
tory period of several pacemakers allows feedback patient may appreciate palpitations in synchronous
of undissipated stimulus afterpotential (capaci- pacemakers, but inhibited pacemakers suppress
tance) from the electrode tissue interface. If the function without warning and may kill a dependent
current is of trigger magnitude, it is not differenti- patient. The signal sources that have been de-
ated from a QRS and reinhibits output for another scribed or tested include various types of electric
cycle. In the Medtronic 5841 and American Optical motors (tools, household, garden) automobile
DB7 or DM7, one recycle always occurs after a ignition systems, arcing television sets, electric on-
paced beat making the paced-to-paced R-R interval off switches (all spark-gap sources), electric razors,
longer than the spontaneous-to-paced R-R interval diathermy, electric cautery, microwave ovens,
Circulation, Volume XLVII, May 1973
1128 ESCHER

power generators, and television, radio, and radar sheath around the electrode. In some radiofrequen-
transmissions.2- 8' 29, 54-63 cy rate-controllable R-wave inhibited pacemakers, a
Fortunately, actual accidents are so infrequent drop in output occurs with an increase in rate (the
that virtually all are reported. Most small motors discontinued Medtronic External 5840 and General
(tools and appliances) have too low an output to Electric implanted demand pulse generators). At
be dangerous unless they are held directly over the threshold to pace this can result in loss of capture.
pacemaker (unlikely). Larger signals, such as from The obsolete Medtronic 5841, however, may be
on-off switches or arcing equipment (i.e. television boosted transiently to threshold by overdrive with
sets), are short-term or intermittent and, except in its external control (5855). This is specific for this
automobile ignitions or razors, not likely to inhibit instrument with failure to pace from battery
the pacemaker for more than a beat or two. depletion.63
Specificity further reduces incidence, so that only (3) Failure to pace. In an R-wave inhibited
some pacemakers in some patients are affected by pulse generator this has special significance, as it is
some equipment. The greater degree of vulnerabili- totally unrecognized in the patient in spontaneous
ty that could be anticipated with radiofrequency rhythm until that rhythm fails and a bradycardia or
receivers (the semiimplants, the General Electric asystole results. It is monitored by testing with
periodic magnetic fixed-rate pacing.
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generators with rate controls) has not, apparently,


been an issue. In high-frequency interference, A-V Sequential Pacemaker
inhibition may be by the carrier wave or a low-
frequency modulation, which brings the impulse A special pacemaker in the R-wave inhibited
into the physiologic rate range (microwave-oven category is the A-V sequential pacemaker.66' 67 It
fans). The most vulnerable environment, particu- uses two electrodes to pace the atrium and/or
larly for external pulse generators, is the hospital ventricle but senses only in the ventricle. In sinus
with its diathermy, cautery, cardioversion, and rhythm or conducted beats at a normal rate, all
electroshock therapy, monitoring equipment, mi- activity is suppressed. Its sensing interval is from
crowave ovens, electric beds, and electrical life-
the last ventricular voltage to the next P wave. In
support equipment. atrial asystole, loss of signal, or sinus bradycardia,
A positive use of ectopic inhibition is external with a normal P-R interval and atrioventricular
chest wall stimulation to suppress the output of an conduction, it senses the slow rate and paces the
implanted pulse generator and display the underly- atrium. With P-R prolongation over a preset
ing rhythm. Care must be taken to protect against interval or atrioventricular block, it senses a delay
asystole or escape arrhythmias.62 63 in ventricular response and paces the ventricle also,
(2) Low sensor signals or loss of sensor signal providing atrioventricular sequential stimulation
with failure of appropriate inhibition that results in (fig. le). Its magnetic mode tests ability to pace
fixed rate, sometimes competitive pacing. The (paces both atrium and ventricle at a higher rate
sources of initially poor signals include an underly-
with a shorter P-R interval) and provides a
ing myocardial scar, inadequate myocardial or "counting" rate for battery evaluation.
endocardial contact (poor position), poor orienta- The A-V sequential pacemaker is an excellent
tion of a bipolar electrode with a less than 2-mv concept but, in practice, it is a complex pacemaker
amplitude in the bipolar voltage (the trigger with an increased potential for malfunction and a
signal) (fig. lf), and abnormal signals that do not relatively high incidence of trouble.67 Sensing diffi-
program appropriately. Abnormal signals include culties, compounded by a short refractory period,
the splintered and discoordinate signals of severe result in complicated competition patterns, and self-
myocardial disease with conduction disruption or inhibition (potentially lethal) may occur, particu-
tall R waves that rise in steps (seen only on an larly in transvenous installations where an atrial
oscilloscope) and are misread by the pacemaker as stimulus from a malpositioned electrode may fail to
a series of subthreshold signals.64' 65 Late loss of pace the atrium and at the same time inhibit the
sensor signal occurs with partial wire break, ventricular stimulus. Battery drain is high (dual-
insulation tear with current leak, malposition to a output circuits and a complex sensing system), and
poor signal area (especially in transvenous systems trouble-free long-term pacing is not yet a satisfac-
where it includes myocardial perforation with or tory clinical reality.
without phrenic pacing), a fresh coronary with loss Temporary or implanted ventricular pacing
of myocardial voltage, and growth of an insulating systems can and are used to pace the atrium
Circulation, Volume XLVII, May 1973
TYPES OF PACEMAKERS 1129
particularly in atrial dysfunction or where there is generator or the patient's myocardium is respon-
intact conduction, to overdrive the ventricle in a sible for the "malfunction."
more physiologic, safer approach.6870 When the It is of note that with all of these possibilities for
atrial electrode is applied by thoracotomy, and if, in complications most patients and their pacemakers
triggered systems, a high-sensitivity pacemaker is coexist in amity and, more important, survive with
used, a stable effective system results. In transve- substantial success and safety.
nous systems unstable electrode positions for pacing
and sensing and low-strength trigger signals are the References
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combined with an appropriately sensitive pace- 1967
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conduction delay,68 electrode displacement with
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Circulation, Volume XLVII, May 1973
1130 ESCHER
16. CAMPO I, GARFIELD G, ESCHER DJW, FURMAN S: 36. SMYTH NP, BASU AP, BACOS JM, MASSUMI R,
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Circ ulaUion, Volume XLVII, May 1973
TYPES OF PACEMAKERS 1131
55. CRYSTAL RG, KASTOR JA, DESANCTrIs RW: Inhibition 67. FURMAN S, REICHER-REISS H, ESCHER DJW: Atrio-
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Circulation, Volume XLVII, May 1973


Types of Pacemakers and their Complications
DORIS J. W. ESCHER

Circulation. 1973;47:1119-1131
doi: 10.1161/01.CIR.47.5.1119
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 1973 American Heart Association, Inc. All rights reserved.
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