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Troubleshooting Part I. Objectives:. Understand the four basic steps used to solve troubleshooting problems Identify ECG abnormalities that result from pacing system malfunction and pseudomalfunction Recognize data and resources available to aid in troubleshooting pacing system anomalies

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  • Understand the four basic steps used to solve troubleshooting problems
  • Identify ECG abnormalities that result from pacing system malfunction and pseudomalfunction
  • Recognize data and resources available to aid in troubleshooting pacing system anomalies
  • Discern pacemaker functions that can affect patient hemodynamics
  • Describe the causes of pacemaker system anomalies and propose a potential solution
the steps used in troubleshooting are simple and remain the same for each type of problem
The Steps Used in Troubleshooting Are Simple and Remain the Same for Each Type of Problem
  • Define the problem
  • Identify the cause of the problem
  • Correct the problem
  • Verify the solution
potential problems identifiable on an ecg can generally be assigned to five categories
Potential Problems Identifiable on an ECG Can Generally Be Assigned to Five Categories:
  • Undersensing
  • Oversensing
  • Noncapture
  • No output
  • Pseudomalfunction
  • An intrinsic depolarization that is present, yet not seen or sensed by the pacemaker

P-wavenot sensed

Atrial Undersensing

undersensing may be caused by
Undersensing May Be Caused By:
  • Inappropriately programmed sensitivity
  • Lead dislodgment
  • Lead failure:
    • Insulation break; conductor fracture
  • Lead maturation
  • Change in the native signal
  • The sensing of an inappropriate signal
    • Can be physiologic or nonphysiologic

...Though no activity is present

Marker channel shows intrinsic activity...

Ventricular Oversensing

oversensing may be caused by
Oversensing May Be Caused By:
  • Lead failure
  • Poor connection at connector block
  • Exposure to interference
noncapture is exhibited by
Noncapture is Exhibited By:
  • No evidence of depolarization after pacing artifact

Loss of capture

noncapture may be caused by
Noncapture May Be Caused By:
  • Lead dislodgment
  • Low output
  • Lead maturation
  • Poor connection at connector block
  • Lead failure
less common causes of noncapture may include
Less Common Causes of Noncapture May Include:
  • Twiddler’s syndrome
  • Electrolyte abnormalities – e.g., hyperkalemia
  • Myocardial infarction
  • Drug therapy
  • Battery depletion
  • Exit block
no output
No Output
  • Pacemaker artifacts do not appear on the ECG; rate is less than the lower rate

Pacing output delivered; no evidence of pacing spike is seen

no output may be caused by
No Output May Be Caused By:
  • Poor connection at connector block
  • Lead failure
  • Battery depletion
  • Circuit failure

Pseudomalfunctions are defined as:

  • Unusual
  • Unexpected
  • Eccentric

ECG findings that appear to result from pacemaker malfunction but that represent normal pacemaker function

pseudomalfunctions may be classified under the following categories
Pseudomalfunctions May Be Classified Under the Following Categories:
  • Rate
  • AV interval/refractory periods
  • Mode
rate changes may occur due to normal device operation
Rate Changes May Occur Due to Normal Device Operation:
  • Magnet operation
  • Timing variations
    • A-A versus V-V timing
  • Upper rate behavior
    • Pseudo-Wenckebach; 2:1 block
  • Electrical reset
  • Battery depletion
  • PMT intervention
  • Rate response
magnet operation
Magnet Operation
  • Magnet application causes asynchronous pacing at a designated “magnet” rate
a to a vs v to v timing

A to A = 1000 ms

A to A = 1000 ms

AV = 150

AV = 200

V-A = 850

V-A = 800

A to A = 1000 ms

A to A = 950 ms

A to A vs. V to V Timing



Atrial rate is held constant at 60 ppm

AV = 150

AV = 200



V-A = 800

V-A = 800

Atrial rate varies with intrinsic ventricular conduction

upper rate behavior
Upper Rate Behavior
  • Pseudo-Wenckebach operation will cause a fluctuation in rate
upper rate behavior21
Upper Rate Behavior
  • 2:1 block operation will cause a drastic drop in rate
electrical reset and battery depletion
Electrical Reset and Battery Depletion
  • Reset may occur due to exposure to electromagnetic interference (EMI) – e.g., electrocautery, defibrillation, causing reversion to a “back-up” mode
    • Rate and mode changes will occur
    • Device can usually be reprogrammed to former parameters
  • Elective replacement indicators (ERI) can resemble back-up mode
    • Interrogating device will indicate ERI (“Replace Pacer”)
pmt intervention
PMT Intervention
  • Designed to interrupt a Pacemaker-Mediated Tachycardia
rate responsive pacing
Rate Responsive Pacing
  • An accelerating or decelerating rate may be perceived as anomalous pacemaker behavior

VVIR / 60 / 120

rate changes may occur due to therapy specific device operation
Rate Changes May Occur Due to Therapy-Specific Device Operation
  • Hysteresis
  • Rate drop response
  • Mode switching
  • Sleep function
  • Allows a lower rate between sensed events to occur; paced rate is higher

Hysteresis Rate 50 ppm

Lower Rate 70 ppm

rate drop response
Rate Drop Response
  • Delivers pacing at high rate when episodic drop in rate occurs
    • Pacing therapy indicated for patients with neurocardiogenic syncope
mode switching
Mode Switching
  • Device switches from tracking (DDDR) to nontracking (DDIR) mode
sleep function






Sleep Function





Wake Time

Bed Time


av intervals refractory periods may appear anomalous due to
AV Intervals/Refractory Periods May Appear Anomalous Due to:
  • Safety pacing
  • Blanking
  • Rate-adaptive AV delay
  • Sensor-varied PVARP
  • PVC response
  • Noncompetitive atrial pace (NCAP)
safety pacing

Ventricular Safety Pace

Safety Pacing
  • Designed to prevent inhibition due to “crosstalk”
    • Delivers a ventricular pace 110 ms after an atrial paced event

DDDR / 60 / 125 / 200 / 225

rate adaptive av delay
Rate-Adaptive AV Delay
  • AV interval shortens as rate increases

PAV delay with no activity: 150 ms

PAV with activity: 120 ms

sensor varied pvarp
Sensor-Varied PVARP
  • PVARP will shorten as rate increases

Long PVARP with little activity

Shorter PVARP with increased activity

pvc response
PVC Response
  • PVARP will extend to 400 ms

DDD / 60 / 120 PVARP 310 ms

noncompetitive atrial pace ncap
Noncompetitive Atrial Pace (NCAP)
  • Prevents atrial pacing from occurring too close to relative refractory period, which may trigger atrial arrhythmias
a change in pacing modes may be caused by
A Change in Pacing Modes May Be Caused By:
  • Battery depletion indicators (ERI/EOL)
  • Electrical reset
  • Mode switching
  • Noise reversion
noise reversion
Noise Reversion
  • Sensing occurring during atrial or ventricular refractory periods will restart the refractory period. Continuous refractory sensing is called noise reversion and will:
    • Cause pacing to occur at the sensor-indicated rate for rate-responsive modes
    • Cause pacing to occur at the lower rate for non- rate-responsive modes
Note: Adverse patient symptoms may occur as a result of any of the previously mentioned pacing system malfunctions and some pseudomalfunctions.
management of patient symptoms may be necessary as a result of
Management of Patient Symptoms May Be Necessary as a Result of:
  • Muscle stimulation
  • Palpitations
  • Pacemaker syndrome
  • Shortness of breath due to inappropriate rate response settings
muscle stimulation may be caused by
Muscle Stimulation May Be Caused By:
  • Inappropriate electrode placement near diaphragm or nerve plexus
  • Break in lead insulation
  • Unipolar pacing
palpitations may manifest from
Palpitations May Manifest From:
  • Pacemaker syndrome
  • Pacemaker-Mediated Tachycardia (PMT)
pacemaker syndrome
Pacemaker Syndrome

“An assortment of symptoms related to the adverse hemodynamic impact from the loss of AV synchrony.”

pacemaker syndrome45
Pacemaker Syndrome

Symptoms include:

  • Dizziness
  • Presyncope
  • Chest tightness
  • Shortness of breath
  • Neck pulsations
  • Apprehension/malaise
  • Fatigue
pacemaker syndrome may be caused by
Pacemaker Syndrome May Be Caused By:
  • Loss of capture, sensing
  • A-V intervals of long duration
  • Onset of 2:1 block
  • Single chamber system
  • Absence of rate increase with exercise
pacemaker mediated tachycardia pmt
Pacemaker-Mediated Tachycardia (PMT)
  • A rapid paced rhythm that can occur with atrial tracking pacemakers
pmt is the result of
PMT is the Result of:
  • Retrograde conduction
  • Tracking fast atrial rates (physiologic or non-physiologic)
retrograde conduction may be caused by
Retrograde Conduction May Be Caused By:
  • Loss of A-V synchrony due to:
    • Loss of sensing/capture
    • Myopotential sensing
    • Premature ventricular contraction (PVC)
    • Magnet application
high rate atrial tracking is caused by
High Rate Atrial Tracking is Caused By:
  • Supra-ventricular tachyarrhythmias
  • Atrial oversensing

General Medtronic Pacemaker Disclaimer


Medtronic pacemakers are indicated for rate adaptive pacing in patients who may benefit from increased pacing rates concurrent with increases in activity (Thera, Thera-i, Prodigy, Preva and Medtronic.Kappa 700 Series) or increases in activity and/or minute ventilation (Medtronic.Kappa 400 Series).

Medtronic pacemakers are also indicated for dual chamber and atrial tracking modes in patients who may benefit from maintenance of AV synchrony. Dual chamber modes are specifically indicated for treatment of conduction disorders that require restoration of both rate and AV synchrony, which include various degrees of AV block to maintain the atrial contribution to cardiac output and VVI intolerance (e.g., pacemaker syndrome) in the presence of persistent sinus rhythm.

9790 Programmer

The Medtronic 9790 Programmers are portable, microprocessor based instruments used to program Medtronic implantable devices.


The Model 9462 Remote Assistant™ is intended for use in combination with a Medtronic implantable pacemaker with Remote Assistant diagnostic capabilities.


Medtronic pacemakers are contraindicated for the following applications:

·       Dual chamber atrial pacing in patients with chronic refractory atrial tachyarrhythmias.

·       Asynchronous pacing in the presence (or likelihood) of competitive paced and intrinsic rhythms.

·       Unipolar pacing for patients with an implanted cardioverter-defibrillator because it may cause unwanted delivery or inhibition of ICD therapy.

·       Medtronic.Kappa 400 Series pacemakers are contraindicated for use with epicardial leads and with abdominal implantation.


Pacemaker patients should avoid sources of magnetic resonance imaging, diathermy, high sources of radiation, electrosurgical cautery, external defibrillation, lithotripsy, and radiofrequency ablation to avoid electrical reset of the device, inappropriate sensing and/or therapy.


Operation of the Model 9462 Remote Assistant™ Cardiac Monitor near sources of electromagnetic interference, such as cellular phones, computer monitors, etc. may adversely affect the performance of this device.

See the appropriate technical manual for detailed information regarding indications, contraindications, warnings, and precautions.

 Caution: Federal law (U.S.A.) restricts this device to sale by or on the order of a physician.


Medtronic Leads

For Indications, Contraindications, Warnings, and Precautions for Medtronic Leads, please refer to the appropriate Leads Technical Manual or call your local Medtronic Representative.

Caution: Federal law restricts this device to sale by or on the order of a Physician.


This presentation is provided for general educational purposes only and should not be considered the exclusive source for this type of information. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in a particular situation.