Table of Contents
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Abstract
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Case Presentations
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Introduction
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Epidemiology
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Critical Appraisal Of The Literature
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Review Of Normal Pacemaker Function
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Components And Lead Placement
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Pacemaker Modes
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Pacemaker Indications
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Sinus Node Dysfunction
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Acquired Atrioventricular Block
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Chronic Bifascicular Or Trifascicular Block
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After Acute Myocardial Infarction
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Cardiac Resynchronization Therapy
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Neurocardiogenic Syncope And Carotid Sinus Syndrome
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Emergency Department Evaluation
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History
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Physical Examination
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Diagnostic Studies
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Electrocardiogram
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Hyperkalemia
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Acute Myocardial Infarction
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Radiology
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Device Interrogation
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Implant-Related Complications
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Hematoma
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Infection
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Lead Dislodgement
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Twiddler Syndrome
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Venous Thrombosis
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Pneumothorax
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Tricuspid Regurgitation
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Pacemaker Syndrome
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Pacing System Malfunctions
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Failure To Capture
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Failure To Pace
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Failure To Sense
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Electromagnetic Interference
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Nonmedical Sources Of Interference
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Medical Sources Of Interference
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Management of Pacemaker-Related Complications and Malfunctions
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Approach To The Pacemaker Patient With Tachycardia
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The Magnet
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Advanced Cardiovascular Life Support In Patients With Pacemakers Or Implantable Cardioverter-Defibrillators
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Approach To The Pacemaker/Implantable Cardioverter-Defibrillator Patient Who Receives A Shock
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Disposition
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Controversies And Cutting Edge
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Remote Monitoring
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Leadless Pacing
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Device Deactivation
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Summary
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Risk Management Pitfalls For Implantable Devices
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Case Conclusions
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Clinical Pathway For Emergency Department Management Of Multiple
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Tables and Figures
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Table 1. American College of CardiologyAmerican Heart Association Classification Of Recommendations And Level Of Evidence
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Table 2. The North American Society For Pacing And ElectrophysiologyBritish Pacing And Electrophysiology Group Generic Pacemaker Code
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Table 3. Indications For Cardiac Resynchronization Therapy
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Table 4. Radiographic Assessment Of The Permanent Pacemaker/Implantable Cardioverter-Defibrillator
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Table 5. Methods To Identify Device Manufacturer
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Table 6. Implant-Related Complications
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Table 7. Causes Of Pacemaker Malfunction%2C By Category
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Table 8. Expected Response To Magnet Placement Over PacemakerImplantable Cardioverter-Defibrillator And Clinical Implications Of Different Magnet Responses
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Table 9. Clinical Applications Of Magnet On Implanted Cardiac Device
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Figure 1. Indications For Permanent Pacing
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Figure 2. Electrocardiogram Tracing Of Paced Rhythms In The Setting Of Severe Hyperkalemia
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Figure 3. Electrocardiogram Tracing Of Myocardial Infarction, Paced Rhythm
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Figure 4. Radiograph Of Dual-Chamber, Biventricular Pacemaker/Implantable Cardioverter-Defibrillator System
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Figure 5. Electrocardiogram Appearance of Pacemaker Failure
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Figure 6. Pacemaker-Mediated Tachycardia
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References
Abstract
The use of implanted pacemaker devices is increasing worldwide, owing to technological advances, new indications, and an aging population. Despite greater experience in implantation and improved device sophistication, patients continue to face complications associated with hardware implantation and device malfunction. This review summarizes current indications for permanent pacing, reviews epidemiologic data relevant to implant complications, and describes a clinical approach to the patient with potential pacing malfunction. The electrocardiographic diagnosis of hyperkalemia and acute myocardial infarction in paced rhythms is also discussed. Potential sources of electromagnetic interference and special considerations pertaining to the cardiac resuscitation of patients with implanted cardiac devices are reviewed. Finally, a basic approach to implanted cardioverter-defibrillator devices (which often accompany pacemaker devices) is presented.
Case Presentations
An ill-appearing 74-year-old woman is brought in on a stretcher by EMS personnel who broke down her door to find her slumped on her couch. Her temperature is normal, her blood pressure is 86/40 mm Hg, and her heart rate is 42 beats/min. On the cardiac monitor, you see extremely wide QRS complexes following pacer artifacts and intermittent pauses where pacing artifacts appear alone. A prior ECG shows a paced rhythm and narrower QRS complexes. What are your critical actions?
A 38-year-old woman who fainted in the grocery store is wheeled into the last unoccupied room in your ED with a cardiac monitor. She has cardiac sarcoidosis and has a DDD pacemaker that was implanted 6 months ago. She tells you that this is the third time she has fainted in the past 24 hours. She is normotensive and her heart rate is 48 beats/min. The cardiac monitor shows pacing artifacts that are completely dissociated from QRS complexes. What steps will you take to diagnose the underlying cause of this patient’s recurrent syncopal episodes?
Introduction
Cardiac pacemakers have evolved from singlechamber devices that deliver a fixed pacing rate to multichamber systems with programmable features that preserve and more closely mimic normal cardiac electrophysiology. Preservation of atrioventricular synchrony, physiologic heart rate, and interventricular synchrony are significant improvements that have been made possible with dual-chamber, rate-adaptive, and biventricular pacing systems. For patients, improved quality of life, increased exercise tolerance, and decreased disease progression are among the clinical outcomes driving new indications for pacemaker implantation and cardiac resynchronization therapy (CRT). At the same time, mortality benefits associated with implanted cardioverterdefibrillator devices (ICDs) in patients with heart failure have translated into an increasing number of biventricular pacing systems with integrated ICD technology. While pacemakers have become more complex and sophisticated, patients continue to present to the emergency department (ED) with symptoms related to device malfunctions. In addition, special considerations with regard to implanted pacemakers are relevant to the diagnostic workup of comorbid illnesses.
Epidemiology
Implanted pacemakers are increasingly prevalent in the United States.1 Approximately 370,000 pacemakers are placed annually,2 the most common indication for which is sinus node disease.3 Regardless of the indication for pacing, dual-chamber pacemakers have been adopted as the technology of choice. However, since United States Food and Drug Administration (FDA) approval in 2001, CRT devices are being implanted more frequently.4 Most of these are combined with defibrillation technology, and CRT-defibrillator (CRT-D) devices have come to comprise approximately 40% of all pacemakers in the United States.5 Compared with the general population, patients receiving implanted devices are older (mean age of implantation of 75.6 years) and carry a higher burden of age-adjusted comorbid illness.1,6
Critical Appraisal Of The Literature
PubMed and the Cochrane Database of Systematic Reviews were searched for English-language articles pertaining to the management of patients with implanted pacemakers and cardiac devices published between January 1, 1990 and February 21, 2014. Search terms included permanent pacemakers and the thematic topics of pacemaker complications, cardiac resynchronization therapy, pacemaker malfunction, and electromagnetic pacemaker interfer ence. The bibliographies of review articles were hand-searched and the level of evidence graded according to the guidelines from the American Heart Association Task Force on Practice Guidelines. (See Table 1.) Guidelines published by the American College of Cardiology Foundation/ American Heart Association (ACCF/AHA), the Heart Rhythm Society (HRS), the European Heart Rhythm Association (EHRA), and the European Society of Cardiology (ESC) were also reviewed.7-11
Risk Management Pitfalls For Implantable Devices
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“The ventricular-paced rhythm makes the ECG uninterpretable for diagnosing MI. I’ll call cardiology if the troponin comes back positive.” While concordant ST-segment changes and exaggerated discordance are insensitive findings for diagnosing acute MI in paced rhythms, they are diagnostically useful, when present.
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“Pacing artifacts appear stranded among widened and regular QRS complexes at a ventricular rate of 42. There must be a problem with the pacemaker.” Hyperkalemia can cause QRS widening, bradycardia, and failure to capture. Obtain a serum potassium level quickly and consider immediate administration of calcium. Always consider hyperkalemia before attributing failure to capture to a hardware problem or programming error.
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“I thought electrical cardioversion was contraindicated in patients with permanent pacemakers.” Electric direct-current cardioversion is safe as long as the electrodes are placed in anterior-posterior orientation at least 8 cm away from the pacemaker device. Device interrogation for proper functioning should be performed after cardioversion.
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“Pacemaker-mediated tachycardia was on my differential, but I was afraid to place a magnet over the pacemaker.” A pacemaker magnet only disables the sensing function, not the pacing function, and it can be effective in terminating pacemaker-mediated tachycardia as well as for differentiating among various types of potential pacemaker malfunction.
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“I thought all newer pacemakers were MRI-compatible.” While advances in pacemaker design have led to the development of pacing leads and pulse generators that are safe for the magnetic environment, safe MRI requires careful screening, established protocols, and physician supervision.
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“I didn’t think to compare the chest x-ray with a previous one or consider lead dislodgement as a complication that could occur so far out from implantation.”Lead migration more commonly occurs shortly after implantation, but it can be a late complication. Comparison with previous x-rays is helpful in detecting macro lead dislodgements.
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“The 12-lead ECG appeared normal. I didn’t think the patient needed device interrogation.” Pacemaker interrogation is critical in evaluating the possibility of pacemaker dysfunction that might not be apparent on a 12-lead ECG.
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“The patient experienced syncope and has a pacemaker, so she is a high-risk cardiac patient and needs to be admitted to telemetry.” Pacemaker interrogation can be performed in the ED to rule out dysrhythmia and pacing malfunction as underlying causes of palpitations, syncope, and light-headedness. Device interrogation may help to avoid unnecessary hospital admission in some of these patients.
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“I didn’t think that hiccoughs could be related to the patient’s pacemaker.” Direct stimulation of the diaphragm or the phrenic nerve occurs with lead dislodgement or with high output from a left ventricular lead placed in the coronary sinus.
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“Ventricular tachycardia clearly wasn’t the cause of his symptoms. If he had ventricular tachycardia, his CRT-D device would have shocked him.”Ventricular tachycardia may occur at rates below the programmed tachycardia detection rate (TDR). Above the TDR, ICD therapy is administered. A low TDR can be programmed, with the risk of administering therapy inappropriately to supraventricular tachyarrhythmias. Antitachycardia pacing and algorithms to improve the specificity of VT detection have reduced the incidence of inappropriate ICD therapy for supraventricular arrhythmias.
Tables and Figures
References
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.
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Greenspon AJ, Patel JD, Lau E, et al. Trends in permanent pacemaker implantation in the United States from 1993 to 2009: increasing complexity of patients and procedures. J Am Coll Cardiol. 2012;60(16):1540-1545. (Retrospective observational; 2.9 million patients)
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Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics--2014 update: a report from the American Heart Association. Circulation. 2014;129(3):e28-e292. (Executive summary)
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v Mond HG, Proclemer A. The 11th world survey of cardiac pacing and implantable cardioverter-defibrillators: calendar year 2009--a World Society of Arrhythmia project. Pacing Clin Electrophysiol. 2011;34(8):1013-1027. (Survey; 1.02 million implantations)
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van Veldhuisen DJ, Maass AH, Priori SG, et al. Implementation of device therapy (cardiac resynchronization therapy and implantable cardioverter defibrillator) for patients with heart failure in Europe: changes from 2004 to 2008. Eur J Heart Fail. 2009;11(12):1143-1151. (Retrospective observational)
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* Young JB, Abraham WT, Smith AL, et al. Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure: the MIRACLE ICD Trial. JAMA. 2003;289(20):2685-2694. (Prospective randomized controlled; 369 patients)
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Uslan DZ, Tleyjeh IM, Baddour LM, et al. Temporal trends in permanent pacemaker implantation: a population-based study. Am Heart J. 2008;155(5):896-903. (Retrospective observational; 1291 patients)
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* 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 abnormalities: 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 Cardiol. 2013;61(3):e6-e75. (Guideline)
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Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/ HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/ AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices) developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;51(21):e1-e62. (Guideline)
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European Society of Cardiology, European Heart Rhythm Association, Brignole M, Auricchio A, Baron-Esquivias G, et al. 2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on Cardiac Pacing and Resynchronization Therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Europace. 2013;15(8):1070-1118. (Guideline)
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Gillis AM, Russo AM, Ellenbogen KA, et al. HRS/ACCF expert consensus statement on pacemaker device and mode selection. Developed in partnership between the Heart Rhythm Society (HRS) and the American College of Cardiology Foundation (ACCF) and in collaboration with the Society of Thoracic Surgeons. Heart Rhythm. 2012;9(8):1344-1365. (Guideline)
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European Heart Rhythm Association, European Society of Cardiology, Heart Rhythm Society, et al. 2012 EHRA/HRS expert consensus statement on cardiac resynchronization therapy in heart failure: implant and follow-up recommendations and management. Europace. 2012;14(9):1236-1286. (Guideline)
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Andersen HR, Nielsen JC, Thomsen PE, et al. Long-term follow-up of patients from a randomised trial of atrial versus ventricular pacing for sick-sinus syndrome. Lancet. 1997;350(9086):1210-1216. (Prospective observational; 225 patients)
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Sweeney MO, Hellkamp AS, Ellenbogen KA, et al. Adverse effect of ventricular pacing on heart failure and atrial fibrillation among patients with normal baseline QRS duration in a clinical trial of pacemaker therapy for sinus node dysfunction. Circulation. 2003;107(23):2932-2937. (Retrospective observational trial; 1339 patients)
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Sweeney MO, Bank AJ, Nsah E, et al. Minimizing ventricular pacing to reduce atrial fibrillation in sinus-node disease. N Engl J Med. 2007;357(10):1000-1008. (Prospective randomized; 1065 patients)
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Thambo JB, Bordachar P, Garrigue S, et al. Detrimental ventricular remodeling in patients with congenital complete heart block and chronic right ventricular apical pacing. Circulation. 2004;110(25):3766-3772. (Prospective cohort; 53 patients)
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Bernstein AD, Daubert JC, Fletcher RD, et al. The revised NASPE/BPEG generic code for antibradycardia, adaptiverate, and multisite pacing. North American Society of Pacing and Electrophysiology/British Pacing and Electrophysiology Group. Pacing Clin Electrophysiol. 2002;25(2):260-264. (Guideline)
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Chan TC, Cardall TY. Electronic pacemakers. Emerg Med Clin North Am. 2006;24(1):179-194. (Review)
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Nielsen JC, Thomsen PE, Hojberg S, et al. A comparison of single-lead atrial pacing with dual-chamber pacing in sick sinus syndrome. Eur Heart J. 2011;32(6):686-696. (Prospective randomized; 1415 patients)
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Dretzke J, Toff WD, Lip GY, et al. Dual chamber versus single chamber ventricular pacemakers for sick sinus syndrome and atrioventricular block. Cochrane Database Syst Rev. 2004(2):CD003710. (Systematic review)
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Brandt J, Anderson H, Fahraeus T, et al. Natural history of sinus node disease treated with atrial pacing in 213 patients: implications for selection of stimulation mode. J Am Coll Cardiol. 1992;20(3):633-639. (Prospective observational; 213 patients)
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Gang UJ, Hvelplund A, Pedersen S, et al. High-degree atrioventricular block complicating ST-segment elevation myocardial infarction in the era of primary percutaneous coronary intervention. Europace. 2012;14(11):1639-1645. (Retrospective observational; 2073 patients)
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American College of Emergency Physicians, Society for Cardiovascular Angiography and Interventions, O’Gara PT, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):e78-140. (Guideline)
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Farwell D, Patel NR, Hall A, et al. How many people with heart failure are appropriate for biventricular resynchronization? Eur Heart J. 2000;21(15):1246-1250. (Retrospective observational; 721 patients)
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Shamim W, Francis DP, Yousufuddin M, et al. Intraventricular conduction delay: a prognostic marker in chronic heart failure. Int J Cardiol. 1999;70(2):171-178. (Retrospective observational; 241 patients)
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Abraham WT, Fisher WG, Smith AL, et al. Cardiac resynchronization in chronic heart failure. N Engl J Med. 2002;346(24):1845-1853. (Prospective randomized controlled; 453 patients)
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Higgins SL, Hummel JD, Niazi IK, et al. Cardiac resynchronization therapy for the treatment of heart failure in patients with intraventricular conduction delay and malignant ventricular tachyarrhythmias. J Am Coll Cardiol. 2003;42(8):1454- 1459. (Prospective randomized controlled; 490 patients)
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* Pavia S, Wilkoff B. The management of surgical complications of pacemaker and implantable cardioverter-defibrillators. Curr Opin Cardiol. 2001;16(1):66-71. (Review)
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* McMullan J, Valento M, Attari M, et al. Care of the pacemaker/ implantable cardioverter defibrillator patient in the ED. Am J Emerg Med. 2007;25(7):812-822. (Review)
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Furman S. Defibrillator twiddler’s syndrome. Ann Thorac Surg. 1995;59(2):544-546. (Comment)
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Link MS, Hellkamp AS, Estes NA 3rd et al. High incidence of pacemaker syndrome in patients with sinus node dysfunction treated with ventricular-based pacing in the Mode Selection Trial (MOST). J Am Coll Cardiol. 2004;43(11):2066- 2071. (Prospective cohort; 182 patients)
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* Trohman RG, Kim MH, Pinski SL. Cardiac pacing: the state of the art. Lancet. 2004;364(9446):1701-1719. (Review)
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Mollazadeh R, Mohimi L, Zeighami M, et al. Hemodynamic effect of atrioventricular and interventricular dyssynchrony in patients with biventricular pacing: implications for the pacemaker syndrome. J Cardiovasc Dis Res. 2012;3(3):200-203. (Cross-sectional; 40 patients)
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* Lamas GA, Lee KL, Sweeney MO, et al. Ventricular pacing or dual-chamber pacing for sinus-node dysfunction. N Engl J Med. 2002;346(24):1854-1862. (Randomized controlled trial; 2010 patients)
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Tracy CM, Epstein AE, Darbar D, et al. 2012 ACCF/AHA/ HRS focused update of the 2008 guidelines for devicebased therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. [corrected]. Circulation. 2012;126(14):1784-1800. (Guidelines)
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Ofman P, Rahilly-Tierney C, Djousse L, et al. Pacing system malfunction is a rare cause of hospital admission for syncope in patients with a permanent pacemaker. Pacing Clin Electrophysiol. 2013;36(1):109-112. (Retrospective observational; 162 patients)
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