Editing Pacemaker (section)

== Considerations ==

=== Insertion ===
A pacemaker may be implanted whilst a person is awake using [[local anesthetic]] to numb the skin with or without [[sedation]], or asleep using a [[general anesthetic]].<ref name=":1">{{Cite book|last=Ramsdale, David R.|title=Cardiac pacing and device therapy|date=2012|publisher=Springer|others=Rao, Archana.|isbn=978-1-4471-2939-4|location=London|oclc=822576869}}</ref> An antibiotic is usually given to reduce the risk of infection.<ref name=":1" />  Pacemakers are generally implanted in the front of the chest in the region of the left or right shoulder.  The skin is prepared by clipping or shaving any hair over the implant site before cleaning the skin with a disinfectant such as [[chlorhexidine]].  An incision is made below the collar bone and a space or pocket is created under the skin to house the pacemaker generator.  This pocket is usually created just above the [[pectoralis major]] muscle (prepectoral), but in some cases the device may be inserted beneath the muscle (submuscular).<ref>{{cite journal |last1=Pena |first1=Rafael E. |last2=Shepard |first2=Richard K. |last3=Ellenbogen |first3=Kenneth A. |title=How to Make a Submuscular Pocket |journal=Journal of Cardiovascular Electrophysiology |date=December 2006 |volume=17 |issue=12 |pages=1381–83 |doi=10.1111/j.1540-8167.2006.00665.x |pmid=17081202 |s2cid=38032736 |doi-access=free }}</ref> The [[Lead (electronics)|lead or leads]] are fed into the heart through a large vein guided by X-ray imaging ([[fluoroscope|fluoroscopy]]). The tips of the leads may be positioned within the [[Ventricle (heart)|right ventricle]], the [[Atrium (heart)|right atrium]], or the coronary sinus, depending on the type of pacemaker required.<ref name=":1" /> Surgery is typically completed within 30 to 90 minutes.  Following implantation, the surgical wound should be kept clean and dry until it has healed.  Some movements of the shoulder within a few weeks of insertion carry a risk of dislodging the pacemaker leads.<ref name=":1" />

The batteries within a pacemaker generator typically last 5 to 10 years. When the batteries are nearing the end of life, the generator is replaced in a procedure that is usually simpler than a new implant. Replacement involves making an incision to remove the existing device, disconnecting the leads from the old device and reconnecting them to a new generator, reinserting the new device and closing the skin.<ref name=":1" />

==== Periodic pacemaker checkups ====
[[File:PaceMakerRemoteMonitoringDevicesTwoKinds.jpg|thumb|Two types of remote monitoring devices used by pacemaker patients]]
Once the pacemaker is implanted, it is periodically checked to ensure the device is operational and performing appropriately; the device can be checked as often as is deemed necessary. Routine pacemaker checks are typically done in-office every six months, though will vary depending upon patient/device status and remote monitoring availability. Newer pacemaker models can also be interrogated remotely, with the patient transmitting their pacemaker data using a transmitter at home connected to a cellular telephone network.

During in-office follow-up, diagnostic tests may include:
* Sensing: the ability of the device to "see" intrinsic cardiac activity (atrial and ventricular depolarization).
* Impedance: A test to measure lead integrity. Large and/or sudden increases in impedance can indicate a lead fracture, while large and/or sudden decreases in impedance can be caused by insulation failure.
* Threshold amplitude: The minimum voltage (generally in hundredths of volts) required in order to pace the atrium or ventricle connected to the lead.
* Threshold duration: The time that the device requires at the preset amplitude to reliably pace the atrium or ventricle connected to the lead.
* Percentage of pacing: The percentage of time that the pacemaker has been actively pacing since the previous device interrogation, which shows how dependent the patient is on the device.
* Estimated battery life at current rate: As modern pacemakers are "on-demand" and only pace when necessary, battery lifespan is affected by how much the pacemaker is utilized. Other factors affecting battery life include programmed output and algorithms (features) that use battery power.
* Any events that were stored since the last follow-up, in particular [[arrhythmias]] such as [[atrial fibrillation]]. These are typically stored based on specific criteria set by the physician and specific to the patient. Some devices have the availability to display intracardiac electrograms showing the onset of an event as well as the event itself, which helps to diagnose its cause or origin.

=== Magnetic fields, MRIs, and other lifestyle issues ===
A patient's lifestyle is usually not modified to any great degree after the insertion of a pacemaker. There are a few activities that are unwise, such as full-contact sports and exposure of the pacemaker to intense magnetic fields.

The pacemaker patient may find that some types of everyday actions need to be modified. For instance, the shoulder harness of a vehicle [[seatbelt]] may be uncomfortable if it falls across the pacemaker insertion site. Women will not be able to wear bras for a while after the operation, and later might have to wear bras with wide shoulder straps.

For some sports and physical activities, special pacemaker protection can be worn to prevent possible injuries, or damage to the pacemaker leads.

Pacemakers may be affected by [[Magnetic field|magnetic]] or [[electromagnetic field]]s, and [[Ionising radiation|ionising]] and [[acoustic radiation]]. However, a 2013 study found that "The overall risk of clinically significant adverse events related to EMI (electromagnetic interference) in recipients of CIEDs (cardiovascular implantable electronic devices) is very low. Therefore, no special precautions are needed when household appliances are used. Environmental and industrial sources of EMI are relatively safe when the exposure time is limited and distance from the CIEDs is maximized. The risk of EMI-induced events is highest within the hospital environment."<ref name=beinart>{{cite journal| last1=Beinart|first1=R|last2=Nazarian|first2=S| title=Effects of external electrical and magnetic fields on pacemakers and defibrillators: from engineering principles to clinical practice| journal=Circulation |date=24 December 2013 | volume= 128 | issue= 25 | pages= 2799–809 | pmid=24366589 | doi=10.1161/CIRCULATIONAHA.113.005697|doi-access=free| pmc=3908865}}</ref> The study lists and tabulates many sources of interference, and many different potential effects: damage to circuitry, asynchronous pacing, etc. Some sources of hazard in older devices have been eliminated in newer ones.

Activities involving strong [[magnetic field]]s should be avoided. This includes activities such as [[arc welding]] with certain types of equipment,<ref>{{cite journal |vauthors=Marco D, Eisinger G, Hayes DL | title = Testing of work environments for electromagnetic interference| journal = Pacing Clin Electrophysiol | volume = 15 | issue = 11 Pt 2 | pages = 2016–22 | date = November 1992 | pmid = 1279591 | doi = 10.1111/j.1540-8159.1992.tb03013.x | s2cid = 24234010}}</ref> and maintaining heavy equipment that may generate strong magnetic fields. Some medical procedures, particularly [[magnetic resonance imaging]] (MRI), involve very strong magnetic fields or other conditions that may damage pacemakers.

However, many modern pacemakers are specified to be [[Safety_of_magnetic_resonance_imaging#Implants|MR conditional or MRI conditional]], safe to use during MRI subject to certain conditions.<ref name=maass>{{cite journal |last1=Maass |first1=A. H. |last2=Hemels |first2=M. E. W. |last3=Allaart |first3=C. P. |title=Magnetic resonance imaging in patients with cardiac implantable electronic devices |journal=Netherlands Heart Journal |date=December 2018 |volume=26 |issue=12 |pages=584–90 |doi=10.1007/s12471-018-1192-3 |pmid=30406601 |pmc=6288036 }}</ref> The first to be so specified was the [[Medtronic]] Revo MRI SureScan, approved by the US FDA in February 2011,<ref>{{cite web | title=Revo MRI SureScan Pacing System – P090013|publisher=U.S. Food and Drug Administration - Medical Device Approvals and Clearances | date=24 February 2011 | url=http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm244469.htm | archive-url=https://web.archive.org/web/20121020065907/http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm244469.htm | archive-date=20 October 2012 | url-status=dead}}</ref> which was the first to be specified as MR conditional.<ref>{{cite web| title=Terminology |publisher=Magnetic Resonance Safety Testing Services | url=http://www.magneticresonancesafetytesting.com/Terminology.php|url-status=live| access-date=13 February 2023|archive-url=https://web.archive.org/web/20131011031738/http://magneticresonancesafetytesting.com/genpg.asp?pgname=Terminology|archive-date=11 October 2013}}</ref><ref>Husten, Larry. [https://www.forbes.com/sites/larryhusten/2013/02/13/fda-approves-second-generation-mri-friendly-pacemaker-system-from-medtronic/ "FDA Approves Second Generation MRI-Friendly Pacemaker System From Medtronic"]. ''Forbes'', 2013-02-13.</ref> There are several conditions to use of MR Conditional pacemakers, including certain patients' qualifications and scan settings. An MRI conditional device has to have MRI settings enabled before a scan, and disabled afterwards.<ref>{{Cite report|chapter-url=https://www.cardiovascular.abbott/content/dam/bss/divisionalsites/cv/pdf/guides/2b323673-151a-480a-9f93-06c2433ca230.pdf|title=MRI-Ready Systems Manual - MRI Procedure Information for the MR Conditional System|publisher=St. Jude Medical|year=2016|chapter=For physicians: V: Select and save MRI settings; VII: Disable MRI settings}}</ref>

{{As of|2014}} the five most commonly used cardiac pacing device manufacturers (covering more than 99% of the US market) made FDA-approved MR-conditional pacemakers.<ref>{{cite journal |last1=Ferreira |first1=António M |last2=Costa |first2=Francisco |last3=Tralhão |first3=António |last4=Marques |first4=Hugo |last5=Cardim |first5=Nuno |last6=Adragão |first6=Pedro |title=MRI-conditional pacemakers: current perspectives |journal= Medical Devices: Evidence and Research|date=7 May 2014 |volume=7 |pages=115–24 |doi=10.2147/MDER.S44063 |pmid=24851058 |pmc=4019608 |doi-access=free }}</ref> The use of MRI may be ruled out by the patient having an older, non-MRI Conditional pacemaker, or by having old pacing wires inside the heart, no longer connected to a pacemaker.

A 2008 US study found<ref>{{cite web
|url=http://www.bidmc.org/News/InResearch/2008/November/MP3PlayerStudy.aspx
|title=MP3 Headphones Interfere With Implantable Defibrillators, Pacemakers – Beth Israel Deaconess Medical Center
|publisher=www.bidmc.org
|access-date=2008-11-10
|archive-date=2010-09-27
|archive-url=https://web.archive.org/web/20100927014850/http://www.bidmc.org/News/InResearch/2008/November/MP3PlayerStudy.aspx
|url-status=dead
}}</ref> that the magnetic field created by some headphones used with portable music players or cellphones may cause interference if placed very close to some pacemakers.

In addition, according to the [[American Heart Association]], some home devices have the potential to occasionally inhibit a single beat. Cellphones do not seem to damage pulse generators or affect how the pacemaker works.<ref>{{cite web|title=What is a pacemaker?|url=http://hrmreview.net/what-is-pacemaker/|publisher=HRMReview|access-date=22 May 2014|url-status=dead|archive-url=https://web.archive.org/web/20140522160829/http://hrmreview.net/what-is-pacemaker/|archive-date=22 May 2014}}</ref> It is recommended that objects containing magnets, or generating a significant magnetic field, should not be in close proximity to a pacemaker. Induction cooktops, in particular, can pose a risk.<ref>{{cite journal |last1=Irnich |first1=Werner |last2=Bernstein |first2=Alan D. |title=Do induction cooktops interfere with cardiac pacemakers? |journal=EP Europace |date=May 2006 |volume=8 |issue=5 |pages=377–84 |doi=10.1093/europace/eul014 |pmid=16635999 }}</ref>

Before medical procedures, the patient should inform all medical personnel that they have a pacemaker. Having a pacemaker does not imply that a patient requires the use of [[antibiotic]]s to be administered before procedures such as dental work.<ref>{{cite journal |last1=Baddour |first1=Larry M. |last2=Epstein |first2=Andrew E. |last3=Erickson |first3=Christopher C. |last4=Knight |first4=Bradley P. |last5=Levison |first5=Matthew E. |last6=Lockhart |first6=Peter B. |last7=Masoudi |first7=Frederick A. |last8=Okum |first8=Eric J. |last9=Wilson |first9=Walter R. |last10=Beerman |first10=Lee B. |last11=Bolger |first11=Ann F. |last12=Estes |first12=N.A. Mark |last13=Gewitz |first13=Michael |last14=Newburger |first14=Jane W. |last15=Schron |first15=Eleanor B. |last16=Taubert |first16=Kathryn A. |title=Update on Cardiovascular Implantable Electronic Device Infections and Their Management |journal=Circulation |date=26 January 2010 |volume=121 |issue=3 |pages=458–77 |doi=10.1161/circulationaha.109.192665 |pmid=20048212 |doi-access=free }}</ref>

=== End-of-life care and pacemaker deactivation ===
A panel of the [[Heart Rhythm Society]], a US specialist organization based in Washington, DC, deemed that it was legal and ethical to honor requests by patients, or by those with legal authority to make decisions for patients, to deactivate implanted cardiac devices. Lawyers say that the legal situation is similar to removing a feeding tube, though {{As of|2010|lc=y}} there was no legal precedent involving pacemakers in the United States. A patient in many jurisdictions (including the US) is deemed to have a right to refuse or discontinue treatment, including a pacemaker that keeps them alive. Physicians have a right to refuse to turn it off, but are advised by the HRS panel that they should refer the patient to a physician who will.<ref>{{cite web |title=Heart devices can be turned off near end of life |url=https://amednews.com/article/20100531/profession/305319943/4/ |website=amednews.com |date=May 31, 2010 |url-status=dead |archive-url=https://web.archive.org/web/20171024071522/https://amednews.com/article/20100531/profession/305319943/4/ |archive-date= Oct 24, 2017 }}</ref><ref>{{Cite web|url=https://www.hrsonline.org/documents/end-life-and-heart-rhythm-devices/download|title=End of Life and Heart Rhythm Devices|publisher=Heart Rhythm Society|year=2014 |url-status=live |archive-url=https://web.archive.org/web/20231023164918/https://www.hrsonline.org/documents/end-life-and-heart-rhythm-devices/download |archive-date= Oct 23, 2023 }}</ref> Some patients consider that hopeless, debilitating conditions, such as severe strokes or late-stage dementia, can cause so much suffering that they would prefer not to prolong their lives with supportive measures.<ref>{{cite news |last1=Butler |first1=Katy |title=What Broke My Father's Heart |url=https://www.nytimes.com/2010/06/20/magazine/20pacemaker-t.html |work=The New York Times |date=18 June 2010 |url-access=subscription |url-status=live |archive-url=https://web.archive.org/web/20240402125756/https://www.nytimes.com/2010/06/20/magazine/20pacemaker-t.html |archive-date= Apr 2, 2024 }}</ref>

=== Privacy and security ===
Security and privacy concerns have been raised with pacemakers that allow wireless communication. Unauthorized third parties may be able to read patient records contained in the pacemaker, or reprogram the devices, as has been demonstrated by a team of researchers.<ref name="ICD-Radio">{{cite conference | date = May 2008 | first = Daniel |  last = Halperin | author2 = Thomas S. Heydt-Benjamin | author3 = Benjamin Ransford|author4=Shane S. Clark|author5=Benessa Defend|author6=Will Morgan|author7=Kevin Fu|author8=Tadayoshi Kohno|author9=William H. Maisel|
url=http://www.secure-medicine.org/icd-study/icd-study.pdf |via=Archimedes Center for Medical Device Security |title=Pacemakers and Implantable Cardiac Defibrillators: Software Radio Attacks and Zero-Power Defenses |conference=IEEE Symposium on Security and Privacy |
access-date = 2008-08-10}}</ref> The demonstration worked at short range; they did not attempt to develop a long range antenna. The proof of concept exploit helps demonstrate the need for better security and patient alerting measures in remotely accessible medical implants.<ref name="ICD-Radio" /> In response to this threat, Purdue University and Princeton University researchers have developed a prototype firewall device, called MedMon, which is designed to protect wireless medical devices such as pacemakers and insulin pumps from attackers.<ref>{{cite web | url=http://www.esecurityplanet.com/network-security/researchers-develop-personal-firewall-solution-for-pacemakers-insulin-pumps.html | title=Researchers Develop Personal Firewall Solution for Pacemakers, Insulin Pumps | publisher=eSecurity Planet |first1=Jeff |last1=Goldman | access-date=2012-04-20 | date=2012-04-20 |url-status=dead |archive-url= https://web.archive.org/web/20120423170749/http://www.esecurityplanet.com/network-security/researchers-develop-personal-firewall-solution-for-pacemakers-insulin-pumps.html |archive-date= Apr 23, 2012 }}</ref>

=== Complications ===
[[File:UOTW 15 - Ultrasound of the Week 1.webm|thumb|[[Ultrasound]] showing non capture of a pacemaker<ref>{{cite web|title=UOTW #15 |first1=Ben |last1=Smith |url=https://www.ultrasoundoftheweek.com/uotw-15/|website=Ultrasound of the Week|access-date=27 May 2017|date=26 August 2014 |url-status=unfit |archive-url=https://web.archive.org/web/20181106201010/https://www.ultrasoundoftheweek.com/uotw-15/ |archive-date= Nov 6, 2018 }}</ref>

]]
Complications from having [[surgery]] to implant a [[Pacemaker failure|pacemaker]] are uncommon (each 1–3% approximately), but could include: infection where the pacemaker is implanted or in the bloodstream; [[allergy|allergic reaction]] to the dye or [[anesthesia]] used during the procedure; swelling, bruising or bleeding at the generator site, or around the heart, especially if the patient is taking [[blood thinners]], elderly, of thin frame or otherwise on chronic [[steroid]] use.<ref>{{Cite web|url=http://www.mayoclinic.org/tests-procedures/pacemaker/details/risks/cmc-20198664|title=Risks – Pacemaker |website=Mayo Clinic |access-date=2016-12-01 |url-status=live |archive-url=https://web.archive.org/web/20170218212112/http://www.mayoclinic.org/tests-procedures/pacemaker/details/risks/cmc-20198664 |archive-date= Feb 18, 2017 }}</ref>

A possible complication of dual-chamber artificial pacemakers is 'pacemaker-mediated tachycardia' (PMT), a form of reentrant tachycardia. In PMT, the artificial pacemaker forms the anterograde (atrium to ventricle) limb of the circuit and the atrioventricular (AV) node forms the retrograde limb (ventricle to atrium) of the circuit.<ref name=Olshansky>{{EMedicine|article|159645|Pacemaker-Mediated Tachycardia}}</ref> Treatment of PMT typically involves reprogramming the pacemaker.<ref name="Olshansky" />

Another possible complication is "pacemaker-tracked tachycardia," where a [[supraventricular tachycardia]] such as [[atrial fibrillation]] or [[atrial flutter]] is tracked by the pacemaker and produces beats from a ventricular lead.<ref>{{cite book |doi=10.1016/B978-1-4377-1616-0.00029-1 |chapter=Pacemaker Troubleshooting and Follow-up |title=Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy |date=2011 |last1=Love |first1=Charles J. |pages=844–888 |isbn=978-1-4377-1616-0 }}</ref> This is becoming exceedingly rare as newer devices are often programmed to recognize supraventricular tachycardias and switch to non-tracking modes.<ref>{{cite journal |last1=Kamalvand |first1=Kayvan |last2=Tan |first2=Kim |last3=Kotsakis |first3=Athanasios |last4=Bucknall |first4=Cliff |last5=Sulke |first5=Neil |title=Is Mode Switching Beneficial? A Randomized Study in Patients With Paroxysmal Atrial Tachyarrhythmias |journal=Journal of the American College of Cardiology |date=August 1997 |volume=30 |issue=2 |pages=496–504 |doi=10.1016/S0735-1097(97)00162-9 |pmid=9247524 |s2cid=23092273 }}</ref>

It is important to consider leads as a potential nidus for [[Thrombosis|thromboembolic]] events. The leads are small-diameter wires from the pacemaker to the implantation site in the heart muscle, and are usually placed intravenously through the [[subclavian vein]] in order to access the right atrium. Placing a foreign object within the venous system in such a manner may disrupt blood-flow and allow for thrombus formation. Therefore, patients with pacemakers may need to be placed on  anti-coagulation therapy to avoid potential life-threatening thrombosis or embolus.<ref>{{cite journal |last1=Noheria |first1=Amit |last2=DeSimone |first2=Christopher V. |last3=Asirvatham |first3=Samuel J. |title=Cardiac Implantable Electronic Device Lead Thrombus as a Nidus for Pulmonary and Systemic Embolization |journal=JACC: Clinical Electrophysiology |date=November 2018 |volume=4 |issue=11 |pages=1437–39 |doi=10.1016/j.jacep.2018.08.019 |doi-access=free |pmid=30466849 }}</ref><ref>{{cite book |doi=10.1007/978-88-470-2139-6_66 |chapter=Pacemaker/ICD Patients: To Anticoagulate or Not to Anticoagulate? |title=Cardiac Arrhythmias 1999 - Vol.1 |date=2000 |last1=Santomauro |first1=M. |last2=Costanzo |first2=A. |last3=Ottaviano |first3=L. |last4=Cresta |first4=R. |last5=Minichiello |first5=S. |last6=Prastaro |first6=M. |last7=Chiariello |first7=M. |pages=494–500 |isbn=978-88-470-0071-1 }}</ref>

These leads may also damage the [[Tricuspid valve|tricuspid valve leaflets]], either during placement or through wear and tear over time. This can lead to [[tricuspid regurgitation]] and [[right-sided heart failure]], which may require [[Valve replacement|tricuspid valve replacement]].<ref>{{cite journal |last1=Lin |first1=Grace |last2=Nishimura |first2=Rick A. |last3=Connolly |first3=Heidi M. |last4=Dearani |first4=Joseph A. |last5=Sundt |first5=Thoralf M. |last6=Hayes |first6=David L. |title=Severe Symptomatic Tricuspid Valve Regurgitation Due to Permanent Pacemaker or Implantable Cardioverter-Defibrillator Leads |journal=Journal of the American College of Cardiology |date=May 2005 |volume=45 |issue=10 |pages=1672–75 |doi=10.1016/j.jacc.2005.02.037 |doi-access=free |pmid=15893186 }}</ref>

Sometimes leads will need to be removed. The most common reason for lead removal is infection; however, over time, leads can degrade due to a number of reasons such as lead flexing.<ref name="Wilkoff">{{cite journal |last1=Wilkoff |first1=Bruce L. |last2=Love |first2=Charles J. |last3=Byrd |first3=Charles L. |last4=Bongiorni |first4=Maria Grazia |last5=Carrillo |first5=Roger G. |last6=Crossley |first6=George H. |last7=Epstein |first7=Laurence M. |last8=Friedman |first8=Richard A. |last9=Kennergren |first9=Charles E.H. |last10=Mitkowski |first10=Przemyslaw |last11=Schaerf |first11=Raymond H.M. |last12=Wazni |first12=Oussama M. |title=Transvenous Lead Extraction: Heart Rhythm Society Expert Consensus on Facilities, Training, Indications, and Patient Management |journal=Heart Rhythm |date=July 2009 |volume=6 |issue=7 |pages=1085–1104 |doi=10.1016/j.hrthm.2009.05.020 |pmid=19560098 }}</ref> Changes to the programming of the pacemaker may overcome lead degradation to some extent. However, a patient who has several pacemaker replacements over a decade or two in which the leads were reused may require lead replacement surgery.

Lead replacement may be done in one of two ways. Insert a new set of leads without removing the current leads (not recommended as it provides additional obstruction to blood flow and heart valve function) or remove the current leads and then insert replacements. The lead removal technique will vary depending on the surgeon's estimation of the probability that simple traction will suffice to more complex procedures. Leads can normally be disconnected from the pacemaker easily, which is why device replacement usually entails simple surgery to access the device and replace it by simply unhooking the leads from the device to replace and hooking the leads to the new device. The possible complications, such as perforation of the heart wall, come from removing the lead{s} from the patient's body.

The free end of a pacemaker lead is actually implanted into the heart muscle with a miniature screw or anchored with small plastic hooks called tines. The longer the leads have been implanted (starting from a year or two), the more likely that they will have additional attachments to the patient's body at various places in the pathway from device to heart muscle, since the body tends to incorporate foreign devices into tissue. In some cases, for a lead that has been inserted for a short amount of time, removal may involve simple traction to pull the lead from the body. Removal in other cases is typically done with a laser or cutting device which threads like a cannula with a cutting edge over the lead and is moved down the lead to remove any organic attachments with tiny cutting lasers or similar device.<ref>{{Cite web |title=What is Laser-Assisted Lead Extraction? {{!}} DFW |url=https://www.heartplace.com/services-laser-lead-extraction |access-date=2022-09-16 |website=HeartPlace |language=en |archive-date=2022-09-20 |archive-url=https://web.archive.org/web/20220920165250/https://www.heartplace.com/services-laser-lead-extraction |url-status=dead }}</ref><ref>{{cite journal |last1=Gaca |first1=Jeffrey G. |last2=Lima |first2=Brian |last3=Milano |first3=Carmelo A. |last4=Lin |first4=Shu S. |last5=Davis |first5=R. Duane |last6=Lowe |first6=James E. |last7=Smith |first7=Peter K. |title=Laser-Assisted Extraction of Pacemaker and Defibrillator Leads: The Role of the Cardiac Surgeon |journal=The Annals of Thoracic Surgery |date=May 2009 |volume=87 |issue=5 |pages=1446–51 |doi=10.1016/j.athoracsur.2009.02.015 |pmid=19379883 }}</ref>

Pacemaker lead malposition in various locations has been described in the literature. Treatment varies, depending on the location of the pacer lead and symptoms.<ref>{{cite journal |last1=Kalavakunta |first1=Jagadeesh Kumar |last2=Gupta |first2=Vishal |last3=Paulus |first3=Basil |last4=Lapenna |first4=William |title=An Unusual Cause of Transient Ischemic Attack in a Patient with Pacemaker |journal=Case Reports in Cardiology |date=2014 |volume=2014 |pages=265759 |doi=10.1155/2014/265759 |pmid=24826308 |pmc=4008350 |doi-access=free }}</ref>

Another possible complication called [[twiddler's syndrome]] occurs when a patient manipulates the pacemaker and causes the leads to be removed from their intended location and causes possible stimulation of other nerves.

Overall life expectancy with pacemakers is excellent, and mostly depends upon underlying diseases, presence of atrial fibrillation, age and sex at the time of first implantation.<ref>{{cite journal |last1=Brunner |first1=M |title=Long-term survival after pacemaker implantation Prognostic importance of gender and baseline patient characteristics |journal=European Heart Journal |date=January 2004 |volume=25 |issue=1 |pages=88–95 |doi=10.1016/j.ehj.2003.10.022|pmid=14683747 |doi-access=free }}</ref>