If the underlying condition for a pacemaker (permanent artificial cardiac pacemaker) implant is corrected, is a 1% pacing percentage considered safe to consider pacemaker removal?

Pacemaker Removal When Underlying Condition Has Resolved

Pacemaker removal is reasonable to consider in patients with only 1% pacing when the original indication has resolved, after careful evaluation of symptoms during a period of monitoring with pacing therapy turned off. 1

Decision-Making Framework for Pacemaker Removal

When considering pacemaker removal in a patient with minimal pacing requirements, follow this algorithm:

1. Confirm resolution of original indication:

   • Review the original indication for pacemaker implantation
   • Verify through diagnostic testing that the underlying condition has truly resolved
   • Ensure no new indications for pacing have developed

2. Evaluate current pacing dependency:

   • 1% pacing suggests minimal dependency
   • Analyze pacemaker interrogation data to determine:
     • Frequency of pacing episodes
     • Time of day when pacing occurs (sleep vs. awake)
     • Duration of pacing episodes

3. Conduct monitored pacemaker deactivation trial:

   • Program pacemaker to "off" or minimal settings
   • Monitor patient with continuous cardiac telemetry for 24-48 hours
   • Document intrinsic heart rhythm and stability
   • Assess for symptoms during deactivation period

Evidence Supporting Pacemaker Removal

The 2019 ACC/AHA/HRS guideline specifically addresses this scenario, stating that discontinuation of pacemaker therapy is reasonable after evaluation of symptoms during a period of monitoring while pacing therapy is off, in patients whose original pacing indication has resolved or is in question (Class IIa recommendation with Level of Evidence C-LD) 1.

A study protocol used to evaluate candidates for pacemaker removal included:

• Clinical evaluation
• Echocardiogram
• Exercise testing
• Tilt table testing (if original indication was syncope)
• Periodic 24-hour ambulatory ECG monitoring for up to 1 year
• Electrophysiology study in selected cases

Using this protocol, 35 of 70 patients had their pacemakers successfully explanted, and after a mean follow-up of 30.3 months, all patients remained asymptomatic except for one who died of a non-cardiac cause 1.

Important Considerations and Cautions

1. Patient-specific risk assessment:

   • Age and comorbidities
   • Original indication for pacing
   • Risk of recurrence of the original condition
   • Procedural risk of device removal

2. Potential complications of device removal:

   • Infection (0.5-1%)
   • Bleeding/hematoma
   • Lead extraction complications if leads are to be removed
   • Risk of needing reimplantation in the future

3. Alternative to complete removal:

   • Consider programming the device to minimal settings
   • Consider elective non-replacement when battery is depleted
   • Explant of pulse generator alone (leaving leads in place)

Special Considerations

If the patient was originally pacemaker-dependent but now shows minimal dependency (1% pacing), this suggests a significant improvement in the underlying conduction system. However, the natural history of bradycardia can be unpredictable, and some conditions may recur over time 1.

For patients whose original indication was carotid sinus hypersensitivity or vasovagal syncope, the risk of recurrence may be higher, and careful evaluation is needed before considering pacemaker removal 1.

The decision to remove a pacemaker must balance the risk of long-term pacemaker-related complications over a lifetime against the risk of recurrent bradycardia. This is especially important in younger patients who would otherwise require multiple generator replacements over their lifetime.