Pacemaker Removal for Minimal Pacing Requirements
Pacemaker removal is reasonable when it is only pacing the heart 0.1% of the time, especially if the original indication for pacing has resolved or is in question, after a period of monitoring with pacing therapy turned off to ensure patient safety. 1
Decision Algorithm for Pacemaker Removal
Step 1: Evaluate Current Pacing Dependency
- Confirm the 0.1% pacing rate through device interrogation
- Determine if this minimal pacing represents:
- Appropriate backup pacing for rare bradycardic episodes
- True non-dependency with resolution of original indication
Step 2: Review Original Implantation Indication
- Identify the original reason for pacemaker implantation
- Determine if the original indication:
- Has completely resolved
- Was questionable or unclear at the time of implantation
- Still exists but is manifesting less frequently
Step 3: Conduct Monitoring Period with Pacing Off
According to the 2019 ACC/AHA/HRS guidelines, patients with minimal pacing requirements should undergo a monitoring period with pacing therapy turned off before considering removal 1:
- Program the pacemaker to minimal settings or "off" mode
- Monitor for symptoms of bradycardia
- Perform periodic ambulatory electrocardiographic monitoring (24-hour Holter)
- Extend monitoring for up to 1 year in appropriate cases
Step 4: Consider Additional Testing
If initial monitoring is negative for symptoms:
- Echocardiogram to assess cardiac function
- Exercise testing to evaluate chronotropic response
- Electrophysiological study to evaluate sinus and AV node function
Evidence Supporting Removal
The 2019 ACC/AHA/HRS guidelines provide a Class IIa recommendation (reasonable to do) for discontinuation of pacemaker therapy when the original indication has resolved or is in question 1. This recommendation is supported by studies showing:
- In a study of 5 patients with resolved pacing indications, pacemakers were safely removed with no symptomatic bradycardia after 18-48 months of follow-up 1
- In a larger study of 70 patients without clear ongoing indications for pacing, 35 had their pacemakers explanted after a comprehensive evaluation protocol, and all remained asymptomatic during a mean follow-up of 30.3 months 1, 2
Risks vs. Benefits Analysis
Benefits of Removal:
- Elimination of device-related complications
- Avoidance of future replacement procedures
- Reduction of psychological burden on patient
- Economic benefits (avoiding future replacements)
Risks of Removal:
- Potential for undetected intermittent bradycardia
- Need for reimplantation if bradycardia recurs
- Procedural risks of device extraction
Important Caveats and Considerations
Patient age and comorbidities: Younger patients have a higher likelihood of requiring device replacement during their lifetime (49.9% for patients <70 years vs. 24.5% for patients ≥70 years) 3, making removal more beneficial for younger patients with minimal pacing needs.
Lead extraction risks: If leads have been implanted for many years, extraction may carry additional risks that must be weighed against benefits.
Original indication: Patients with certain indications (e.g., complete heart block) may have a higher risk of recurrence even if currently showing minimal pacing requirements.
Alternative to complete removal: Consider pulse generator removal but leaving leads in place if lead extraction poses significant risks.
Monitoring capability: Ensure adequate follow-up and monitoring capabilities are available after device removal.
By following this systematic approach, clinicians can make informed decisions about pacemaker removal in patients with minimal pacing requirements, potentially avoiding unnecessary device replacements while maintaining patient safety.