Can an 11-year-old pacemaker (permanent artificial cardiac pacemaker) be removed?

Removal of an 11-Year-Old Pacemaker

Yes, an 11-year-old pacemaker can be safely removed if the original indication for pacing has resolved or is in question, following appropriate evaluation to confirm the patient no longer requires pacing therapy. 1

Assessment Before Pacemaker Removal

When considering removal of a long-standing pacemaker, a structured approach is necessary:

1. Evaluate Original Indication:

   • Review the initial indication for pacemaker implantation
   • Determine if the condition was potentially reversible or permanent 1
   • Assess if the pathological process that necessitated pacing has resolved

2. Pacemaker Dependency Assessment:

   • Temporarily program the pacemaker to minimal settings
   • Monitor for adequate intrinsic rhythm
   • Document stable heart rate and rhythm without pacing support 1

3. Extended Monitoring Period:

   • Perform 24-hour ambulatory electrocardiographic monitoring
   • Consider monitoring for up to 1 year in some cases to ensure stability 1
   • Look for evidence of bradycardia, pauses, or symptoms during minimal pacing

Decision Algorithm for Pacemaker Removal

The 2019 ACC/AHA/HRS guideline provides a Class IIa recommendation (Level of Evidence: C-LD) supporting discontinuation of pacemaker therapy when the original indication has resolved or is questionable 1.

For an 11-year-old device specifically:

• Battery life is likely approaching end of service
• Lead extraction complexity increases with implant duration
• Risk of infection during replacement must be weighed against benefits of continued pacing

Procedure for Pacemaker Removal

If removal is deemed appropriate:

1. Complete device and lead removal is the standard approach for:

   • Patients with device pocket infection
   • Patients with device-related endocarditis
   • Patients with occult staphylococcal bacteremia 1

2. For non-infected devices where pacing is no longer needed:

   • The pulse generator can be explanted
   • Lead management options include:
     • Complete lead extraction
     • Capping and abandoning leads in situ (may be preferable with older leads)

Risks and Considerations

The risks of pacemaker removal after 11 years include:

• Lead extraction complications: Higher risk with older leads due to fibrosis and calcification
• Procedural complications: 4.0% major complication rate for generator replacement without lead addition 2
• Infection: Approximately 1.4% risk within 6 months following device-related procedures 2

Follow-up After Removal

After pacemaker removal:

• Regular cardiac monitoring for 6-12 months
• Patient education regarding symptoms of bradycardia
• Clear instructions on when to seek medical attention

Special Considerations

• Age and comorbidities affect the risk-benefit ratio of device removal
• Terminal illness: In terminally ill patients, pacemakers generally should be left intact as removal typically neither hastens nor prolongs the natural course of illness 3
• Leadless pacemakers have different considerations for removal versus abandonment 4

In a study of five patients who had their pacemakers removed after determining they no longer required pacing, none experienced recurrent symptomatic bradycardia during 18-48 months of follow-up 5, suggesting that carefully selected patients can safely have their pacemakers removed.