High thresholds may alter end-of-life behavior in a dual chamber pacemaker

We noted a series of 12 consecutive patients with a DDD Genisis(R) pacemaker that showed an unexpected and a relatively rapid fall in battery voltage and output as these devices approached end-of-life (EOL). Twenty-one of 24 leads were Vitatron Helifix(R) leads and there was a relatively high mean threshold (atrial 2.5 +/- 0.94 V; ventricular 2.9 +/- 0.65 V). These devices were replaced after 65 +/- 12 months. During the 9.3 +/- 3.5 months before replacement, a striking fall in voltage from 2.7 +/- 0.04 V to 2.49 +/- 0.05 V was seen. Battery impedance rose from 3 +/- 1.2 K Ohm to 10.2 +/- 4.3 K Ohm during this same period. We unexpectedly observed a marked difference between programmed and telemetered output for both atrial (50%) and ventricular leads (30%). A discrepancy between measured and telemetered magnet rate was also seen. Despite this relatively rapid fall in battery voltage, several of these devices did not meet the manufacturer's recommended replacement time (RRT) criteria by magnet rate or according to the projected RRT determined by the relationship of battery impedance to current drain. These data have implications for the selection of RRT and EOL criteria for this device. Magnet rate measured by surface ECG was the safest indicator for RRT. Follow-up for this pulse generator should be increased to every 2 months when battery impedance is > 2 KOhms or if there is a difference between programmed and measured output amplitude of more than 25%. The data also highlight the effect of combining high threshold leads with modern pacemakers with relatively ''small'' batteries as well as certain problems with telemetered data.