Heart, Lung and Circulation

Long-Term Implications of Pacemaker Insertion in Younger Adults: A Single Centre Experience

Published:February 23, 2022DOI:


      The long-term implications of pacemaker insertion in younger adults are poorly described in the literature.


      We performed a retrospective analysis of consecutive younger adult patients (18–50 yrs) undergoing pacemaker implantation at a quaternary hospital between 1986–2020. Defibrillators and cardiac resynchronisation therapy devices were excluded. All clinical records, pacemaker checks and echocardiograms were reviewed.


      Eighty-one (81) patients (median age 41.0 yrs IQR=35–47.0, 53% male) underwent pacemaker implantation. Indications were complete heart block (41%), sinus node dysfunction (33%), high grade AV block (11%) and tachycardia-bradycardia syndrome (7%). During a median 7.9 (IQR=1.1–14.9) years follow-up, nine patients (11%) developed 13 late device-related complications (generator or lead malfunction requiring reoperation [n=11], device infection [n=1] and pocket revision [n=1]). Five (5) of these patients were <40 years old at time of pacemaker insertion. At long-term follow-up, a further nine patients (11%) experienced pacemaker-related morbidity from inadequate lead performance managed with device reprogramming. Sustained ventricular tachycardia was detected in two patients (2%). Deterioration in ventricular function (LVEF decline >10%) was observed in 14 patients (17%) and seven of these patients required subsequent biventricular upgrade. Furthermore, four patients (5%) developed new tricuspid regurgitation (>moderate-severe). Of 69 patients with available long-term pacing data, minimal pacemaker utilisation (pacing <5% at all checks) was observed in 13 (19%) patients.


      Pacemaker insertion in younger adults has significant long-term implications. Clinicians should carefully consider pacemaker insertion in this cohort given risk of device-related complications, potential for device under-utilisation and issues related to lead longevity. In addition, patients require close follow-up for development of structural abnormalities and arrhythmias.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Heart, Lung and Circulation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Krzemien-Wolska K.
        • Tomasik A.
        • Wojciechowska C.
        • Baranska-Pawelczak K.
        • Nowalany-Kozielska E.
        • Jachec W.
        Prognostic factors in patients with an implanted pacemaker after 80 years of age in a 4-year follow-up.
        Gerontology. 2018; 64: 107-117
        • Gillam M.H.
        • Pratt N.L.
        • Inacio M.C.S.
        • Shakib S.
        • Sanders P.
        • Lau D.H.
        • et al.
        Rehospitalizations for complications and mortality following pacemaker implantation: A retrospective cohort study in an older population.
        Clin Cardiol. 2018; 41: 1480-1486
        • Hinton T.C.
        • Adams Z.H.
        • Baker R.P.
        • Hope K.A.
        • Paton J.F.R.
        • Hart E.C.
        • et al.
        Investigation and treatment of high blood pressure in young people: too much medicine or appropriate risk reduction?.
        Hypertension. 2020; 75: 16-22
        • Debski M.
        • Ulman M.
        • Zabek A.
        • Boczar K.
        • Haberka K.
        • Kuniewicz M.
        • et al.
        Association of selected factors with long-term prognosis and mortality after dual-chamber pacemaker implant.
        Cardiol J. 2019; 26: 717-726
        • Zecchin M.
        • Torre M.
        • Carrani E.
        • Sampaolo L.
        • Ciminello E.
        • Ortis B.
        • et al.
        Seventeen-year trend (2001-2017) in pacemaker and implantable cardioverter-defibrillator utilization based on hospital discharge database data: an analysis by age groups.
        Eur J Intern Med. 2021; 84: 38-45
        • Bradshaw P.J.
        • Stobie P.
        • Knuiman M.W.
        • Briffa T.G.
        • Hobbs M.S.
        Trends in the incidence and prevalence of cardiac pacemaker insertions in an ageing population.
        Open Heart. 2014; 1e000177
        • Healey J.S.
        • Toff W.D.
        • Lamas G.A.
        • Andersen H.R.
        • Thorpe K.E.
        • Ellenbogen K.A.
        • et al.
        Cardiovascular outcomes with atrial-based pacing compared with ventricular pacing: meta-analysis of randomized trials, using individual patient data.
        Circulation. 2006; 114: 11-17
        • de Vries L.M.
        • Dijk W.A.
        • Hooijschuur C.A.
        • Leening M.J.
        • Stricker B.H.
        • van Hemel N.M.
        Utilisation of cardiac pacemakers over a 20-year period: Results from a nationwide pacemaker registry.
        Neth Heart J. 2017; 25: 47-55
        • Kirkfeldt R.E.
        • Johansen J.B.
        • Nohr E.A.
        • Jorgensen O.D.
        • Nielsen J.C.
        Complications after cardiac implantable electronic device implantations: an analysis of a complete, nationwide cohort in Denmark.
        Eur Heart J. 2014; 35: 1186-1194
        • Elder D.
        • Szwejkowski B.
        • Jain R.
        • Cook A.
        • Lang C.
        • Struthers A.
        • et al.
        Younger age at time of pacemaker implantation is associated with worse survival.
        Ciculation. 2018; 122
        • Poole J.E.
        • Gleva M.J.
        • Mela T.
        • Chung M.K.
        • Uslan D.Z.
        • Borge R.
        • et al.
        Complication rates associated with pacemaker or implantable cardioverter-defibrillator generator replacements and upgrade procedures: results from the REPLACE registry.
        Circulation. 2010; 122: 1553-1561
        • Udo E.O.
        • Zuithoff N.P.
        • van Hemel N.M.
        • de Cock C.C.
        • Hendriks T.
        • Doevendans P.A.
        • et al.
        Incidence and predictors of short- and long-term complications in pacemaker therapy: the FOLLOWPACE study.
        Heart Rhythm. 2012; 9: 728-735
        • Mayosi B.M.
        • Little F.
        • Millar R.N.
        Long-term survival after permanent pacemaker implantation in young adults: 30 year experience.
        Pacing Clin Electrophysiol. 1999; 22: 407-412
        • Ellenbogen K.A.
        • Hellkamp A.S.
        • Wilkoff B.L.
        • Camunas J.L.
        • Love J.C.
        • Hadjis T.A.
        • et al.
        Complications arising after implantation of DDD pacemakers: the MOST experience.
        Am J Cardiol. 2003; 92: 740-741
        • Eberhardt F.
        • Bode F.
        • Bonnemeier H.
        • Boguschewski F.
        • Schlei M.
        • Peters W.
        • et al.
        Long term complications in single and dual chamber pacing are influenced by surgical experience and patient morbidity.
        Heart. 2005; 91: 500-506
        • Sagar S.
        • Shen W.K.
        • Asirvatham S.J.
        • Cha Y.M.
        • Espinosa R.E.
        • Friedman P.A.
        • et al.
        Effect of long-term right ventricular pacing in young adults with structurally normal heart.
        Circulation. 2010; 121: 1698-1705
        • Bond R.
        • Augustine D.
        • Dayer M.
        Pacemaker complications in a district general hospital.
        Br J Cardiol. 2012; 19: 90-94
        • Nowak B.
        • Misselwitz B.
        • Expert Committee Pacemaker IoQAH
        Effects of increasing age onto procedural parameters in pacemaker implantation: results of an obligatory external quality control program.
        Europace. 2009; 11: 75-79
        • Ozcan K.S.
        • Osmonov D.
        • Altay S.
        • Donmez C.
        • Yildirim E.
        • Turkkan C.
        • et al.
        Pacemaker implantation complication rates in elderly and young patients.
        Clin Interv Aging. 2013; 8: 1051-1054
        • Armaganijan L.V.
        • Toff W.D.
        • Nielsen J.C.
        • Andersen H.R.
        • Connolly S.J.
        • Ellenbogen K.A.
        • et al.
        Are elderly patients at increased risk of complications following pacemaker implantation? A meta-analysis of randomized trials.
        Pacing Clin Electrophysiol. 2012; 35: 131-134
        • de Voogt W.G.
        Pacemaker leads: performance and progress.
        Am J Cardiol. 1999; 83: 187D-191D
        • Mond H.G.
        • Helland J.R.
        • Stokes K.
        • Bornzin G.A.
        • McVenes R.
        The electrode-tissue interface: the revolutionary role of steroid-elution.
        Pacing Clin Electrophysiol. 2014; 37: 1232-1249
        • Yang Z.
        • Kirchhof N.
        • Li S.
        • Hine D.
        • McVenes R.
        Effect of steroid elution on electrical performance and tissue responses in quadripolar left ventricular cardiac vein leads.
        Pacing Clin Electrophysiol. 2015; 38: 966-972
        • Gabriels J.
        • Wu M.
        • Rosen L.
        • Patel A.
        • Goldner B.
        Clinical significance of nonsustained ventricular tachycardia on stored electrograms in permanent pacemaker patients.
        Pacing Clin Electrophysiol. 2016; 39: 1335-1339
        • Mohammed S.
        • Gierula J.
        • Jamil H.A.
        • Paton M.F.
        • Lowry J.E.
        • Cubbon R.M.
        • et al.
        Asymptomatic nonsustained ventricular tachycardia detected on pacemaker interrogation not associated with adverse outcomes and treatment remains unproven.
        Circulation. 2018; 134
        • Kim J.J.
        • Friedman R.A.
        • Eidem B.W.
        • Cannon B.C.
        • Arora G.
        • Smith E.O.
        • et al.
        Ventricular function and long-term pacing in children with congenital complete atrioventricular block.
        J Cardiovasc Electrophysiol. 2007; 18: 373-377
        • Shalganov T.N.
        • Paprika D.
        • Vatasescu R.
        • Kardos A.
        • Mihalcz A.
        • Kornyei L.
        • et al.
        Mid-term echocardiographic follow up of left ventricular function with permanent right ventricular pacing in pediatric patients with and without structural heart disease.
        Cardiovasc Ultrasound. 2007; 5: 13
        • Vatasescu R.
        • Shalganov T.
        • Paprika D.
        • Kornyei L.
        • Prodan Z.
        • Bodor G.
        • et al.
        Evolution of left ventricular function in paediatric patients with permanent right ventricular pacing for isolated congenital heart block: a medium term follow-up.
        Europace. 2007; 9: 228-232
        • Thambo J.B.
        • Bordachar P.
        • Garrigue S.
        • Lafitte S.
        • Sanders P.
        • Reuter S.
        • et al.
        Detrimental ventricular remodeling in patients with congenital complete heart block and chronic right ventricular apical pacing.
        Circulation. 2004; 110: 3766-3772
        • Hong W.J.
        • Yung T.C.
        • Lun K.S.
        • Wong S.J.
        • Cheung Y.F.
        Impact of right ventricular pacing on three-dimensional global left ventricular dyssynchrony in children and young adults with congenital and acquired heart block associated with congenital heart disease.
        Am J Cardiol. 2009; 104: 700-706
        • Ebert M.
        • Jander N.
        • Minners J.
        • Blum T.
        • Doering M.
        • Bollmann A.
        • et al.
        Long-term impact of right ventricular pacing on left ventricular systolic function in pacemaker recipients with preserved ejection fraction: results from a large single-center registry.
        J Am Heart Assoc. 2016; 5
        • Yu C.M.
        • Chan J.Y.
        • Zhang Q.
        • Omar R.
        • Yip G.W.
        • Hussin A.
        • et al.
        Biventricular pacing in patients with bradycardia and normal ejection fraction.
        N Engl J Med. 2009; 361: 2123-2134
        • Khurshid S.
        • Epstein A.E.
        • Verdino R.J.
        • Lin D.
        • Goldberg L.R.
        • Marchlinski F.E.
        • et al.
        Incidence and predictors of right ventricular pacing-induced cardiomyopathy.
        Heart Rhythm. 2014; 11: 1619-1625
        • Kobza R.
        • Schoenenberger A.W.
        • Erne P.
        Effects of right ventricular pacing on left ventricular ejection fraction in a pacemaker clinic.
        Acta Cardiol. 2012; 67: 577-582
        • Sharma A.D.
        • Rizo-Patron C.
        • Hallstrom A.P.
        • O'Neill G.P.
        • Rothbart S.
        • Martins J.B.
        • et al.
        Percent right ventricular pacing predicts outcomes in the DAVID trial.
        Heart Rhythm. 2005; 2: 830-834
        • Hussain M.A.
        • Furuya-Kanamori L.
        • Kaye G.
        • Clark J.
        • Doi S.A.
        The effect of right ventricular apical and nonapical pacing on the short- and long-term changes in left ventricular ejection fraction: a systematic review and meta-analysis of randomized-controlled trials.
        Pacing Clin Electrophysiol. 2015; 38: 1121-1136
        • Lin G.
        • Nishimura R.A.
        • Connolly H.M.
        • Dearani J.A.
        • Sundt 3rd, T.M.
        • Hayes D.L.
        Severe symptomatic tricuspid valve regurgitation due to permanent pacemaker or implantable cardioverter-defibrillator leads.
        J Am Coll Cardiol. 2005; 45: 1672-1675

      Linked Article

      • The Necessary Perils of Pacemaker Implantation in Young Individuals—Can We Do Better?
        Heart, Lung and CirculationVol. 31Issue 7
        • Preview
          In the last two decades, there has been an increase in the implantation of permanent pacemakers (PPMs) [1–3]. Unlike similarly developed countries, Australia has not yet reached a plateau in demand for pacemaker implants [3]. Although the increase is driven by the ageing population, a rise in implantation of PPMs has been noted across all age groups. Acute complications from pacemaker implantation are well-recognised but the long-term implications of pacemaker implantation remain less well characterised, especially in the younger population.
        • Full-Text
        • PDF