Preventing complications in cardiac pacemaker therapy: a lifecycle-based risk management framework

Pacemaker implantation remains an established therapeutic strategy for a broad range of bradyarrhythmias and conduction system disorders. As implantation volumes continue to increase worldwide, device-related complications have emerged as significant determinants of patient outcomes, healthcare utilization, and long-term prognosis. Pacemaker-related complications demonstrate substantial heterogeneity in terms of temporal onset, underlying pathophysiological mechanisms, and clinical impact. These events may arise from procedural factors, lead or device dysfunction, device-associated infection, or subsequent structural and functional alterations of the heart. This review proposes a structured lifecycle-based risk management framework that integrates complication prevention across the entire continuum of pacemaker therapy. This approach highlights the dynamic nature of complication risk across different phases of device therapy. Within this lifecycle risk-management paradigm, complication prevention should extend beyond isolated perioperative measures and encompass structured preprocedural assessments, standardized intraoperative techniques, and longitudinal postprocedural surveillance. By synthesizing current evidence regarding the underlying mechanisms and clinical manifestations of pacemaker-related complications and contemporary prevention and management strategies for these complications, this work provides a comprehensive overview. This framework-based approach offers a practical strategy to enhance risk stratification, guide procedural decision-making, and improve long-term outcomes in patients undergoing pacemaker therapy.