Successful removal of pacemakers in patients with Lyme carditis

Reversible heart block from Lyme disease means patients may not need permanent pacemakers for life. Two cases demonstrate successful removal of permanent pacemakers after antibiotic treatment restored normal cardiac conduction. Both patients maintained 1:1 conduction at heart rates exceeding 120 beats per minute during exercise stress testing, proving their heart block had completely resolved.

Pacemaker Removal: Proof of Reversibility

In their study “Pacemaker Explantation in Patients With Lyme Carditis,” Wamboldt and colleagues describe two cases involving the removal of pacemakers in patients with Lyme carditis, which highlights the importance of including Lyme carditis in the differential diagnosis for high-degree AV block.

Furthermore, these cases demonstrate the “benefits of early device interrogation in patients who have been treated for Lyme carditis and received a pacemaker during their treatment,” the authors explain.

These cases prove that heart block from Lyme disease is truly reversible — not just theoretically but practically, with permanent pacemakers successfully removed after conduction normalizes.

Understanding Lyme Carditis Conduction Disorders

Lyme carditis can lead to cardiac arrhythmias and conduction disorders, most commonly atrioventricular (AV) blocks.

When Borrelia burgdorferi spirochetes infiltrate the heart’s electrical conduction system, they disrupt the transmission of electrical signals from the atria to the ventricles. This disruption manifests as varying degrees of heart block — from first-degree (slowed conduction) to complete block (no conduction).

The critical question these cases address: once pacemakers are implanted, must they remain permanently, or can they be removed after antibiotics resolve the infection?

Case 1: 48-Year-Old Woman with Complete Heart Block

“A 48-year-old woman presented with shortness of breath and dizziness secondary to complete heart block,” the authors write. “Given the presence of symptomatic bradycardia, she was transferred to a tertiary hospital for pacemaker implantation.”

The presentation was classic for severe Lyme carditis: complete (third-degree) heart block causing symptoms from inadequate heart rate. With no electrical conduction between atria and ventricles, her heart couldn’t maintain adequate cardiac output for normal activities.

She had a non-specific rash on her abdomen 3 months before symptom onset.

This timeline is typical — cardiac symptoms develop weeks to months after initial tick bite, often after the rash has resolved. The three-month gap meant she likely didn’t connect the rash to her current cardiac symptoms.

Lyme disease testing was positive.

Case 2: 58-Year-Old Man with Atrial Fibrillation and Pauses

A 58-year-old man presented with dizziness, syncope, headache and myalgia. “His initial electrocardiogram showed atrial fibrillation with slow ventricular response,” the authors write. “During his admission he experienced symptomatic pauses lasting 4 to 10 seconds.”

This case demonstrates the diverse cardiac manifestations of Lyme disease. Rather than classic heart block, he presented with atrial fibrillation — an irregular rhythm — combined with dangerously slow ventricular response and pauses up to 10 seconds.

Ten-second pauses are life-threatening. During these pauses, no blood flows to the brain or vital organs. The dizziness and syncope resulted from inadequate cerebral perfusion during these episodes.

He also had a pacemaker implantation.

Lyme disease testing was positive.

Both patients were treated successfully with antibiotics.

Why Permanent Pacemakers Were Placed

Typically, Lyme disease patients with conduction problems are placed on a temporary pacemaker. In both of these cases, the patients were placed on a permanent pacemaker.

Standard practice for Lyme carditis is temporary pacing — using external pacemakers or temporary leads that can be removed once antibiotics restore conduction.

Permanent pacemakers should be avoided when possible, especially in younger patients who would require decades of device management.

• Lyme disease not recognized initially
• Hemodynamic instability
• Institutional practice patterns
• Patient circumstances requiring rapid stabilization

Regardless of why permanent devices were placed, these cases demonstrate they can be successfully removed after treatment.

Exercise Testing Proves Conduction Recovery

On follow-up, both pacemakers were functioning. “Both patients underwent exercise stress testing and were able to maintain 1:1 conduction at heart rate >120 beats/min,” according to the authors.

This testing was essential to prove heart block had resolved.

Successful Pacemaker Removal

The permanent pacemakers were removed successfully.

Pacemaker explantation involves extracting both the generator and the leads attached to the heart muscle.

“Within the first year of insertion, transvenous lead extraction has a high success rate and a low complication rate,” the authors explain.

The pacemaker becomes more difficult to remove after a year because fibrotic tissue forms around the leads.

Importance of Early Follow-Up

“This highlights the importance of close follow-up so that early pacemaker explantation can be arranged if clinically indicated,” the authors suggest.

Patients with pacemakers placed during treatment for Lyme carditis should undergo follow-up evaluation once infection has been treated and conduction recovers.

Clinical Insight

Frequently Asked Questions

Can heart block from Lyme disease be reversed?

Yes. Lyme carditis can cause reversible heart block. Antibiotic treatment often restores normal electrical conduction once the infection resolves.

Can permanent pacemakers be removed from Lyme carditis patients?

Yes. When conduction recovers and stress testing confirms normal function, pacemaker removal may be possible.

Why is early pacemaker removal important?

Pacemaker leads become embedded in heart tissue over time through fibrotic changes. Removal within the first year is typically easier and safer.