Pacemaker dependency is observed in an appreciable number of chronically paced patients. Although there is no standard definition, pacemaker dependency has a significant impact on the management of patients in several clinical settings. In this review, we provide a comprehensive overview of the available data regarding definition, testing, clinical significance, epidemiology, and mechanisms of pacemaker dependency. Several issues regarding the underlying pathophysiology remain obscure and the potential value of interventions that may alter its incidence, clinical course, and consequences remains to be elucidated.