The use of both magnetic resonance imaging (MRI) and pacing devices has vastly increased worldwide in recent years. A significant number of implanted patients will likely need monitoring using magnetic resonance imaging (MRI) over the course of the lifetime of their device. Some studies have demonstrated that with appropriate precautions, MRI can be safely performed in patients with selected implantable pacemakers. However, MRI is still contraindicated in patients with pacemakers. Recently, new pacing systems have been specifically designed for safe use in the MRI environment. The first reported experience suggests that the technology is safe and may allow patients with these new pacemakers to undergo MRI. This review will describe the outstanding issues and controversies surrounding the safety of MRI in patients with pacemakers, and the potential benefits of the new MRI-conditional technology. We will also discuss how to decide whether an MRI-conditional system should be implanted, and highlight key issues that warrant further studies.