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      Intermittent Right Ventricular Outflow Tract Capture due to Chronic Right Atrial Lead Dislodgement

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          Abstract

          A 58 year old male, known case of type 2 diabetes and hypertension, had undergone implantation of a dual chamber pacemaker(DDDR) in 2007 for complaints of recurrent syncope and trifascicular block with a normal ejection fraction andnormal coronaries. His post implantation parameters were normal at that time.He now presented to our pacemaker clinic where his ECG done showed two types o fpaced complexes. The first few complexes were consistent with atrial sensed right ventricular apical pacing with left superior axis. Later complexes showed loss of atrial sensing with pacing from right ventricular outflow tract(inferior axis) with subtle oscillation in it's axis. On application of magnet, two pacemaker spikes were visible withinterspike interval of 120 ms and paced complexes with inferior axis starting from the first spike suggesting that the atrial lead was responsible for RVOT depolarization. On interrogation of the pacemaker, atrial EGM showed sensed activity from atrium followed by large sensed ventricular complex. Fluoroscopy confirmed that the atrial lead was dislodged and was intermittently prolapsing into the RVOT. Since the patient was asymptomatic, he refused any intervention and subsequentlyhis atrial lead was switched off by telemetry. The above case signifies that asymptomatic lead dislodgement is no talways manifested as loss of capture and even subtle variation of the axis o fthe paced complexes can provide us with a clue that can be confirmed by telemetry of the pacemaker and fluoroscopy.

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          Most cited references 4

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          Long term complications in single and dual chamber pacing are influenced by surgical experience and patient morbidity.

          To determine how short and long term complication rates after pacemaker implantation are influenced by patient morbidity, operator experience, and choice of pacing system. Retrospective analysis of 1884 patients who received VVI (n = 610), VDD (n = 371), or DDD devices (n = 903) between 1990 and 2001. Follow up period was 64 (34) months. The influence of age, sex, coronary artery disease, myocardial infarction, reduced left ventricular (LV) function, right ventricular (RV) dilatation, atrial fibrillation, device type, and operator experience on operation time and complication rate were analysed. Operation time was prolonged in patients with coronary artery disease, inferior myocardial infarction, reduced LV function, and RV dilatation. Implantation of DDD pacemakers prolonged operation time, particularly among operators with a low or medium level of experience. The overall complication rate was 4.5%. Sixty seven per cent of these complications occurred within the first three months. Complication rate was increased by age, reduced LV function, and RV dilatation. Implantation of DDD systems led to a higher complication rate (6.3%) than implantation of VVI (2.6%) or VDD pacemakers (3.2%). These differences were present only among operators with a low or medium level of experience. Operation time and complication rate increased with age, impaired LV function, and RV dilatation. Complication rates were higher with DDD than with VVI or VDD implantation and were excessive among inexperienced but not experienced operators.
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            Intermittent capture of the right ventricular outflow tract by atrial pacing in a patient with a dual-chamber pacemaker.

            We describe a previously unreported phenomenon of intermittent outflow right ventricular tract capture from the atrial lead of a dual-chamber pacemaker. This was more obvious at slower paced atrial rates and disappeared by decreasing the atrial pulses voltage. Electroanatomical mapping showed that the onset of activation was nearly simultaneous at the insertion site of the atrial lead and at an intermediate level of the right ventricular outflow tract. This exceptional finding might be erroneously diagnosed as due to pseudo-pseudo fusion beats. Copyright © 2012 Elsevier Inc. All rights reserved.
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              Cross-stimulation due to malposition of an atrial lead of a dual-chamber pacemaker.

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                Author and article information

                Affiliations
                Department of Cardiology, GB Pant Hospital, New Delhi, India
                Author notes
                Address for correspondence: Dr. Partha Prateem Choudhury, Assistant Professor, Department of Cardiology, GB Pant Hospital, New Delhi, India. drparthapc79@ 123456gmail.com
                Journal
                Indian Pacing Electrophysiol J
                Indian Pacing Electrophysiol J
                Indian Pacing Electrophysiol J
                Indian Pacing and Electrophysiology Journal
                Indian Heart Rhythm Society
                0972-6292
                Jul-Aug 2014
                15 July 2014
                : 14
                : 4
                : 217-222
                4100087 ipej140217-00
                Copyright: © 2014 Choudhury et al.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Case Report

                Cardiovascular Medicine

                electrogram (egm), dual chamber pacemaker, lead dislodgement

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