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Challenges in Clinical Electrocardiography
March 2018

A Case of Possible Pacemaker Malfunction: The Pacemaker That Did Not Make Sense

Author Affiliations
  • 1Department of Medicine, University of California San Francisco
  • 2Division of Cardiology, Department of Medicine, University of California San Francisco
  • 3Department of Medicine, University of California San Francisco
  • 4Division of Cardiology, Department of Medicine, San Francisco General Hospital, San Francisco, California
JAMA Intern Med. 2018;178(3):408-410. doi:10.1001/jamainternmed.2017.8303

A man in his 50s with a dual-chamber pacemaker implanted for sinus node dysfunction presented to the emergency department reporting 1 month of severe back pain, fevers, drenching night sweats, and a 10-lb weight loss. The device had been implanted 10 years prior and its atrial lead was subsequently recalled. The lead was programmed off, but not extracted, and the pacing system was programmed to VVI mode (ventricular pacing and sensing, with inhibition of the pacing stimulus on sensing native QRS complexes). He denied a history of intravenous drug use but admitted to inhaled methamphetamine use. In the emergency department, he was afebrile with normal vital signs. Examination was remarkable only for lumbar spinal tenderness. No cardiac murmurs were appreciated. Laboratory data were within normal limits. Chest x-ray revealed the implanted device with leads projecting appropriately over the right atrium and right ventricular apical area.

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