Management of an unexpected finding during a routine pacemaker follow-up – what action would you take?
Chief Cardiac Physiologist, Epsom & St Helier NHS Trust
Dr John P Foran
Consultant Cardiologist & Electrophysiologist, Epsom & St Helier NHS Trust, and Royal Brompton & Harefield NHS Trust.
Disclosure: The author has no conflict of interests to declare.
An 84-year-old male with symptomatic sinus node dysfunction underwent dual pacemaker implantation in 2017, with a Medtronic Ensura ENDR01 DR implantable pulse generator and two Medtronic 5076 active-fixation, bipolar pacing electrodes.
His past medical history includes hypertension and paroxysmal atrial fibrillation. Prescribed medication included: Lisinopril, Bisoprolol, Flecainide and Apixaban. Device Settings were programmed as follows;
Base rate: 70 ppm
Upper sensor rate: 110 ppm
Atrial pace/sense configuration: bipolar/bipolar
Ventricular pace/sense configuration: bipolar/bipolar
He attended his local pacing clinic for a routine annual follow-up. At the appointment he reported no new or worsening symptoms since his last review. Device interrogation revealed an estimated battery longevity of 4.5 years, no atrial or ventricular high-rate episodes, AAI pacing 99.9% of the time with VVI pacing <0.1%. The right ventricular lead was found not to capture at maximum outputs (8.0 V at 1.0 msec) and the following RV impedance trend was obtained (figure 1).
Figure 1. RV electrode impedance trend (bipolar configuration).