A chest radiograph demonstrated probable lead fracture. Pacing continued with pacemaker spikes occurring at a fixed interval following each native QRS. The lead impedance was 2904 ohms, but the device failed to capture at maximum output. Upon interrogation of her device, the pacemaker was at the elective replacement indicator and the mode had been automatically reset from VVIR at a lower rate limit of 75 to VVI at a rate of 65. Her initial electrocardiogram (ECG) showed complete heart block with a junctional or ventricular escape rhythm of 45 beats per minute (bpm) with noncapturing ventricular pacing stimulus artifacts ( Figure 1). Owing to our concerns for possible lead failure, we brought the patient in for evaluation and interrogation of her device. The device was not interrogated at that time. The patient had largely been asymptomatic aside from a 1-time complaint of shortness of breath with exertion, for which she was evaluated in a local emergency room. There had been a sudden rise in lead impedance from an average lead impedance of 303 to 1891 ohms 2 months previously, and the current transmission reported an impedance of 3827 ohms. She was followed but moved out of state for several years, and on moving back to our area, her first CareLink transmission noted a ventricular lead programmed output 5.00 V at 1.00 ms in unipolar mode, with the generator at the recommended replacement time. She underwent 2 generator changes with retention of the original lead, the last 5 years prior (Medtronic Adapta ADSR01). A 12-year-old girl with a history of congenital complete atrioventricular block had implantation of a single-chamber epicardial pacemaker in infancy using a unipolar lead (Medtronic 4965-25).
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