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Case of the Month 01/12

This 62 year old male who had had a AICD placed about three weeks ago presented to the ED complaining that he was having very frequent electric shock-like sensations and spasms in his right chest and abdomen.

Question 1: What’s wrong with this picture?

radiology image

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Answer 1:

The atrial lead is no longer in the right atrium as it should be (see circle on patient’s CXR, labeled CXR below and repeat CXR after his lead revision.)

Question 2: Below is the EKG that was done in the ED. What’s wrong with this picture?

radiology image

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Answer 2:

Pacemaker spikes are seen at various locations in the QRS complex which do not appear to be triggering the appropriate electrical activity.

On interrogation, it was confirmed that the atrial lead was not capturing at all. The atrial lead displacement was thought to be triggering phrenic nerve activation causing the patient’s symptoms. The AICD was reprogrammed to sense and pace only the ventricle and the patient was sent for lead revision.

PPM displacements are most likely to occur within the first 6 weeks of placement and are more common in the atrial than in the ventricular lead.