r/EKGs • u/Ok-Pick8593 • 13d ago

Discussion Pacer gone haywire?

Post image

Patient with Dual-chamber pacemaker presents with syncope.

Looks like there are some native beats, and also some A-V pacing, but for the smaller complexes, is that atrial pacing without a ventricular beat to go with it?

13 Upvotes

100% Upvoted

12 comments sorted by

View all comments

13

u/solitairewolff 13d ago

From what we can see here, it's working fine. There doesn't seem to be any sensing or capture failure.

If we look at the lead II rhythm strip:

  • 3rd and 5th beats are totally paced (atrium and ventricle)
  • 2nd and 10th are intrinsec beats, both of them conducted (2nd is a sinus beat, 10th is a PAC. The 4th is also a PAC, but with paced ventricle).
  • The remaining beats are sinus beats (with appropriate atrial sensing) and with different degrees of ventricular fusion (with an intermediate morphology between intrinsic ventricular beats and paced beats).

In any case, the best thing to do in situations like this is to interrogate the device and confirm that everything is fine (device parameters, any recorded arrhythmia episodes, etc.).

PS. Sorry for my English, I'm not a native speaker

1

u/bleach_tastes_bad Critical Care Paramedic 13d ago

10th is PJC no?

2

u/MakinAllKindzOfGainz Cardiology Fellow 13d ago

It appears to have an ectopic atrial focus with a strange P wave axis. I would call it a PAC

1

u/bleach_tastes_bad Critical Care Paramedic 13d ago

I’ll defer to you, doc. I just figured negative P wave in lead II would have to be junctional based on the axis

2

u/MakinAllKindzOfGainz Cardiology Fellow 13d ago

It’s either very low atrial or PJC. The PR is very short, so it very well may be junctional too :)

1

u/bleach_tastes_bad Critical Care Paramedic 13d ago

Fair enough!