Late presentation of recurrent syncope after permanent pacemaker implantation due to Lead−Header malapposition

Figures

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  Fig. 1. Stored electrograms at the time of the syncopal episode. Stored electrograms corresponding to the time of the patient’s syncopal episode showing high frequency, non-physiologic (cycle length = 150 msec) noise on the ventricular (V) channel which saturates the amplifier. The pacemaker interprets the noise as ventricular tachycardia (VT) on the marker channel (M). There is pacing inhibition (no ventricular pace [VP]) is noted). A = atrial channel, V = ventricular channel, M = marker channel, VT = ventricular tachycardia, AS = atrial sense, PVP = Post ventricular atrial refractory period extension.

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  Fig. 2. Magnified view of the pacemaker generator on chest radiography. Antero-posterior chest radiograph with a magnified view of the pacemaker generator showing that the ventricular lead is not fully inserted into the header and the terminal pin is not seen past the distal set screw (black arrow). In contrast, the atrial lead is fully inserted.

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  Fig. 3. Intra-operative photo confirming lead-header malapposition. Photograph of the generator taken at the time of the lead revision procedure confirming that the ventricular lead terminal pin was not completely or fully inserted into the header (white arrow). A = atrial lead port, V = ventricular lead port.

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  Fig. 4. Impedance trend. Stable impedance values were noted in the months prior to lead revision procedure during which lead header malappostion was noted.