Bradycardia‐Dependent Elevation of Atrial Pacing Threshold Mimicking Lead Failure Early After Pacemaker Implantation

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Sick sinus syndrome with bradycardia-dependent elevation of atrial pacing threshold (n=1). Intervention: Conservative observation and pacemaker reprogramming. Primary outcome: Atrial pacing threshold over time.

Ayano Shibata; Rikitake Kogawa; Yukitoshi Ikeya; Toshiko Nakai; Yasuo Okumura

doi:10.1002/joa3.70478

September 23, 2026Journal of ArrhythmiaOpen Access

Bradycardia‐Dependent Elevation of Atrial Pacing Threshold Mimicking Lead Failure Early After Pacemaker Implantation

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Key result

Conservative observation and reprogramming resolve bradycardia-dependent elevated atrial pacing thresholds, avoiding lead revision.

n=1

Figures

Graphical abstract published by Journal of Arrhythmia — Graphical abstract · Published by Journal of Arrhythmia · CC BY

Why the study?

Atrial pacing failure after pacemaker implantation does not always indicate lead malfunction, and non-invasive assessment can identify underlying causes to avoid unnecessary lead revision.

Key Points

To describe the diagnosis and non-invasive management of transient, rate-dependent atrial pacing threshold elevation that mimics acute lead malfunction after pacemaker implantation.
Evaluated a woman in her 70s with sick sinus syndrome who developed intermittent atrial pacing failure on postoperative day 3 after dual-chamber pacemaker implantation.
Reprogrammed pacemaker parameters conservatively and tracked atrial lead sensing, impedance, and thresholds through 7 months of follow-up.
Device interrogation on postoperative day 6 revealed an atrial pacing threshold of 3.0 V at 0.4 ms at 50 bpm, which improved to 2.0 V at 60 bpm, 1.0 V at 70 bpm, and 1.0 V at 80 bpm.
Lead impedance (456 Ω) and sensing amplitude (1.6 mV) remained stable with no radiographic displacement, ruling out mechanical dislodgement.
At 7-month follow-up, the rate-dependent threshold elevation resolved, reaching 0.75 V at 50 bpm and 0.5 V at 60, 70, and 80 bpm (0.4 ms) without surgical lead revision.

Study Design

Type

Case Report (n=1)

Structured PICO

P

Population

A woman in her 70s with sick sinus syndrome who developed bradycardia-dependent elevation of atrial pacing threshold mimicking lead failure early after pacemaker implantation.

I

Intervention

Dual-chamber pacemaker implantation with active-fixation leads in the right atrial appendage and right ventricular septum

O

Outcome

Atrial pacing threshold and capture success at varying pacing rates

Limitations

Intracardiac atrial electrograms and pharmacological testing with adenosine triphosphate were not performed, so the mechanism could not be definitively demonstrated.
Subtle changes in the lead tip-myocardial interface due to micro-dislodgement cannot be completely excluded.
Intracardiac atrial electrograms and pharmacological testing with adenosine triphosphate were not performed
Subtle changes in the lead tip-myocardial interface due to micro-dislodgement cannot be completely excluded

Implication

Bradycardia-dependent elevation of atrial pacing thresholds can mimic lead failure early after pacemaker implantation but may resolve spontaneously with appropriate device programming, avoiding unnecessary lead revision.

Abstract

Atrial pacing failure after pacemaker implantation does not always indicate lead malfunction. Non-invasive assessment can identify the underlying cause and may avoid unnecessary lead revision.

Discussion

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Cite This Study

Shibata et al. (2026) conducted a case report in Sick sinus syndrome with bradycardia-dependent elevation of atrial pacing threshold (n=1). Conservative observation and pacemaker reprogramming was evaluated on Atrial pacing threshold over time. Conservative observation and appropriate device programming allowed spontaneous improvement of bradycardia-dependent elevation of atrial pacing thresholds over 7 months, avoiding unnecessary lead revision.

synapsesocial.com/papers/6ad0fd263afa093ea9ad0223 https://doi.org/10.1002/joa3.70478

Topics

Heart failure

HFrEF treatment

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Bradycardia‐Dependent Elevation of Atrial Pacing Threshold Mimicking Lead Failure Early After Pacemaker Implantation

Figures

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Topics

Bradycardia‐Dependent Elevation of Atrial Pacing Threshold Mimicking Lead Failure Early After Pacemaker Implantation

Figures

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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