Paroxysmal Atrioventricular Block in a Patient With Pacemaker Following Long-Distance Casting During Sea Fishing

A 74-year-old man who underwent VVI-pacemaker implantation for complete atrioventricular block (AVB) 13 years ago in a different hospital was referred to our emergency department because of syncope. His symptoms had developed 2 months prior. ECG demonstrated paroxysmal AVB due to inappropriate pacing inhibition, which synchronized with the dropping of his left arm (Figure A, Supplementary Movie). The pacing remained stable when the patient brought his palms together in front of his chest. High output pacing could not induce the lead abnormality. Device interrogation revealed an elevation of the pacing threshold with a transient increase in lead impedance for 2 months (Figure B). The patient’s interview revealed that he went sea fishing and had attempted a long-distance casting on the day before the onset of symptoms. Chest X-ray demonstrated lead kinking at the subclavian level (Figure C). Comparing it with previous images confirmed the kink was present 35 months ago (Figure D: 35 months; Figure E: 44 months ago). An additional lead implantation procedure was immediately performed. Intraprocedural findings included a crushed conductor with patent insulation (Figure F).

Figure.

(A) Monitor-ECG (red arrow: paroxysmal atrioventricular block while dropping the left arm). (B) Device interrogation (arrow: day of attempting long-distance casting). Chest X-ray images on admission (C), 35 months (D), and 44 (E) months previously. (C–E) Lower panels show a magnified image of inset in the upper panels. (F) Gross examination of the lead (arrow: crushed conductor). (G) Three-dimensional computed tomography (arrows: compressed lead).

The patient developed lead compression (Figure G) due to implantation via the classic subclavian puncture. Although the kink had been observed previously, the lead had functioned normally for nearly 3 years. The drastic movement of the left arm while casting prompted lead failure. Our observations suggest that additional lead implantation is required immediately for patients with abnormal lead findings, especially if there are signs of lead disturbance such as transient impedance elevation and elevation of pacing threshold.

Disclosures

M.Y. is a member of Circulation Journal’s Editorial Team.

Funding

None.

Ethics

Written informed consent was obtained.

Supplementary Files

Supplementary Movie. Paroxysmal atrioventricular block while dropping the left arm.

Please find supplementary file(s);

http://dx.doi.org/10.1253/circj.CJ-21-1028