Orthostatic hypotension onset after invasive procedure?

Written by Willy FrickA man in his 70s with a history of HFrEF and sick sinus syndrome s/p dual chamber pacemaker placement was admitted for overnight observation following outpatient placement of a mitral valve clip. The procedure note indicates uncomplicated clip placement. The next morning, the following ECG was obtained.What do you think?The tracing shows sinus rhythm with PVCs and non-specific ST&T wave abnormality. But there is something more important to notice, which is the pacer spikes. They do not make sense. Some of them are in the middle of or after P waves, and there ' s even one that falls at the end of the QRS! Here is the V5 rhythm strip blown up with numbered pacing spikes.Comparing spikes 2, 3, 4, and 5 for example, we see that they all very clearly occur at different times in the cardiac cycle. Spike 2 occurs at the conclusion of the P wave, spikes 3 and 4 occur near the peak of the P wave, and spike 5 occurs just before the onset of the QRS. This is unambiguous evidence of pacemaker malfunction. When it comes to malfunction, we often sort into two categories (although there are other things that can go wrong with pacemakers)." Failure to sense " occurs when the pacemaker does not recognize native function appropriately, and results in excess pacing spikes. Imagine the pacemaker is set at a minimum rate of 60. If it does not sense a native rhythm (perhaps from lead fracture or displacement), it will attempt to pace at 60 beats per minute,...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs