A man in his early 70s with a history of permanent atrial fibrillation treated with atrioventricular junction ablation and biventricular pacemaker implantation was hospitalized with decompensated heart failure and acute kidney injury. His history was notable for nonischemic cardiomyopathy with ejection fraction of 40% and idiopathic pulmonary fibrosis, for which he underwent single-lung transplant 9 years prior. Following diuresis and medical optimization, repeated echocardiogram showed a newly depressed ejection fraction (30%). His electrocardiogram (ECG) was notable for alternating QRS morphologies (Figure 1A). The left ventricular (LV) pacing vector was programmed from LV tip to right ventricular (RV) lead ring. During pacemaker threshold testing, a change in QRS morphology was observed as the output was reduced (Figure 1B). Chest radiography revealed severe right pulmonary fibrosis leading to ipsilateral mediastinal shift and pacemaker lead position unchanged from implantation.
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Corresponding Author: Matthew C. Hyman, MD, PhD, Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, 3400 Spruce St, 9 Gates Pavilion, Philadelphia, PA 19104 (Matthew.Hyman@pennmedicine.upenn.edu).
Published Online: August 11, 2021. doi:10.1001/jamacardio.2021.2755
Conflict of Interest Disclosures: None reported.
Funding/Support: This work was supported by a grant from the Fondation Leducq (TNE FANTASY 19CV03).
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: We thank the patient’s daughter for granting permission to publish this information on the patient’s behalf.
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