Shortness of breath and palpitations in an elderly man: Bad device behavior or malfunction?

70-year-old male with sinus node dysfunction (SND) and paroxysmal atrial fibrillation presents with shortness of breath and palpitations. Presenting EKG shows AF with rapid ventricular rates requiring direct current cardioversion (DCCV). Post-DCCV EKG shows sinus rhythm with competing ventricular pacing. Device interrogation demonstrates the patient's generator at the elective replacement indicator (ERI) and has been forced to VVI 65 bpm causing dyssynchronous ventricular pacing and inducing AF. This case highlights the importance of close device follow up with timely PPM generator change prior to ERI, especially in patients with Medtronic Adapta devices, to avoid unnecessary dyssynchronous ventricular pacing. In addition, device manufacturers should focus on maintaining AV synchrony in pacemakers when they reach ERI.