Case: A 72-year-old woman was hospitalized with dyspnea on exertion and edema. She had a history of surgical repair of atrial septal defect and a VVI pacemaker implantation for symptomatic sick sinus syndrome. Physical examination showed a sign of right heart failure: heaved motion of the internal jugular vein (V wave) during systole, and an increased central venous pressure on inspiration (Kussmaul sign). Electrocardiography revealed no apparent P wave with regular ventricular pacing rhythm of 80 bpm. Echocardiography showed preserved left ventricular ejection fraction with moderate tricuspid regurgitation. Right-sided heart failure was suspected and furosemide was administrated intravenously. Electro-physiological study revealed preserved ventriclo-atrial conduction, suggesting the presence of viable atrial myocardium. Additional atrial lead was inserted and AAI pacing was started. On physical examination, the V wave and the Kussmaul sign disappeared immediately after the procedure. Her symptom improved. Conclusions: Kussmaul sign observed after VVI pacemaker implantation suggested the presence of right-sided heart failure caused by both non-physiological pacing and ventriclo-atrial conduction.
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