Symptomatic unilateral cannon "a" waves in a patient with a ventricular pacemaker

A 64-year-old woman was referred because of intermittent pulsations of the left side of the neck, face, and scalp that were first noticed after the insertion of a ventricular pacemaker. The pacemaker had been inserted because of symptomatic 2:1 atrioventricular block. Right cardiac catherization showed cannon "a" waves, and phlebographic studies revealed stenosis of the right innominate and internal jugular veins. The symptoms were abolished by conversion to an atrial synchronous pacing system. Comments are offered on the hemodynamic findings, the "pacemaking syndrome", and the use of atrial synchronous pacing.