False inhibition of an atrial demand pacemaker caused by an insulation defect in a polyurethane lead

A patient who had an atrial demand pacemaker (AAI) presented with irregular pacing at a routine examination 5 months after implantation. When a magnet was applied over the pulse generator regular fixed rate pacing was obtained, thus proving oversensing in the system. Reprogramming the input sensitivity level to 2.5 and 5.0 mV did not solve the problem. Programming the pulse generator to the triggered mode (AAT) showed acceleration of the stimulation rate but also inhibition of the system. An S-S interval of 1260 ms was measured at a programmed interval of 857 ms (70 bpm). The pulse generator was disconnected and the intra-atrial electrogram was recorded. This showed different spurious signals varying in morphology and amplitude. Fortunately we were able to remove the lead (Medtronic 6991-U) from the atrial appendage. Subsequently a Helifix 12 mm AT lead was successfully implanted in the right atrial appendage and the same pulse generator was connected to the newly implanted lead. When the removed lead was examined by the manufacturer, a small tear in the insulation of the wire was detected. The dimensions of the tear were 0.1 X 0.7 mm. The tear was caused by stress corrosion cracking in the polyurethane tubing of the lead.