Right hemidiaphragmatic twitching: a complication of bipolar atrial pacing

A patient with an atrioventricular sequential pacemaker developed rhythmic contractions of the right hemidiaphragm. This was found to be the result of right phrenic nerve stimulation, which was directly related to the wide distance between the poles of an ELA atrial lead when pacing in bipolar mode. Pole separation in current atrial leads is discussed.