Epicardial pacemaker implantation in an elderly patient with pre-existing bilateral subclavicular deep brain stimulators

A 78-year-old woman presented with complete atrioventricular block, with a slow ventricular escape rhythm of 38 bpm. The patient received bilateral subthalamic nucleus deep brain stimulation (DBS) in 1998, because of uncontrolled fluctuations and dyskinesia due to advanced Parkinson’s disease. As both neurostimulators (Soletra neurostimulators, Medtronic Inc.) were implanted in the subclavicular region bilaterally, an epicardial pacemaker (PM) (Evia SR-T, Biotronik Inc.) was implanted (Fig. 1A). DBSs were turned off during pacemaker implantation. As recommended by the manufacturer, the generator was implanted more than 15 cm away from DBSs. It was implanted by minimally invasive subxiphoid approach and placed in an abdominal pocket, below the fascia of the right rectus abdominis muscle. The ventricular electrogram amplitude was 10.4 mV, the pacing threshold was 0.9 V/0.4 ms pulse width, and the lead impedance was 468 Ohms. A second ventricular lead was implanted and left capped, for later use, in case the first lead fails. The output setting of the right DBS was 3.0 V with a pulse width of 90 ms, at a stimulation frequency of 160 Hz. The output