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A 65 year old man with a past history of rheumatic fever was admitted to our institution with a history of recent melaena stools. His only regular medication was aspirin. Blood tests confirmed microcytic anaemia and subsequent gastroscopy revealed two small (0.25 cm) gastric ulcers and the patient was placed on long term proton pump inhibitors. Five years earlier the patient had received a single chamber (ventricular VVI mode) pacemaker for sick sinus syndrome at another institution.
An ECG performed during the current admission showed ventricular pacemaker spikes followed by pattern of depolarisation associated with right bundle branch block
(below left), rather than the typical pattern of left bundle branch block. Subsequent echocardiography showed that he had a secundum type atrial septal defect with the ventricular pacing lead crossing the defect and then being tethered to the posterior leaflet of the mitral valve and lateral left ventricular wall (below). There was prolapse of the anterior mitral leaflet associated with moderate mitral regurgitation. No action was taken as there had been no complications during the previous five years and pacemaker and lead functions were normal.