An 89 year old woman presents to the Emergency Department after a fall without loss of consciousness. She has had a dual chamber pacemaker implanted 2 years ago for syncope secondary to sinus arrest and second–degree AV block. Her ECG is shown below: 

• Sinus rhythm with demand DDD pacing, ventricular rate of 54/min 
• Atrial sensed, ventricular paced, and atrial paced, ventricular paced complexes 
• Prolonged AV conduction  
• Abbot pacemaker VIP mode (Intermittent extension of paced AV delay to promote intrinsic conduction) 

Comment: Positive complexes noted in V1 and V2 likely related to superior positioning of these leads – all other leads consistent with RV apical pacing.