1. When can an electronic pacemaker produce an extra sound? When does the extra sound occur?
ANS: When it causes intercostal skeletal muscle contraction, it can produce a high-pitched, clicking sound just preceding the M1, so that it sounds like a widely split Sl. It is accentuated by inspiration and occurs about 6 ms after the pacing stimulus. Perforation of the myocardium of the RV by a transvenous pacing electrode should be suspected when the pacemaker-induced sound occurs. This, however, is not a necessary concomitant.
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