The airman has good ventricular escape rhythm, which would probably prevent incapacitation, should pacemaker failure occur during flight. However, he is pacemaker-dependent, and that has necessitated 6 pacemaker placements with numerous additional independent lead placements. The congenital hypoplastic mitral valve has resulted in 4 mitral valve replacement procedures and associated coumadin therapy. Good lead placement and acceptably low thresholds for capture have been historically difficult to obtain in this airman. The current pacemaker tests show acceptable lead placement with adequately low threshold values.
Thromboembolism poses a significant risk of sudden incapacitation.
This airman's risk of a thrombotic event is further increased by the presence of atrial fibrillation. The risk of anticoagulation therapy is also present for airmen with prosthetic mitral valves. His last mitral valve replacement was 6 years ago, with coumadin therapy following the mitral valve replacement. The literature indicates a significant risk of embolism or thrombosis of the prosthesis in patients with a St. Jude mitral valve who are not anticoagulated with coumadin. Antiplatelet agents alone have not been shown to provide adequate benefit.