Permanent pacemakers are used for a variety of conditions and are commonly encountered in the perioperative period. This report describes the anesthetic management of a patient with a permanent pacemaker with a rate drop response (RDR) who presented for a laparoscopic left adrenalectomy. The RDR setting is a novel pacemaker mode often used in patients with a history of vasovagal syncope. There are no previous reports describing the anesthetic management of such a pacemaker. This case report describes the features of the RDR setting with the goal of educating clinicians who may encounter patients with this type of pacemaker. The patient described in this case report had large swings in blood pressure intraoperatively due to the natural function of his pacemaker. This report highlights the importance of understanding pacemaker modes in patients about to undergo surgery, especially because pacemaker functions are becoming increasingly sophisticated and more personalized to meet patients’ specific needs.