Haseeb Jafri, MD, Alan Cheng, MD, FHRS HeartRhythm Case Reports

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Presentation transcript:

Pacemaker-induced tachycardia in a DDI-programmed ICD: What is the mechanism? Haseeb Jafri, MD, Alan Cheng, MD, FHRS HeartRhythm Case Reports Volume 1, Issue 4, Pages 198-200 (July 2015) DOI: 10.1016/j.hrcr.2015.02.006 Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 1 Atrial pacing at baseline. The device was programmed to DDI 90 (662 milliseconds) with a programmed paced AV interval of 350 milliseconds. This resulted in a VA interval of 662 – 350 = 312 milliseconds. Because DDI pacing is dependent on ventricular-based timing cycles, the next atrial paced (AP) event is not triggered 662 milliseconds from the preceding AP event. Rather, it occurs 312 milliseconds from the preceding ventricular-sensed event. Hence, the AP-AP interval is actually 297 + 312 = 609 milliseconds. See text for details. HeartRhythm Case Reports 2015 1, 198-200DOI: (10.1016/j.hrcr.2015.02.006) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 2 Recorded episode of tachycardia from implantable cardioverter-defibrillator device: repetitive reentrant atrioventricular synchrony. A: Three premature atrial complexes (PAC, asterisks) are seen, each conducting through the AV node to the ventricle (green arrows). The first PAC is sensed (AS), the second fell in the refractory period (noted with marker), and the third fell in the blanking period (no label or marker). The timing of the VS events is fortuitous such that they occur just outside the postatrial ventricular blanking period of the preceding atrial pacing (AP) event. Given the ventricular-based timing cycle, the next AP then occurs 312 milliseconds (calculated VA interval based on programmed lower pacing rate and paced AV interval) afterward. The tachycardia persists and eventually terminates because of decremental block in the AV node. See text for details. B: An illustration of the same episode of tachycardia captured on bedside telemetry. Leads II and V1 are shown. Atrial pacing with intrinsic ventricular conduction is observed. Loss of atrial pacing is seen to occur with the fourth QRS complex (red arrow), with subsequent pacing-associated tachycardia. The QRS morphology during tachycardia is similar to that of the initial portion of the rhythm strip, arguing against a ventricular tachycardia. At the termination of the tachycardia, the pacing spike to the QRS interval appears to begin lengthening (blue arrow) with abrupt termination of tachycardia and resumption of atrial pacing at a slower rate. HeartRhythm Case Reports 2015 1, 198-200DOI: (10.1016/j.hrcr.2015.02.006) Copyright © 2015 Heart Rhythm Society Terms and Conditions