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Pacemaker Mediated Tachycardia... or not?
This patient has a history of heart failure and was admitted for worsening symptoms. She has a cardiac resynchronization therapy defibrillator (CRT-D) implanted but continues to have episodes of nonsustained ventricular tachycardia. Device interrogation revealed a mechanism of pacemaker-mediated tachycardia involving retrograde conduction of premature ventricular complexes triggering the device to pace the atria, initiating a reentrant loop. Changing the device settings eliminated this tachycardia.
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Pacemaker Mediated Tachycardia... or not?
- 1. EP Teaching 21 Oct 2016 Supervisor: Dr Tan Boon Yew
- 2. History 69 Chinese Female ICMP • CRTD implanted 2012, baseline NYHA 2 post CRT • AdmiMed for CCF symptoms – 2nd admission in last 2 years – Diuresed well – Referred for EP consult for mulPple episodes of “NSVT” noted on telemetry – Carvedilol increased to 12.5mg bd (SBP 95mHg) ... but cannot be suppressed!
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- 4. Now what? 1. Increase Carvedilol to 25mg BD 2. Switch to Bisoprolol and take out another BP lowering drug 3. Amiodarone 4. Ablate 5. Interrogate Device 6. Don’t Know
- 5. Pre CRT ECG Height: Unknown Weight: Unknown SINUS RHYTHM PROBABLE ABERRANTLY CONDUCTED SUPRAVENTRICULAR EXTRASYSTOLES LEFT AXIS DEVIATION BROAD R IN I, V5 OR V6 PROLONGED QRS DURATION LEFT BUNDLE BRANCH BLOCK Q WAVES IN INFERIOR LEADS T WAVE INVERSION ALSO PRESENT INFERIOR INFARCTION AS PREVIOUSLY SUMMARY: NO SIGNIFICANT CHANGE COMPARED TO ECG(S) OF 04/11/2011 14:16:05 PR: 186 P Axis: 77 QRS Dur: 142 QRS Axis: -34 QT: 428 T Axis: 160 QTc: 491 HR: 79 QT Disp: 64 BP: Requested By: Taken By: HNUA ECG Cart Serial Number: Location: Undefined: Undefined: DX: RX: Previous ECG: 04/11/2011 14:16:05 (Abnormal ECG) Abnormal ECG PRELIMINARY REPORT - PHYSICIAN MUST REVIEW(. .) I aVR V1 V4 II aVL V2 V5 III aVF V3 V6 II SHS - Singhealth - NHC - National Heart Centre - W44 - Ward 44 F 0.5 - 150 Hz 25 mm/sec 10 mm/mV
- 6. Post CRT ECG Name: chua chai teen, MRN: S0147783H Age: 61 Yrs DOB: 24/12/1954 Gender: Female Ethnic origin: Unknown Date: 03/10/2016 20:50:14 Height: Unknown Weight: Unknown REGULAR VENTRICULAR PACING NO FURTHER ANALYSIS MADE BECAUSE OF PACEMAKER RHYTHM. NO OTHER FINDINGS SUMMARY: SOME ABNORMALITIES NO LONGER PRESENT COMPARED TO ECG(S) OF 03/10/2016 14:40:49 PR: 0 P Axis: 53 QRS Dur: 128 QRS Axis: -171 QT: 482 T Axis: -25 QTc: 494 HR: 63 QT Disp: 124 BP: Requested By: Taken By: HNUC ECG Cart Serial Number: Location: US81305433 Undefined: BLK4,LVL7/ECG04 Undefined: DX: RX: Previous ECG: 03/10/2016 14:40:49 (Abnormal ECG) Abnormal ECG PRELIMINARY REPORT - PHYSICIAN MUST REVIEW I aVR V1 V4 II aVL V2 V5 III aVF V3 V6 II SHS - Singhealth - NHC - National Heart Centre - W47B - Ward 47B F 0.5 - 100 Hz 25 mm/sec 10 mm/mV (US81)
- 7. ECG during “NSVT” Name: chua chai teen, MRN: S0147783H Age: 61 Yrs DOB: 24/12/1954 Gender: Male Ethnic origin: Unknown Date: 03/10/2016 09:33:29 Height: Unknown Weight: Unknown REGULAR VENTRICULAR PACING NO FURTHER ANALYSIS MADE BECAUSE OF PACEMAKER RHYTHM. NO OTHER FINDINGS SUMMARY: SOME ABNORMALITIES NO LONGER PRESENT COMPARED TO ECG(S) OF 17/03/2016 04:03:54 PR: 0 P Axis: -20 QRS Dur: 190 QRS Axis: 167 QT: 382 T Axis: -20 QTc: 503 HR: 104 QT Disp: 42 BP: Requested By: Taken By: gaes ECG Cart Serial Number: chua chai teen Location: s0147783h Undefined: Undefined: DX: RX: Previous ECG: 17/03/2016 04:03:54 (Abnormal ECG) Abnormal ECG PRELIMINARY REPORT - PHYSICIAN MUST REVIEW I aVR V1 V4 II aVL V2 V5 III aVF V3 V6 II SHS - Singhealth - SGH - Singapore General Hospital - GCAE - Accident and Emergency F 60~ 0.15 - 100 Hz 25 mm/sec 10 mm/mV (US40)
- 8. CRT Se`ngs • Mode DDD • Base Rate 60 • Paced AV delay 150ms • Sensed AV delay 100ms • Max Track Rate 110 • LV -‐> RV, 40ms • PVARP 275ms • PVAB 100ms
- 10. Rate ResPonsive Rate ResPonsivePVARP/V Ret Ventricular Safefi StandbY 1:Markers 2: 110,0 mm/mV 3: A Sense Amp A.ltoca!!-1J0J1mfllrny Unify Quadrars 3251-4OQ CRT-D (1064845 prC'E'9A) Merl'in'" PCS (#12053842 3330 v21'1 2 rev 1) Low On 4: V Sense AmP Ar.rtoGain (0,9 mmimV) 5: LV Distaltip 1 - Mid 2 Autocain (0,7 mm/mv) Presenting Rhythm Freeze Page 1 of 1 5C,c'2016 12"23
- 11. Ventricular Safety StandbY 1:Markers 4:V Sense AmP Autocain (0,9 mm/l11V) 5: LV Distaltip 1 - Mid 2 AutoGain (0,7 mmlnV) 2: 110,0 mmlmV 3: A Bioolar AutoGain (10,0 Eq4nV) Unify QuadrarM 3251-4OQ CRT-D (1064845 prC'E'9A) PCS (#12053842 3330 v21'1'2 rev 1) Freeze CaPture Page 1 of 'l 50d2016 12"23
- 12. Now what? 1. Increase Carvedilol to 25mg BD 2. Switch to Bisoprolol and take out another BP lowering drug 3. Amiodarone 4. Ablate 5. Interrogate Device -‐> Refer EP 6. Don’t Know
- 13. DDD pacing @ 60
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- 19. PMT Mechanism • PVC/PAC è
- 20. PMT Mechanism • PVC/PAC è retrograde VA conducPon
- 21. PMT Mechanism • PVC/PAC è retrograde VA conducPon è A-‐sensed è
- 22. PMT Mechanism • PVC/PAC è retrograde VA conducPon è A-‐sensed è Paced AVI triggered
- 23. PMT Mechanism • PVC/PAC è retrograde VA conducPon è A-‐sensed è Paced AVI triggered è V-‐ paced
- 24. PMT Mechanism • PVC/PAC è retrograde VA conducPon è A-‐sensed è Paced AVI triggered è V-‐ paced è retrograde VA èèè…
- 25. PMT Mechanism • PVC/PAC è retrograde VA conducPon è A-‐ sensed è Paced AVI triggered è V-‐paced è retrograde VA èèè… • Morphologies during DDD BiV pacing different from PMT BiV pacing – ContribuPon from the 3 wave fronts: • His septal acPvaPon • RV pace • LV pace – During PMT: loss of His contribuPon