Desynchronization in a cardiac resynchronization device induced by a pacemaker-mediated tachycardia algorithm

Abstract

This report describes the occurrence of desynchronization in a patient with a cardiac resynchronization device programmed with an active pacemaker-mediated tachycardia algorithm based on AV delay modification. Desynchronization was precipitated by sinus tachycardia and the abrupt return of the prevailing AV delay that followed the periodic prolongation of the AV delay mandated by activity of the algorithm. Prevention of desynchronization in this setting requires programming a right ventricular upper rate interval longer than the sum of the programmed ventriculoatrial interval and the AV delay.

Causes of impaired biventricular pacing in cardiac resynchronization devices with left ventricular sensing

“…Devices with LV sensing capability are susceptible to a variety of problems exclusively related to the (potentially inadequate) inhibition of LV pacing (eg, noise on the LV sensing channel, FFPWO, LV upper rate lock‐in [Figure 2A and B]) 16 . Inadequate programming (active LV sensing and T‐wave protection, see Supporting Information) had a detrimental effect in almost two‐thirds of patients, who transmitted “CRT pacing interrupt” episodes.…”

“…Devices with LV sensing capability are susceptible to a variety of problems exclusively related to the (potentially inadequate) inhibition of LV pacing (eg, noise on the LV sensing channel, FFPWO, LV upper rate lock-in [ Figure 2A and B]). 16 LV electrodes for sensing may increase the likelihood of inadvertent oversensing of p-waves. 17,18 The most common consequence of temporary LV pacing inhibition was LV upper rate lock-in, which accounted for the majority of all LV pacing interruptions that we observed.…”

Termination of desynchronization rhythm and restoration of cardiac resynchronization by left‐sided ventricular premature complexes

“…A specific desynchronization in a BIOTRONIK CRT‐D device programmed to LV sensing can occur in the following circumstances: (a) when the atrial rate exceeds the programmed LV upper rate or, (b) at a pacing rate lower than the LV upper rate but faster than the critical desynchronization rate. This condition requires a disruptive event such as an atrial premature complex, common ventricular premature complex, a sudden change in the AV delay, or even temporary suppression of LV pacing as in automatic test algorithms . The critical desynchronization interval is AA = IVC + LVURI + VV where AA = atrial cycle duration, IVC = interventricular conduction interval (RVp – LVs interval where RVp = RV paced event and LVs = LV sensed event), LVURI = LV upper rate interval, and VV = programmed interventricular interval.…”