Abstract
Case summary A 56-year-old man with a history of myocardial infarction, left bundle branch block, and severe left ventricular systolic dysfunction (ejection fraction of 30%) underwent implantation of a biventricular implantable cardioverter-defibrillator (Medtronic Protecta D364TRG, Minneapolis, MN). The patient was referred to our institution for the implantation of a left ventricular lead following an unsuccessful attempt. Device check revealed a P wave of 2.4 mV, R wave of 11 mV, and satisfactory pacing thresholds and lead impedance. Shortly after presentation, the patient complained of palpitations and breathlessness. Electrocardiogram showed a regular broad complex tachycardia at a cycle length of 480 ms with intermittent pacing spikes (Figure 1). The programmed parameters were as follows: Pacing mode: DDD; Lower rate: 80 beats/min; Upper track rate: 130 beats/min; Paced/sensed atrioventricular (AV) delay: 350 ms; Mode switch: 171 beats/min; Ventricular safety pacing (VSP): ON; Noncompetitive atrial pacing: ON; Ventricular fibrillation detection: 188 beats/min; Ventricular tachycardia detection: 150 beats/min (monitor); What is the cause of the intermittent pacing stimuli?
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