Right ventricular lead induced ventricular arrhythmia—A rare complication of cardiac resynchronization therapy

Abstract

Background:A 53-year-old male with heart failure secondary to anterior wall myocardial infarction treated with cardiac resynchronization-defibrillator (CRT-D) device presented with ventricular arrhythmia: repetitive incessant slow ventricular tachycardias (VT) below the CRT-D detection zone, accelerated ventricular rhythm, and numerous premature ventricular ectopic beats (ExV), resulting in loss of biventricular pacing. Methods and Results: Nonsustained monomorphic VT (nsVT) and ExV were observed in an electrocardiogram under biventricular stimulation. During noninvasive CRT-D programming, ventricular bigeminy reproducibly recurred only at right ventricular (RV) pacing and its morphology was almost identical to the stimulated beats. The left ventricular (LV) pacing failed to induce ventricular ectopy or tachycardia.Conclusions: This unusual case shows a rare phenomenon of late proarrhythmic effect due to the RV lead pacing-a new finding reported only in a few publications.Here we present our approach to CRT programming that suppressed the clinical arrhythmia without the need of catheter ablation and achieving the high biventricular pacing capture rate along with optimal hemodynamic CRT-D performance. K E Y W O R D Sarrhythmia mechanism, biventricular implantable cardioverted-defibrillator, biventricular pacing, cardiac resynchronization therapy, device programming, proarrhythmia, ventricular arrhythmia, ventricular tachycardia

Cardiac resynchronization therapy for pacing induced cardiomyopathy: Role of baseline right ventricular pacing burden

“…This has implications for the decision of upgrading to a device with defibrillator capability versus pacing device alone, as irreversible LVEF ≤35% remains the guideline‐endorsed criteria for primary prevention ICD 23 . Even though patients with severe PICM remain at risk of ventricular arrhythmias in the interim period before recovery of LVEF, these events tend to be slow non‐sustained monomorphic ventricular tachycardia episodes, 13,24 and the real risk of sudden cardiac death in this population is low at <1 per 100 patient years in the study by Barra et al 25 . The decision to upgrade to ICD at time to CRT upgrade must weigh the risk and cost involved in revising a chronic RV pacing lead to an ICD lead and the likelihood of recovery of LVEF with CRT against the risk of subjecting the patient to an additional procedure to upgrade to a defibrillator should the systolic dysfunction fail to recover after CRT.…”

“…remains the guideline-endorsed criteria for primary prevention ICD. 23 Even though patients with severe PICM remain at risk of ventricular arrhythmias in the interim period before recovery of LVEF, these events tend to be slow non-sustained monomorphic ventricular tachycardia episodes, 13,24 and the real risk of sudden cardiac death in this population is low at <1 per 100 patient years in the study by Barra et al 25 The…”

On the Management of Ventricular Arrhythmias Following Leadless Pacemaker Implantation

“…In several cases, the arrhythmia was only abolished by discontinuation or modification of pacing (both left and/or right ventricular). 1 , 4 Some cases have been successfully managed with ablation, frequently close to the stimulation site 5 , 6 or pharmacologically with antiarrhythmic drugs, β-blockers, and/or steroids. 1 Closer proximity of the pacing site to the putative reentry circuit is known to be proarrhythmic as demonstrated by pacing protocols from the right and left ventricular pacing sites.…”

Mechanically induced electrical storm as a complication of cardiac resynchronization therapy: A case report

“…Cardiac resynchronization therapy (CRT) has been shown to improve both the functional status and mortality of chronic heart failure patients with left bundle branch block in large, randomized controlled trials [ 1 , 2 ]. However, evidence in recent case reports and cohort studies suggest left ventricular (LV) epicardial or right ventricular (RV) pacing in a CRT device may be proarrhythmic [ [3] , [4] , [5] , [6] , [7] ]. The proposed mechanisms include pacing into regions of arrhythmic substrate leading to scar related reentry, and LV epicardial pacing causing reversal of ventricular activation and prolongation of transmural dispersion of repolarization (TDR) [ 8 ].…”