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left bundle branch block morphology&#44; superior axis and positive QRS in all precordial leads were documented &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Electrical cardioversion was delivered&#44; and&#44; after return to sinus rhythm&#44; no repolarization abnormalities were detected&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">After admission to the hospital&#44; urgent coronary angiography showed normal epicardial coronary arteries and cardiac biomarkers levels were not significantly raised&#46; A detailed transthoracic echocardiogram was performed showing ejection fraction of 46&#37; and hypokinesia and slight hyperechogenicity of the mid and basal portions of the posterior and inferior walls&#46; Cardiac magnetic resonance imaging &#40;MRI&#41; was not performed due to the presence of a non-MRI compatible device&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The tachycardia episode was retrieved from device memory&#44; which enabled the detailed sequence of events that started the arrhythmia to be observed&#46; The episode began with a ventricular premature beat &#40;VPB&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>a&#41; with retrograde &#40;ventriculoatrial&#41; conduction &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>b&#41;&#46; Due to the VPB and the post-ventricular atrial refractory period &#40;PVARP&#41; extension algorithm being programmed on&#44; the retrograde atrial activity was sensed as a refractory atrial event&#46; As the patient had suffered paroxysmal AF episodes&#44; the device&#39;s non-competitive atrial pacing algorithm &#40;NCAP&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> &#40;Medtronic&#44; Minneapolis&#44; MN&#44; USA&#41; had also been switched on&#46; This algorithm is designed to avoid pacing in the atrium in the vulnerable period after a premature beat&#44; which could potentially induce AF&#46; So&#44; when an atrial refractory event is sensed&#44; a 300-ms window is opened&#44; during which no atrial pacing is delivered &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>c&#41;&#46; Atrial pacing then resumes &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>d&#41;&#46; Concomitantly&#44; to avoid excessive variation in ventricular cycles due to the NCAP delay&#44; after the atrial stimulus&#44; although a paced atrioventricular interval begins at the programmed value&#44; the ventricular stimulus is delivered earlier&#44; nominally 30 ms after the atrial stimulus &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>e&#41;&#46; In this particular case&#44; the combination of these two algorithms induced a short-long-short sequence&#44; which together with a probable vulnerable substrate induced sustained monomorphic VT &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>f&#41;&#46; Considering hemodynamically unstable VT started by a properly timed extra stimulus provided by the device&#44; and the clues favoring the existence of a vulnerable myocardial substrate&#44; with an electrocardiogram showing a ventricular tachycardia whose morphology suggests originated in the hypokinetic region identified in the echocardiogram&#44; an upgrade to a dual-chamber implantable cardioverter-defibrillator was performed and VT ablation was planned&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="par0025" class="elsevierStylePara elsevierViewall">This case shows how&#44; in the appropriate setting&#44; a normally functioning pacemaker&#44; with modern algorithms designed to avoid adverse events&#44; can also be proarrhythmic&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Case report
Ventricular tachycardia induced by pacing algorithm designed to avoid atrial fibrillation
Indução de taquicardia ventricular por algoritmo de pacemaker de prevenção de fibrilhação auricular
David Roque
Autor para correspondência
roque_866@hotmail.com

Corresponding author.
, Nuno Cabanelas, João Augusto, Francisco Madeira, Hugo Vasconcelos, Carlos Morais
Serviço de Cardiologia, Hospital Professor Doutor Fernando da Fonseca, EPE, Amadora, Portugal
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left bundle branch block morphology&#44; superior axis and positive QRS in all precordial leads were documented &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Electrical cardioversion was delivered&#44; and&#44; after return to sinus rhythm&#44; no repolarization abnormalities were detected&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">After admission to the hospital&#44; urgent coronary angiography showed normal epicardial coronary arteries and cardiac biomarkers levels were not significantly raised&#46; A detailed transthoracic echocardiogram was performed showing ejection fraction of 46&#37; and hypokinesia and slight hyperechogenicity of the mid and basal portions of the posterior and inferior walls&#46; Cardiac magnetic resonance imaging &#40;MRI&#41; was not performed due to the presence of a non-MRI compatible device&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The tachycardia episode was retrieved from device memory&#44; which enabled the detailed sequence of events that started the arrhythmia to be observed&#46; The episode began with a ventricular premature beat &#40;VPB&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>a&#41; with retrograde &#40;ventriculoatrial&#41; conduction &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>b&#41;&#46; Due to the VPB and the post-ventricular atrial refractory period &#40;PVARP&#41; extension algorithm being programmed on&#44; the retrograde atrial activity was sensed as a refractory atrial event&#46; As the patient had suffered paroxysmal AF episodes&#44; the device&#39;s non-competitive atrial pacing algorithm &#40;NCAP&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> &#40;Medtronic&#44; Minneapolis&#44; MN&#44; USA&#41; had also been switched on&#46; This algorithm is designed to avoid pacing in the atrium in the vulnerable period after a premature beat&#44; which could potentially induce AF&#46; So&#44; when an atrial refractory event is sensed&#44; a 300-ms window is opened&#44; during which no atrial pacing is delivered &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>c&#41;&#46; Atrial pacing then resumes &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>d&#41;&#46; Concomitantly&#44; to avoid excessive variation in ventricular cycles due to the NCAP delay&#44; after the atrial stimulus&#44; although a paced atrioventricular interval begins at the programmed value&#44; the ventricular stimulus is delivered earlier&#44; nominally 30 ms after the atrial stimulus &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>e&#41;&#46; In this particular case&#44; the combination of these two algorithms induced a short-long-short sequence&#44; which together with a probable vulnerable substrate induced sustained monomorphic VT &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>f&#41;&#46; Considering hemodynamically unstable VT started by a properly timed extra stimulus provided by the device&#44; 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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Markers retrieved from the pacemaker memory detailing the sequence of events inducing ventricular tachycardia &#40;VT&#41;&#58; ventricular premature beat &#40;a&#41; with retrograde &#40;ventriculoatrial&#41; conduction &#40;b&#41;&#59; since an atrial refractory event is sensed a window is opened during which no atrial pacing is delivered &#40;c&#41;&#59; atrial pacing then resumes &#40;d&#41;&#44; and a ventricular stimulus is delivered earlier than normal &#40;e&#41;&#44; leading to the induction of monomorphic sustained VT &#40;f&#41;&#46;</p>"
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                  "referenciaCompleta" => "Medtronic&#46; 27th March 2013&#46; Non-competitive atrial pacing &#40;NCAP&#41; feature&#46; Retrieved from&#58; <a target="_blank" href="https://www.medtronicacademy.com/features/non-competitive-atrial-pacing-ncap-feature">https&#58;&#47;&#47;www&#46;medtronicacademy&#46;com&#47;features&#47;non-competitive-atrial-pacing-ncap-feature</a>"
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