Interesting bigeminal atrial paced rhythm. What is going on? #Cardiology #ECG

Furthermore, there is clear biventricular pacing (2 spikes). If LV adaptive had been operative, there should have been only LV pacing (1 spike), given the rate and relatively short PR.

Patient developed full blown defibrillation lead failure over time. This seemingly innocent ECG was the first clue of a problem in the defibrillation lead. Understanding of timing cycles is crucial to device troubleshooting.

Further testing showed that there was intermittent oversensing of noise in the V channel, triggering PVARP.

There was indeed intermittent "undersensing" of P waves with failure to track and intrinsic AV conduction with LBBB. Atrial "undersensing" could be real or functional, when the A signal falls in PVARP.

Medtronic's (AdaptivCRT) extends the AV delay for one beat every 100 beats. However, unless one turns the default ventricular sense response (VSR) off, there will be the spike at the time of sensing the intrinsic R. So less likely in this case.

Thank you for the participation. Adaptive algorithm was a good thought. Abbott's (SyncAV) extends the AV delay for 3 consecutive beats, so not the case.

DDI(R) was developed to allow dual-chamber pacing in patients with paroxysmal atrial fibrillation in the pre mode-switch era. This old paper reflects our early experience.

Middle age woman with CRT-D several years ago, super-responder. Do you worry? #ECG #Cardiology

Those who answered "long PVARP" were on the right track. Indeed, DDI is best conceived as a DDD mode in which the PVARP extends for the whole VA escape interval! Or DDD with same lower and upper rates.

Thank you for all the participation. This is indeed normal functioning DDI. Initial indication was sinus bradycardia, patient then developed heart block. Pacemaker was then reprogrammed DDD.

Interesting pacemaker alternans. What's going on? Is the pacemaker malfunctioning? #ECG #Cardiology #fellowsfirst

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We are waiting for your ECGs.

This is the 12-lead ECG