Pacemaker-mediated tachycardia: management by pacemaker interrogation/reprogramming in the ED

We report a case of a patient with symptomatic pacemaker-mediated tachycardia (PMT). PMT should be suspected when asynchronous pacing induced by magnet application causes temporary resolution of an unknown tachycardia in a patient with a pacemaker. The underlying mechanism of PMT is either reentrant tachycardia or atrial triggering. PMT is better discerned with an intracardiac electrocardiogram (ECG) obtained through pacemaker interrogation (PI) than the standard 12-lead ECG. In the case reported, the interrogator was used to demonstrate that the initiating dysrhythmia was atrial flutter. Next, the programmer was used to overdrive the atrium restoring normal sinus rhythm. After pacemaker reprogramming, the patient was discharged from the emergency department (ED) in improved condition. We believe this to be the first reported case of a patient with PMT diagnosed, treated, and discharged effectively after PI, overdrive pacing and reprogramming from the ED. The pacemaker interrogator/programmer is a rapid noninvasive device that has practical applications in the ED.