A Cautionary Tale on Atrial Capture Management, Biventricular Pacing, and Recurrent Asystole

Capture management algorithms in current cardiac implantable electronic devices (CIEDs) can enhance device performance and battery longevity. Although generally safe, these algorithms have on rare occasions been implicated in the onset of significant complications, especially in pacemaker-dependent patients. CIEDs implanted in patients with postoperative congenital heart disease (CHD) often require epicardial pacing leads rather than transvenous leads; unfortunately, epicardial leads can experience higher rates of malfunction. We herein report on a young adult with a status of postoperative CHD and complete atrioventricular block following implantation of a epicardial dual-chamber cardiac resynchronization therapy pacemaker (CRT-P; Consulta^®; Medtronic, Minneapolis, MN, USA) who developed frequent periods of asystole after malfunction of one of the ventricular leads. The underlying cause of asystole was found to be due to the atrial capture management (ACM) algorithm of the CRT-P device, temporarily converting biventricular to right ventricular-only pacing as part of the algorithm. This case highlights implications of the ACM algorithm in devices with a similar platform for pacemaker-dependent patients.