Reversible left ventricular dysfunction due to endless loop tachycardia in patient with dual chamber pacemaker- A...

A 60 years male patient underwent permanent pacemaker [DDDR -with dual chamber pacing (D) with dual chamber sensing (D) with dual mode of response (D) with rate responsive pacing(R) -St Jude's medical (Abbott- Endurity 2160)] implantation for complete heart block (CHB). After 4 months patient was admitted for congestive heart failure. 12 Lead electrocardiograms (ECG) was suggestive of tachycardia at 130 beats per minute (regular rhythm), with ventricular complexes preceded by pacing spikes and maintenance of 1:1 atrio-ventricular relationship. Echocardiography showed global hypokinesia of left ventricular (LV) myocardium with reduced LV ejection fraction. LV dysfunction and heart failure were attributed to tachy-cardiomyopathy. Pacemaker telemetry data demonstrated that the tachycardia was likely to be pacemaker-mediated endless loop tachycardia (ELT). ELT in this case was perpetuated secondary to shortening of post ventricular atrial refractory period (PVARP), intact retrograde ventriculo-atrial (VA) conduction and addition of antiarrhythmic drugs prolonging retrograde VA conduction. Rate response (Dynamic) PVARP was reprogrammed allowing PVARP extension. Following this ELT was terminated. LV ejection fraction was normalized on subsequent follow up visit after seven days.