A New Algorithm for a High Level of Protection Against Pacemaker-Mediated Tachycardia

Pacemaker-mediated tachycardia (PMT) is a well-known complication of DDD pacing. PMT needs a permeable V-A conduction and is usually initiated by a premature ventricular or atrial systole, artifact sensing, or misprogramming (long AV delay [AVD]). Today, protection against PMT is expected from pacemaker multiprogrammability. Unfortunately, this prevention is often ineffective; postventricular atrial refractory period (PVARP) must be prolonged, which limits the upper tracking rate and the patient capacity. The new Chorus ELA Medical DDD pacemaker provides classic protection against PMT (PVARP prolongation after premature V or A complex, magnet application, noise sensing), hut also automatically reduces an eventual PMT and adjusts AVD or PVARP for a high level of protection. The process is divided in four steps: (1) a sensing step for 16 cycles, with V-P conduction analysis; (2) confirmation of the presence of the PMT and analysis of V-A conduction time; (3) a termination step, by extending the PVARP after the following ventricular heart beat; and (4) in case of immediate recurrence of the tachycardia, reprogramming of the AVD and eventually of the PVARP. By first reducing AVD, before reprogramming PVARP, the pacemaker preserves point 2:1, providing a higher exercise capacity. This algorithm was successfully tested in three patients who had a permeable V-A conduction, without any adverse effect.