Pacemaker Mediated Tachycardias In Single Chamber Rate Responsive Pacing

Although pacemaker mediated tachycardias are classically associated with dual chamber pacemakers, single chamber rate responsive pacemakers are also susceptible to such tachycardias under special circumstances. A unipolar activity sensing rate responsive pacemaker (Activitrax 8403) was implanted in an 83-year-old man with complete atrioventricular block. The pacemaker was programmed at an output of 5 V, activity threshold medium, rate response 5, and lower and upper rates of 70 and 125 beats/min, respectively. He presented with palpitations at rest and muscle twitching of the pacemaker pocket 4 months after implantation. Examination confirmed that the pacemaker had flipped over, resulting in pocket pacing which in turn activated the activity sensor, resulting in a rate response. The increase in pacing rate lead to a higher frequency of pocket pacing, thus leading to positive feedback increase in rate. With the patient at rest, pacemaker mediated rates were 106, 91, and 74 beats/min at low, medium and high thresholds, respectively. Decreasing the output to 2.5 V eliminated pocket pacing and the tachycardia. As a result of the reversal of the pacemaker, a similar rate response during exercise could only be achieved at a more sensitive rate responsive setting. Thus, pacemaker mediated tachycardia can complicate pacemaker "flipping" in single chamber activity sensing rate responsive pacemakers. Methods for the avoidance and treatment of pacemaker flipping are discussed. A review of other sensor mediated tachycardias is also presented.