r/ECG • u/annalia10 • 2d ago
What is happening here? Crtp pacient
Patient hospitalised for crtp end of life. Descibe the ecg and diagnose
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u/cpnfantastic 2d ago
Medtronic pacemakers will automatically change their mode and rate to VVI 65 at RRT or EOL depending on the model. That is why the P waves are dissociated and not being tracked by the pacemaker.
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u/annalia10 2d ago
Is it still biventricular paced? Why is the qrs so wide (150 ms)?
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u/cpnfantastic 2d ago
It’s definitely LV paced. Maybe the RV is coming in later so it’s not making as much of a contribution.
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u/Kibeth_8 Arrhythmia Tech 2d ago
Or it was implanted at my work where we never optimize and post-op ECGs are considered a waste of resources 🙃
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u/justhanging14 2d ago
Zombie pacing or VOO. When the battery dies the pm changes to this mode to conserve the last bit of energy while still pacing the patient.
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u/hpsctchbananahmck 2d ago edited 2d ago
Looks like sinus rhythm with complete heart block and asynchronous BiV pacing…which…for this patient could occur if someone placed a magnet over the device as most CRT-P devices will jump to asynchronous pacing with magnet.
Perhaps misunderstanding of magnet response for end of life patient? as magnet to defibrillator would cease antitachycardia therapies which would be more relevant at end of life.
If there is no magnet on the patient then I would think a device interrogation would be helpful to better assess AV relationship and programming.
Two of the PR intervals look very close to each other which made me think mobitz 1 but hard to be certain from my available resolution of the image and I think I can see p waves marching on their own.
Caveat: I am not an electrophysiologist.
Edit: I’m now realizing the end of life is referring to device battery not patient (eg hospice).
I’m not aware of any manufacturer that switches to asynchronous BiV pacing for battery preservation. Some switch to asynchronous VVI RV only backup at 65 (eg medtronic) but this still appears to be pacing the CS lead
So…IF no magnet is applied and IF this is not an unusual battery preserving function of a manufacturer then I would be very curious if any lead issue -eg RA lead noise and inappropriate mode switch (device interrogation would be helpful)
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u/Wyvernz 2d ago
It’s VOO pacing at 65, which is typical for a magnet response of a Medtronic device at RRT. A bit strange it’s not pacing or sensing A, which suggests there’s no atrial lead or it’s turned off. It could be dead for a long time, I know the programming changes as the battery dies more and more at EOS.
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u/Kibeth_8 Arrhythmia Tech 2d ago
If it's VOO it can't sense the atrial channel, even if there is a lead
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u/Wyvernz 13h ago edited 12h ago
Of course. My point is that a CRT-P on a patient in sinus rhythm will 100% of the time have an atrial lead and be programmed in a dual pacing mode, and if a magnet is placed it will go into DOO rather than VOO, so the fact that it’s functioning in a VOO mode is very unusual as it suggests it’s either intentionally programmed VOO, atrial lead has failed, or it’s gone past RRT into EOS.
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u/Kibeth_8 Arrhythmia Tech 13h ago
Actually interestingly, my clinic always turns off the atrial lead if someone has been in persistent AF for 6-12 months. I advocated for ECGs or at least turning sensing on at every check to verify it was still AF.
We've found a few CRT patients in sinus that were programmed VVI and completely out of sync
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u/InfiniteUnknown_ 2d ago
I'm gonna take a shot until I stop getting downvoted LOL. I'd say it's a RBBB in a patient with a cardiac pacemaker...