The first line corresponds to lead I with the superimposed markers, the second line to the atrial EGM and the last line to lead III with the superimposed intervals;
This tracing allows emphasizing an essential point in the management of patients with PMT. While it is highly important to program the interruption algorithm of these PMTs, it is imperative to also rectify the cause initiating the PMT. The best treatment for PMTs is prevention. The following events can promote AV dissociation, retrograde conduction and triggering of a PMT: ventricular extrasystole (most common cause), atrial extrasystole with increased AV delay in order to meet the programmed maximal tracking heart rate, AV delay programmed too long (the nodo-Hisian pathway has exited from its refractory period at the time of ventricular pacing), external or myopotential interference sensed by the atrial chain, lack of sensing or atrial pacing, absence of PVARP prolongation after removal of a magnet, application and removal of a magnet, programming the VDD mode in a patient with a sinus rhythm that is slower than the programmed minimum rate.
In this patient, the main issue is the loss of atrial capture. An increase in the amplitude of atrial pacing with sufficient margin allowed solving the problem.
A programming option may also be considered in this patient with complete atrioventricular block and sinus dysfunction: if, despite the programming modifications, there is persisting occurrence of PMTs, a programming in DDIR mode would enable an atrial and ventricular pacing, a rate response and would permanently prevent PMTs (an atrial sensing in DDI mode does not trigger AV delay or ventricular pacing).