Entrainment of ventricular tachycardia with a permanent biventricular pacemaker

Biventricular pacing has been introduced as a treatment for congestive heart failure. These devices presently pace and sense from two disparate ventricular sites. Antitachycardia pacing (ATP) is used for termination of sustained monomorphic ventricular tachycardia (VT) and has been incorporated with simultaneous dual site ventricular pacing for treatment of VT. We report a case of entrainment of sustained monomorphic VT in a 62-year-old female with an ischemic cardiomyopathy and VT, who received a biventricular pacemaker-implantable cardioverter defibrillator, Contak CD (Guidant, St. Paul, MN). Biventricular pacing sites were at the right ventricular apex and the middle of the anterior cardiac vein on the left ventricle. The entrained VT has a left bundle branch block and left axis deviation morphology with a cycle length of 350 msec. ATP at 270 msec produced concealed entrainment of an induced VT. Only one pacing site demonstrated capture. The inability to capture both pacing sites simultaneously was the result of ventricular refractoriness at one of the sites during ATP of the VT. The entrance and exit points of the loop for VT appeared to rest between the two pacing sites in the intraventricular septum. This case illustrates one of the sensing limitations of today's biventricular pacing defibrillator systems.