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Case Reports
. 2025 Jun 11;30(14):103638.
doi: 10.1016/j.jaccas.2025.103638. Epub 2025 Apr 1.

When Sleep Mode Becomes a Nightmare

Mihai Firescu  1 , Sahar Mohmed  1 , Andrew Thornley  2 , Matthew Dewhurst  3
Affiliations
Case Reports

When Sleep Mode Becomes a Nightmare

Mihai Firescu et al. JACC Case Rep. .

Abstract

Background: Atrioventricular node (AVN) ablation preceded by pacemaker insertion is a safe procedure used for both rate and symptom control in symptomatic atrial fibrillation.

Case summary: This is a case of bradycardia-induced PMVT which occurred after AVN ablation, despite the presence of a VVI-R pacemaker inserted a few months prior. Lower pacing rates were allowed during the night due to 'sleep mode' being enabled. The nocturnal bradycardia resulted in ventricular escape rhythm with frequent ectopy, leading to 'R on T' mediated PMVT. Turning the sleep function off suppressed the ectopic activity and prevented further PMVT.

Discussion: PMVT following AVN ablation has been well described in literature. Be it after AVN ablation, or when changing pacemaker programming, the common denominator is a relative bradycardic state which promotes ventricular ectopy and "R on T".

Keywords: ablation; atrial fibrillation; cardiac pacemaker; ventricular arrhythmia.

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Conflict of interest statement

Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Initial Presenting Rhythm Polymorphic ventricular tachycardia electrocardiogram strip recorded by paramedics on arrival.
Figure 2
Figure 2
12-Lead ECG With Paramedics Post-defibrillation electrocardiogram showing junctional rhythm, with frequent ventricular ectopy.
Figure 3
Figure 3
12-Lead ECG in the Emergency Department Baseline ventricular escape rhythm at 48 beats/min showing ventricular couplets and the “R on T” phenomenon with short coupling interval.
Figure 4
Figure 4
Device Electrogram Electrogram showing the “R on T” onset of tachyarrhythmia (arrow), polymorphic ventricular tachycardia, its sudden termination (arrowhead), and subsequent resumption of paced rhythm.
Figure 5
Figure 5
12-Lead ECG After ‘Sleep Mode’ Was Deactivated Electrocardiogram showing paced rhythm at 90 beats/min.
Figure 6
Figure 6
Medtronic Programming Screen The Medtronic programming screen showing the sleep mode location.
See this image and copyright information in PMC

References

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