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A 43-year-old male with a history of dilated cardiomyopathy and a cardiac resynchronization therapy (CRT) defibrillator (Unify Quadra; St. Jude Medical Inc., St. Paul, MN, USA) implanted 5 years earlier for primary prevention presented at the cardiac rhythm and device clinic for regular follow-up. Device interrogation showed normal parameters (Table 1). The device was programmed in DDD mode at 60 ppm with sensed and paced atrioventricular (AV) delays of 120 milliseconds and 150 milliseconds, respectively. Biventricular pacing was at 50%. The patient’s clinical and echocardiographic situation had not improved since CRT implantation. The echocardiogram revealed a severely dilated left ventricle with an ejection fraction of 20%. The device diagnostic summary showed 48% premature ventricular complexes (PVCs), inhibiting biventricular pacing (Fig. 1). However, there were no PVCs observed during device interrogation. What are the next steps? What caused the reduced biventricular pacing, and what circumstances should be considered in this case?

Reduced Biventricular Pacing: What is the mechanism and how to manage?