Kaya et al. Is it a typical crosstalk: Need for re‐implantation?

I have read with attention the case report by Kaya et al. entitled “Is it a typical crosstalk: Need for re-implantation?” [1] The authors described atrial lead malfunction in a patient with a dual-chamber pacemaker. The right atrial lead tip was in close proximity to the tricuspid valve, but was it located in the ventricle or atrium? Pacing of the ventricle and the low sensitivity for detection of atrial activation suggest that the tip is located in the ventricle with far-field atrial activity sensation. Changing the pacemaker mode to VDD is a good approach in cases of normal sinus node function and loss of atrial lead capture, especially if atrial sensing is stable. In this case, Short AV delay is a good way to reduce the risk of R on T phenomenon which is theoretically possible if a ventricular ectopy is sensed by the atrial lead before the ventricular lead, which may cause inappropriate ventricular spiking after programmed AV delay. But as an AV delay optimization improves hemodynamics and clinical parameters in patients treated with a dual-chamber-pacemaker, if this short AV delay causes atrioventricular dyssynchrony, with a stable P-wave sensation by atrial lead, a DDD mode with an active ventricular safety pacing may be a better option for this case. [2] It should be noted that ventricular safety pacing is not an option when the device is operating with VDD mode. Lastly, if P-wave sensing is not stable and the patient still has dyspnea at follow-up, atrial lead replacement should be considered.