Large discrepancy in optimal atrioventricular delay between sensed and paced atrial events in a pacemaker patient

A 74-year-old man experienced complete atrioventricular (AV) block 2 days after catheter ablation for right atrial (RA) macroreentrant tachycardia. We performed DDD pacemaker implantation with atrial septal pacing because other sites of pacing threshold were not acceptable. The maximum left ventricular outflow tract velocity time integral was 15.8 cm with sensed AV delay (40 ms) and 15.0 cm with paced AV delay (220 ms); however, this exceeded the pacemaker's maximum difference of 100 ms. We herein report the case of a large discrepancy in optimal AV delay intervals between sensed and paced atrial events, requiring consideration of proper pacemaker settings.