Heat-aggregated immunoglobulins increase in vivo immunogenicity of mouse hapten (TNP)-derivatized macrophages by upregulation of interleukin-12 secretion and expression of B7-1 and B7-2 costimulatory molecules

Antigen-antibody complexes (IC) can up or down regulate immune responses by induction of immunoregulatory cells. We have studied the effect of mouse heat-aggregated immunoglobulin (Ig) (HA) which have many biological activities similar to IC on immunogenicity of TNP-substituted macrophages (TNP-Mphi). Our results show that: (1) mouse oil-induced peritoneal macrophages treated with HA produce in vitro significantly higher levels of interleukin (IL-1beta), tumor necrosis factor (TNF)-alpha, IL-6, IL-10 and particularly IL-12 and express more B7-1 and B7-2 and ICAM-1 cell surface costimulatory molecules than Mphi treated with monomeric Ig (MM); (2) Mphi derivatized with TNP, treated or not with MM, induce in vivo antigen-specific unresponsiveness. In contrast TNP-Mphi treated with HA induce significant contact sensitivity reaction even when injected into previously tolerized recipient animals. Treatment of recipients with anti-IL-12 Ab prevents immunization by TNP-Mphi-HA. These results indicate that bypass of tolerance by treatment of TNP-Mphi with HA is a result of an increased production of IL-12 by these cells and an enhanced expression of costimulatory molecules important in T cell-Mphi interactions. We suggest that a similar overcoming of tolerance through the action of IC may be responsible for the generation of autoantibodies of heterologous specificity in pathological conditions in which such complexes are formed.

[Where should the implantable ECG event recorder be placed?]

Aim of our study was the comparison of bipolar ECG quality (with a 4 cm lead distance) at different sites within the anterior thorax to find the preferable implantation site for an ECG event recorder (ECG-ER). In 70 patients a bipolar ECG with a short electrode distance and in the vertical position was registered at the following sites: left and right subclavicular, left and right parasternal (4th-5th ICR), left and right anterior axilla (4th-5th ICR), at the heart apex and subxiphoidal. Then it was compared to the standard lead II. In 34 patients, an additional comparison between vertical and horizontal ECG registration was performed at the above mentioned sites. During implantation of an ECG-ER in 5 patients, ECG signals were compared with electrodes placed towards the skin or towards the muscle. The best ECG quality (greatest QRS amplitude, visible P-wave and pacemaker spike, measurable QT period and bundle-branch block) and the best agreement with standard lead II was found in 67% left parasternal, significant less often (p < 0.001) right parasternal (14.3%), left subclavicular (7.1%), apical (5.7%), and subxiphoidal (4.3%). In a vertical electrode position a significantly higher QRS amplitude and a more often visible P wave was found in comparison to a horizontal electrode position. In all cases, there was good agreement between bipolar surface ECG at the implantation site and ECG-ER stored signals. When the ECG-ER is positioned with electrodes towards the muscle, significant noise-signal occurred in all 5 patients. Only in 3 patients was a P wave visible, but with a slightly greater QRS amplitude than in ECG-ERs positioned with electrodes towards the skin. From these results, it is recommended to implant ECG-ERs vertically with electrodes towards the skin and in the parasternal position.

[Results of pretherapeutic lymph node diagnosis in head and neck tumors. Clinical value of 18-FDG positron emission tomography (PET)]

BACKGROUND

Histological studies demonstrate that there is a high percentage of occult nodal metastasis in head and neck malignomas. Patients with positive lymph nodes have a comparatively worse prognosis. A neck dissection is required in these cases. By demonstrating morphological abnormalities, imaging procedures like ultrasound, computer tomography (CT), and magnetic resonance imaging (MRI) can provide important initial informations about possible malignant alteration of the lymph nodes. Positron emission tomography (PET) allows functional metabolic imaging of a suspected tumor site. The aim of this study was a comparative evaluation of different diagnostic procedures with special emphasis on the value of PET in the pretherapeutic diagnosis of nodal spread in head and neck cancer.

PATIENTS AND METHODS

Forty patients (28 male and 12 female) with a suspected malignoma in the head and neck region underwent clinical examination including palpation of the neck sides, ultrasound, CT, and PET to detect a nodal spread of the malignancy. Fifty neck dissections were performed in 28 patients. Lymph node biopsies were performed in the remaining patients. The results of the diagnostic procedures were compared to the histology and the clinical course of the patients. The mean follow-up period was 12.5 months.

RESULTS

A nodal metastasis was verified in 35% of all cases. Sensitivity of all imaging procedures including PET was 82%. Palpation had a sensitivity of only 61%. Specificity was 85% for ultrasound, 94% for CT and palpation, and 87% for PET. PET produced false negative results in 13.4% of all cases. Inflammation was detected in these cases. The positive predictive value was marginally better for PET than for ultrasound (77% vs. 75%). It proved to be lower than the values for palpation (86%) and CT (88%). Negative predictive value was 90-91% for all imaging procedures.

CONCLUSION

In the primary diagnosis of nodal alterations in the head and neck region, a PET scan has the same diagnostic value as ultrasound or CT. By imaging the metabolism of a suspected nodal metastasis, PET can help to improve the assessment of regions with uncertain anatomic features. To avoid false positive results, acute and chronic inflammatory alterations have to be ruled out before the PET imaging.

Soluble T cell receptors modulate cytokine production and oxygen metabolism by peritoneal macrophages

Preincubation of peritoneal macrophages and their subsequent culture with recombinant soluble T cell receptor (sTCR) results in significant increase of: TNF-alpha, IL-1beta, IL-6, IL-10, IL-12 production and nitric oxide (NO) synthesis and this phenomenon was dose dependent. Moreover, treatment of macrophages with sTCR showed two to three fold increase of luminol dependent chemiluminescence (LCL) when compared to untreated macrophages (Mf). In contrast, in our study we did not find any influence of sTCR on co-stimulatory (B7.1 and B7.2), adhesion molecule (ICAM-1) or FcRII/III expression by macrophages. However, macrophages treated with control supernatants received after phosphatidylinositol-specific phospholipase C (PI-PLC) treatment of BW1100 cells or thymocytes termed s-BW or s-Th did not influence their biological activity.

Diagnostic evaluation of malignant head and neck cancer by F-18-FDG PET compared to CT/MRI

AIM

Evaluation of F-18-FDG PET in comparison to CT/MRI as diagnostic tool in primary and recurrent head and neck cancer.

METHODS

78 F-18-FDG PET studies were performed in 71 patients with known or suspected primary (n = 48) or recurrent (n = 30) head and neck cancer and compared to CT (n = 75) or MRI investigations (n = 3) concerning detection of the primary or recurrent tumor and detection of regional lymph node metastases in the ipsilateral and contralateral neck sides. Glucose uptake (SUV) of PET findings was correlated to tumor location, grading and dignity of the lesion.

RESULTS

Sensitivity and specificity for PET in detection of primary tumors were 87%* and 67%, respectively (CT/MRI 67%* and 44%) (*p < 0.05), in detection of local recurrence 86% and 75%, respectively (CT/MRI 57% and 92%), in detection of necks affected by lymph node metastases 80% and 92%, respectively (CT/MRI 80% and 84%). Laryngeal, buccal (cheek) and salivary gland tumors had significant lower glucose uptake (SUV) when compared to tumors of the hypopharynx (p < 0.05). G1-tumors (mean SUV 4.26) had significant (p < 0.05) lower glucose uptake when compared to G2- and G3-tumors (mean SUV 7.73 and 8.19, respectively). Mean SUV of malignant PET findings (7.88) was significant (p < 0.05) higher than mean SUV of benign PET findings (5.70). However, a SUV threshold to improve diagnostic accuracy could not be defined.

CONCLUSIONS

F-18-FDG PET is significantly more accurate than CT/MRI for detection of head and neck cancer. Both methods are valuable for detection of cervical lymph node metastases. Glucose uptake shows correlation to histological grading. A quantitative SUV analysis does not improve diagnostic accuracy.

27Al NMR study in ZrNiAl

We have studied the microscopic properties of the hexagonal ZrNiAl, a model compound for a wide family of intermetallic compounds crystallizing in this type of structure, by using 27Al NMR spectroscopy. We have investigated the lineshape of static and MAS NMR spectra as a function of magnetic field strength (4.7-9.4 T) and temperature (5-300 K). Our data indicate that the 27Al NMR spectra result from a combined effect of quadrupole and anisotropic shift interactions. The 27Al nuclei are in an environment characterized by the quadrupole coupling constant e2qQ/h of 3.3 MHz, asymmetry parameter etaQ of 0.42, isotropic shift delta(iso) of 393 ppm, shift anisotropy delta(anis) = delta(zz) - (delta(xx) + delta(yy))/2 of 150 ppm, and asymmetry factor etaS of 0.5. They are found to be temperature independent. The spin-lattice relaxation rate measured at 7.05 T is proportional to the temperature with T1T = 135 s K. The mechanisms responsible for observed values of delta(iso), delta(anis), T1T, and the enhanced Korringa constant are discussed.

Diagnostic evaluation of malignant head and neck cancer by F-18-FDG PET compared to CT/MRI

AIM

Evaluation of F-18-FDG PET in comparison to CT/MRI as diagnostic tool in primary and recurrent head and neck cancer.

METHODS

78 F-18-FDG PET studies were performed in 71 patients with known or suspected primary (n = 48) or recurrent (n = 30) head and neck cancer and compared to CT (n = 75) or MRI investigations (n = 3) concerning detection of the primary or recurrent tumor and detection of regional lymph node metastases in the ipsilateral and contralateral neck sides. Glucose uptake (SUV) of PET findings was correlated to tumor location, grading and dignity of the lesion.

RESULTS

Sensitivity and specificity for PET in detection of primary tumors were 87%* and 67%, respectively (CT/MRI 67%* and 44%) (*p < 0.05), in detection of local recurrence 86% and 75%, respectively (CT/MRI 57% and 92%), in detection of necks affected by lymph node metastases 80% and 92%, respectively (CT/MRI 80% and 84%). Laryngeal, buccal (cheek) and salivary gland tumors had significant lower glucose uptake (SUV) when compared to tumors of the hypopharynx (p < 0.05). G1-tumors (mean SUV 4.26) had significant (p < 0.05) lower glucose uptake when compared to G2- and G3-tumors (mean SUV 7.73 and 8.19, respectively). Mean SUV of malignant PET findings (7.88) was significant (p < 0.05) higher than mean SUV of benign PET findings (5.70). However, a SUV threshold to improve diagnostic accuracy could not be defined.

CONCLUSIONS

F-18-FDG PET is significantly more accurate than CT/MRI for detection of head and neck cancer. Both methods are valuable for detection of cervical lymph node metastases. Glucose uptake shows correlation to histological grading. A quantitative SUV analysis does not improve diagnostic accuracy.

27Al NMR study in UNiAl

The ternary compound UNiAl exhibiting an antiferromagnetic order below T(N) = 19.3 K has been studied in the paramagnetic state using the 27Al NMR technique and different magnetically oriented samples. The quadrupole coupling constant e2qQ/h = 1.56 MHz is temperature independent. The dominant, longitudinal component of the Knight shift with respect to the hexagonal c axis, Kparallel, is positive and increases upon lowering the temperature down to 50 K. Much smaller in magnitude, the transverse component, Kperpendicular, is also positive and only slightly temperature dependent. The plots of the Knight shift vs magnetic susceptibility Kparallel(chi parallel) and Kperpendicular (chi perpendicular) form the same line, which implies that the transferred hyperfine field of 9.2 kOe/microB for 27Al nuclei should be considered isotropic.

Regulation of murine dendritic cell functions in vitro by taurine chloramine, a major product of the neutrophil myeloperoxidase-halide system

Taurine chloramine (TauCl) is a major chloramine generated in activated neutrophils as a result of the reaction of highly toxic hypochlorous acid and taurine, the most abundant free amino acid in cytosol. In this study we have tested the influence of TauCl on the properties of murine dendritic cells (DC), the major cell population involved in the initiation of an adaptive immune response against pathogenic organisms. N418+, MHC II+, B7-2+ dendritic cells, generated from the mouse bone marrow cells cultured in the presence of granulocyte-macrophage colony-stimulating factor, were stimulated by interferon-gamma and lipopolysaccharide to produce nitric oxide, reactive oxygen species, interleukin-6 (IL-6), tumour necrosis factor-alpha, and IL-12, in the presence of different doses of TauCl. TauCl differently inhibited the generation of these inflammatory mediators in a dose-dependent manner. Furthermore, TauCl selectively modulated the ability of DC to induce the release IL-2 and IL-10 from T cells. These results suggest that neutrophil-derived mediators, such as TauCl, at a site of inflammation, may affect the functions of sentinel DC and macrophages, and play a role in maintaining the balance between the inflammatory response and the induction of an antigen-specific immune response.

[Quantification of repositioning errors in PET studies through superimposition of emission and transmission scans. Comparison between acquisition with and without repositioning]

AIM

The purpose of this study was to quantify positioning discrepancies between emission (E) and transmission (T) scan using image fusion. A direct comparison of one-step and two-step acquisitions was performed where all studies were analyzed in respect to artifacts caused by inaccurate positioning. In addition, phantom measurements were conducted to estimate the consequences of repositioning errors on standardized uptake value calculations (SUV).

METHODS

40 patients were examined by two-step whole-body scans using PET and 15 patients were subject to one-step examinations in the head/neck area. Repositioning between the scans was achieved by a laser matrix positioning system in combination with external body markings. After reconstruction and image fusion of the scans, the positioning discrepancies were measured as the distances between the outer boundaries of E and T in four different body regions. Additional evaluations of the SUV by increasing E-T dislocation were performed using a Jaszczak phantom containing hollow spheres.

RESULTS

For the two-step acquisitions, the mean spatial deviations along the three orthogonal axes x, y, and z were between 8.9 mm and 13.8 mm, whereas for the one-step examinations mean values between 3.5 mm and 4.3 mm were determined (level of significance in each direction p < 0.0001). Artifacts were found in 47.5% of the whole body scans, but in none of the head/neck studies. The development of image artifacts was simulated by phantom studies. In contrast, the deviations of the computed SUV caused by increasing positioning discrepancies were minimal because of the minimal differences between the attenuation coefficients of the media involved.

CONCLUSION

The presented data show that an artifactfree reconstruction of attenuation-corrected studies requires a precise positioning of the patient. One-step examination protocols without repositioning are advantageous due to the significantly lower positioning discrepancies. The additional reconstruction of nonattenuation-corrected studies has proven to be useful in discovering image artifacts and is therefore recommended.

Low-energy epicardial pacing in children: the benefit of autocapture

BACKGROUND

Permanent cardiac pacing in children results commonly in augmented energy consumption because of the high pacing rates and the ample stimulation safety margin applied in children. Cardiovascular anatomy and limited venous access sometimes preclude the otherwise preferred endocardial approach. In this multicenter patient series, we studied the feasibility, safety, and energy saving obtained by a combination of steroid-eluting epicardial leads with autocapture devices capable of ongoing adjustment of the stimulation output to the prevailing threshold.

METHODS

Autocapture devices (Pacesetter Microny SR+/- and Regency SR+/-; Pacesetter, Solna, Sweden) and steroid-eluting epicardial pacing leads (Medtronic CapSure Epi 10366; Medtronic, Inc, Minneapolis, MN) were implanted in 14 children. Thresholds, telemetry data, evoked response, and polarization signals were obtained at discharge and follow-up, and battery service life was calculated.

RESULTS

During a median follow-up of 6.5 months, autocapture pacing was applied in 12 of 14 children. The automatically adjusted pulse amplitude of autocapture devices demonstrated low-energy pacing with no significant changes between discharge and 6 months follow-up (1.1 +/- 0.3 versus 0.9 +/- 0.3 V). Autocapture-programmed pacemakers had calculated life spans of 7.8 +/- 1.4 years (Microny) and 21.0 +/- 1.6 years (Regency). No adverse effects were noted.

CONCLUSIONS

Autocapture-controlled pacing with bipolar epicardial pacing leads is feasible and safe in children. Autocapture programming results in substantial energy savings and extends battery life markedly.

[Intraoperative flow measurement of coronary bypass grafts using the ultrasound transit time flowmeter]

The aim of the study was to compare the mean and maximum flow and the flow pattern of coronary vein grafts (SVG) supplying target vessels of the inferior and lateral wall with internal mammary (IMA) grafts to the left anterior descending artery (LAD). In 21 patients 25 bypass grafts (13/25 SVG, 12/25 IMA) were investigated. Using the transit time ultrasound method, flow was measured every 5 ms and the flow data of 60 s were acquired. The flow pattern showed significant differences between both graft types during their cycle. IMA grafts showed only one peak occurring after 22.1+/-12.3% and the second after 63.4+/-15.5% of their cycle. The mean flow was not different in both graft types (IMA: 45.3+/-27.0 ml/min and SVG: 41.8+/-26.7 ml/min, p = n. s.) as it was the case for the maximum flow (IMS: 98. 4+/-45.2 ml/min and SVG: 75.7+/-55.4 ml/min, p = n. s.). In conclusion, there is a different flow pattern for both graft types concerning the number and the occurrence of flow-peaks in the bypass cycle. The mean and peak flow showed no significant difference.

[Various dynamics of Tc-99m-tetrofosmin and Tc-99m-MIBI in a parathyroid adenoma]

Case report of a patient with hypercalcemia and suspected parathyroid adenoma. Because of a previous strumectomy a precise preoperative localization of the suspected parathyroid adenoma was demanded. Tc-99m-tetrofosmin scintigraphy in double phase technique failed to detect a parathyroid adenoma by failing to show a region of increased focal uptake with delayed washout in relation to the thyroid gland. Only comparison of the Tc-99m-tetrofosmin images with a Tc-99m-pertechnetate scan revealed a right caudal parathyroid adenoma. A double phase Tc-99m-MIBI study of the same patient was able to localize this parathyroid adenoma without the need of a corresponding Tc-99m-pertechnetate scintigraphy due to a differential washout with persistent focal uptake in the parathyroid adenoma and a progressively decreasing uptake in the thyroid tissue. This case indicates that Tc-99m-tetrofosmin is a suitable agent for parathyroid imaging only if used together with Tc-99m-pertechnetate but it seems to lack the differential washout characteritics of Tc-99m-MIBI according parathyroid gland and thyroid gland.

27Al and 65Cu NMR study in UCu5Al

We have studied the microscopic properties of the tetragonal UCu5Al Kondo compound by 27Al and 63,65Cu NMR in the paramagnetic state. NMR and susceptibility measurements performed on the powdered sample, but oriented along the applied field, showed chi(parallel) > chi(perpendicular). Plots of K(parallel)(T) against chi(parallel)(T) at temperatures T > or = 100 K yield the transferred hyperfine fields of +5.9 kOe/micron(B) for 27Al nuclei, and +5.3 and -7.0 kOe/micron(B) for 65Cu nuclei in crystallographically inequivalent Cu(2) and Cu(1) sites, respectively. The Knight shift vs. susceptibility plots for T < 100 K exhibit a deviation from the linear behaviour (absolute values of shifts become smaller than expected). We attribute this finding to the crystalline electric field effect in similar way as it was reported for several Ce-based compounds. The random distribution of the Al and Cu(2) atoms in the crystal lattice we consider as a reason of an unusual broadening of the NMR spectra, particularly at low temperatures.

Cardiac pacing in premature infants and neonates: steroid eluting leads and automatic output adaptation

BACKGROUND

Appropriate generator and lead selection as well as techniques of implantation are most important aspects of cardiac pacing in the extremely young patient. Here we report the clinical results using a new technique with automatic output adaptation based on evoked response in combination with steroid-eluting epicardial leads in small children.

METHODS

One neonate and 2 premature infants underwent permanent pacemaker implantation because of congenital high-degree atrioventricular block or postoperative complete heart block, respectively. Steroid-eluting epicardial leads and a multiprogrammable pacemaker with automatic output adaptation were used.

RESULTS

Intermuscular abdominal generator placement and epicardial suture-fixation of the bipolar lead through a subcostal approach was without complications. Serial follow-up examinations revealed safe and consistent pacemaker function up to 12 months after operation.

CONCLUSIONS

The technique represents an excellent alternative for permanent cardiac pacing in extremely small patients. We believe that it provides an increase in functional lifetime of the devices and delays the need for battery replacement with its associated complications in this young patient population.

Accumulation of metals in the teeth of inhabitants of two towns in the south of Poland

Metals and Ca, Na and K were examined in human teeth taken from inhabitants of two towns Sosnowiec and Katowice in the south of Poland (n = 170 samples) during 1993/1994. They are located in Upper Silesia, a heavily industrialised and urbanised region of Poland. The concentrations of Pb, Mn, Fe, Cd, Cu, Ni, Co, Zn and Cr were determined by AAS, and Na, Ca and K by flame photometer. Variations in the Pb/Fe, Pb/Mn, Pb/Ca and Cd/Ca ratios of elements in human teeth were examined. Influence of age, sex type of teeth on concentrations of elements for inhabitants from the two different towns (Katowice and Sosnowiec) and on levels of ratios of the elements were analysed using one-way ANOVA. Cluster Analysis was used to investigate relationships among metals. The smallest duster distances were obtained for: Ca-Fe, Mn-Cd and Na-Co, which indicated the strongest relation between elements in teeth for the investigated population living in a heavily industrialised and urbanised region.

Taking advantage of sophisticated pacemaker diagnostics

The ever-increasing complexity of pacing systems, combined with functions that vary from one manufacturer to another, can pose challenges during analysis of device function. Standard pacemaker diagnostics are measured data, electrogram telemetry, maker annotations and event counters, albeit with their current limitations. New diagnostic features discussed include time-based diagnostics, histograms of sensed amplitudes, pacing thresholds, or impedance trending. Mode-switching algorithms, combined with diagnostic features, facilitate the use of dual-chamber devices in patients with paroxysmal atrial tachyarrhythmias. The introduction of electrogram storage into pacemakers further improves diagnostic capabilities and allows a permanent validation and optimization of diagnostic and therapeutic algorithms. External diagnostic devices, which provide Holter recordings with continuous marker annotations and patient-triggered diagnostics, are additional features that will become increasingly important.

Cross-talk between gammadelta T lymphocytes and immune cells in humoral response

The role of gamma delta T cells in immunoregulation is largely unknown. In the current study we noted that gamma delta T cells play a positive role in the humoral response. These positively acting gamma delta T cells are required for the successful adoptive cell transfer of the humoral response, as well as for in vitro generation of plaque-forming cells (PFC). The presented results show that gammadelta T cells cause an increase in interleukin-10 (IL-10) production, which partly elucidates the mechanism of action of these cells. However, experiments with cell culture inserts strongly suggest that direct cell-cell contact between immune and gamma delta H-2-compatible regulatory T cells is critical to the exertion of the positive immunoregulatory function of gamma delta cells. The mechanism of cross-talk between these two cell populations is still not clear but we regard as most likely that the positively acting gamma delta T cells may interact with a complex of heat-shock protein-non-polymorphic MHC (IB) on the surface of T helper type 2 and/or B cells. This could provide, by direct cell-cell contact, the cognate recognition between gamma delta T-cell receptors and heat-shock protein-MHC that leads to positive internal signalling in the immune cells.

Pacemaker therapy in premature children with high degree AV block

The smallest pacemaker pulse generator and a steroid-eluting bipolar epicardial lead were implanted in two premature children with symptomatic AV block. Stable capture threshold and high amplitude evoked response electrogram resulted in normal function of the pacemaker Autocapture algorithm, which adjusts output 0.3 V above the measured capture threshold. Autocapture had previously been used only with endocardial leads. Longer-term observation is required.

Is atrial sensing of ventricular far-field signals important in single-lead VDD pacing?

In single-lead VDD pacing the atrial sensitivity frequently is programmed to sensitive values. Atrial sensing of ventricular far-field signals should be reduced by differential atrial sensing. The aim of the study was to evaluate the effectiveness of this approach.

METHODS

The study included 10 patients with a single-lead VDD pacemaker (Thera 8948, Lead 5032). The atrial sensitivity was set to its most sensitive value of 0.18 mV and the telemetered intraatrial EGM was continuously recorded. After atrial tracked ventricular pacing, VVI pacing was performed with pacing rates from 100 to 160 beats/min in steps of 10 beats/min and up to 165 beats/min. The peak-to-peak amplitudes of P waves (P) and ventricular far-field signals (VFFS) were measured from the recordings. The ratio P/VFFS that defines the atrial signal-to-noise ratio was calculated, and the time from stimulus to maximum of the far-field signals amplitude (Tmax) was measured.

RESULTS

P measured 0.98 +/- 0.76 mV. A VFFS was visible in the atrial channel in all patients with an amplitude of 0.45 +/- 0.25 mV (range 0.01-1.0 mV), independent of the pacing rate. The ratio P/VFFS was 3.9 +/- 4.2 (range 0.9-21.0). Tmax measured 99.4 +/- 15.2 ms during sinus rhythm. A rate dependent shortening of Tmax to 92.7 +/- 11.2 ms at 140 beats/min was observed (P = 0.001). At rates above 140 beats/min no further shortening occurred.

CONCLUSION

Ventricular far-field signals are measurable in the atrial channel of VDD systems and may reach considerable amplitudes, which are not rate dependent. Although differential sensing provides favorable P waves to ventricular far-field signal ratios, refractory periods are needed to avoid far-field sensing. The rate dependent shortening of the ventricular signal can be detected in the atrial channel in VDD pacing.