The influence of atrial activity on ventricular capture by failing artificial pacemakers. I. Report of two new cases and review of the literature

Underestimation of Pacing Threshold as Determined by an Automatic Ventricular Threshold Testing Algorithm

In this case report, we describe markedly different pacing thresholds determined by a manual threshold test and the automatic Ventricular Capture Management algorithm. The discrepancy in pacing threshold values reported was due to the difference in the AV intervals used with the different testing methods. We propose that the differences in right ventricular dimensions with altered diastolic filling periods affected the threshold in this patient with a new passive fixation lead in the right ventricular apex.

Changes in morphology of the paced QRS complex related to atrial contraction

A patient with 2:1 AV block underwent temporary ventricular pacing. All the paced stimuli resulted in ventricular capture, but a marked variability in morphology of the paced QRS complexes occurred. Two different types of paced QRS complex (labeled A and B) were recognized. Type B complexes were manifest only when the pacing stimulus was preceded by a sinus P wave within a time interval ranging from 0.15 to 0.52 sec. The P wave-induced changes in morphology of the paced QRS complexes were interpreted as due to displacement of the pacing ventricular lead caused by atrial systole.

Mechanically mediated pacemaker pseudomalfunction

A case is described of pacemaker pseudomalfunction caused by intermittent displacement of the ventricular lead. The displacement was shown to be caused by critically timed atrial contractions, dislodging the looped ventricular lead, and resulting in intermittent failure to stimulate the heart.

Atrial systole and ineffective pacemaker stimuli

An unusual case of pacemaker failure induced by atrial activity is presented. The pacemaker stimulus was ineffective for ventricular capture not only with low energy output (decreased pulse duration) of the generator, but also with pulse width two to three times the stimulation threshold. The two possible mechanisms of this phenomenon, one electrotonic and the other mechanical, are discussed. This report strongly supports the mechanical hypothesis.

The influence of atrial systole on ventricular capture by failing artificial pacemakers. II. Experimental observations

The mechanism by which atrial systeole influences the efficacy of ventricular capture by a failing pacemaker was investigated in 12 dogs with atrioventricular heart block. Atrial systole caused facilitation of ventricular capture in eight dogs, and inhibition of capture in 10 dogs. Interpolating atrial extrasystoles caused an enhancement or depression of the hemodynamic performance of the atrial systole that affected the efficacy of the pacemaker stimulus. These interpolation experiments showed that atrial systole influenced the efficacy of capture by a mechanical mechanism and not by an electrotonic mechanism. Atrial systole probably caused motion of the endocardial pacing catheter and/or ventricular myocardium. This motion increased or decreased the contact between the pacing electrode and the endocardium with subsequent changes in the efficacy of capture. In three dogs with pacing through epicardial electrodes, atrial systole had no effect on the efficacy of capture.