Verification of pacemaker automatic mode switching for the detection of atrial fibrillation and atrial tachycardia with Holter recording

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Enhanced detection of atrial tachyarrhythmias with pacing devices by using more accurate atrial sensing

Purpose

Cardiac pacing devices can detect and monitor atrial tachyarrhythmias (ATA) which increase the risk of thromboembolic complications. The aim of this study was to compare (1) two different atrial leads and (2) standard and optimized settings to detect ATA and reject far-field R-wave signal (FFRW).

Methods

This was a prospective, randomized multi-center trial comparing St. Jude Medical OptiSense lead (tip-to-ring spacing 1.1 mm) and Tendril lead (tip-to-ring spacing 10.0 mm), having programmed atrial sensitivity at 0.2 mV and post-ventricular atrial blanking at 60 ms. We measured intra-atrial amplitudes of FFRW, intrinsic atrial signals, the amount of FFRW oversensing, and other inappropriate mode switching.

Results

One hundred and ten patients were enrolled. The mean amplitude of sensed and paced FFRW bipolar signal was 0.13 mV vs. 0.21 mV (p < 0.001) and 0.13 mV vs. 0.26 mV (p < 0.001) with OptiSense and Tendril lead, respectively. The mean amplitude of the atrial bipolar signal was 2.84 mV with OptiSense and 3.48 mV with Tendril lead, p = 0.014. With the optimized settings with OptiSense lead, one patient out of 20 (5%) had FFRW oversensing, none had undersensing of ATAs due to 2:1-blanking of atrial depolarizations, and the concordance of the ATAs by Holter and pacemaker memory was high (Spearman’s rank correlation coefficient = 0.90). In the Tendril group, 12 out of 25 patients (48%) had oversensing and 4 had atrial undersensing (p < 0.001).

Conclusions

The technique with an atrial lead with short tip-to-ring spacing combined with optimized pacemaker programming resulted in reliable and accurate atrial arrhythmia detection.

Trial registration

ClinicalTrials.gov number NCT01074749.

Cardiac implantable devices during exercise: Normal function and troubleshooting

Normal function and the most common problems that occur during pacemaker operation while performing physical exercise, are discussed. Physically active individuals with an implantable cardiac device, should be evaluated during exercise, because some conflicts issues may arise that are not detectable during routine, at rest, telemetry.

Long-term efficacy and safety of radiofrequency catheter ablation of atrial fibrillation in patients with cardiac implantable electronic devices and transvenous leads

INTRODUCTION

Long-term efficacy and safety are uncertain in patients with cardiac implantable electronic devices (CIED) and transvenous leads (TVL) undergoing radiofrequency catheter ablation of atrial fibrillation (AF). Thus, we assessed the outcome of AF ablation in those patients during long-term follow-up using continuous atrial rhythm monitoring (CARM).

METHODS AND RESULTS

A total of 190 patients (71.3 ± 10.7 years; 108 (56.8% men) were included in this study. At index procedure 81 (42.6%) patients presented with paroxysmal AF and 109 (57.4%) with persistent AF. The ablation strategy included pulmonary vein isolation in all patients and biatrial ablation of complex fractionated electrograms with additional ablation lines, if appropriate. AF recurrences were assessed by CARM- and CIED-related complications by device follow-up. After a mean follow-up of 55.4 ± 38.1 months, freedom of AF was found in 86 (61.4%) and clinical success defined as an AF burden less than or equal to 1% in 101 (72.1%) patients. Freedom of AF was reported in 74.6% and 51.9% (P = 0.006) and clinical success in 89.8% and 59.3% (P < 0.001) of patients with paroxysmal and persistent AF, respectively. In 3 of 408 (0.7%) ablation procedures, a TVL malfunction occurred within 90 days after catheter ablation. During long-term follow-up 9 (4.7%) patients showed lead dislodgement, 2 (1.1%) lead fracture, and 2 (1.1%) lead insulation defect not related to the ablation procedure.

CONCLUSION

Our findings using CARM demonstrate long-term efficacy and safety of radiofrequency catheter ablation of AF in patients with CIED and TVL.

Association between paced QRS duration and atrial fibrillation after permanent pacemaker implantation: A retrospective observational cohort study

Right ventricular pacing often results in prolonged QRS duration (QRSd) as the result of right ventricular stimulation, and atrial fibrillation (AF) may result. The association of pacing-induced prolonged QRSd and AF in patients with permanent pacemakers is unknown.We selected 180 consecutive patients who underwent pacemaker implantation for complete/advanced atrioventricular block. All of the patients were paced from the right ventricular septum. Electrocardiography recordings were obtained at the beginning and the end of pacemaker implantation. QRSd was measured in all 12 leads. The QRSd variation was calculated by subtracting the preimplantation QRSd from the postimplantation QRSd.The occurrence of AF was observed in 64 (35.56%) patients (follow-up 33.62 ± 21.47 mo). No significant differences in preimplantation QRSd were observed between the AF occurrence and nonoccurrence groups. The QRSd variation in leads V4 (54.22 ± 29.03 vs 42.66 ± 33.79 ms, P = .022), and V6 (64.62 ± 23.16 vs 48.45 ± 34.40 ms, P = .001) differed significantly between the occurrence and nonoccurrence groups. More QRSd variation in lead V6 (P = .005, HR = 1.822, 95% CI 1.174-2.718, interval scale of QRSd was 40 ms) and left atrial diameter (P = .045, HR = 1.042, 95% CI 1.001-1.086) were independent risk factors for AF occurrence. Receiver operating characteristic curve suggested that QRSd variation in lead V6 could predict AF occurrence, especially for patients with long preimplantation QRSd (≥120 ms, area under the curve was 0.826, 95% CI 0.685-0.967).QRSd variation in lead V6 might be positively correlated with postimplantation AF occurrence. In patients with pacemaker implantation, QRSd could be a complementary criterion for optimizing the right ventricular septal pacing site, and smallest QRSd might be worth pursuing.

Performance of an Implantable Cardiac Monitor to Detect Atrial Fibrillation: Results of the DETECT AF Study

INTRODUCTION

Reliable detection and monitoring of atrial fibrillation (AF) is essential for accurate clinical decision making, which can now be done continuously with the introduction of implantable cardiac monitors (ICM) The DETECT AF study evaluated the performance of the Confirm DM2102 ICM (St. Jude Medical, St. Paul, MN, USA) to accurately detect and monitor AF.

METHODS

Ninety patients previously implanted with the ICM and with either suspected or known paroxysmal AF were enrolled at 12 centers in Germany and The Netherlands. At least 2 weeks after ICM implant, patients wore a Holter monitor for 4 days, while the ICM monitored for AF episodes lasting at least 2 minutes. Holter monitor data was analyzed by a blinded, independent core laboratory and compared to the ICM AF detections. Patient and episode sensitivity (SE), specificity (SP), positive predictive value (PPV), and negative predictive (NPV) were calculated using standard analysis and a generalized estimation equation method where appropriate.

RESULTS

A total of 79/90 subjects (61% male, 65.7 ± 9.6 years old) were included in the analysis, totaling 6,894 hours of Holter monitoring. Using a per patient analysis SE was 100%, PPV was 64.0%, SP was 85.7%, and NPV was 100%. Using a per episode analysis, SE was 94.0% and PPV was 64.0%. With an AF duration analysis, the SE was 83.9%, PPV was 97.3%, SP was 99.4% with an NPV of 98.5%.

CONCLUSION

The SJM Confirm DM2102 can accurately and repeatedly detect paroxysmal AF episodes of at least 2 minutes in length.

Clinical, Echocardiographic, and Electrocardiographic Predictors of Persistent Atrial Fibrillation after Dual-Chamber Pacemaker Implantation: An Integrated Scoring Model Approach

Persistent atrial fibrillation (PeAF) predictors after dual-chamber pacemaker (PM) implantation remain unclear. We sought to determine these predictors and establish an integrated scoring model. Data were retrospectively reviewed for 649 patients (63.8 ± 12.3 years, 48.6% male, mean CHA₂DS₂–VASC score 2.7 ± 2.0) undergoing dual-chamber PM implantation. PeAF was defined as documented AF on two consecutive electrocardiograms acquired ≥7 days apart. During a 7.1-year median follow-up (interquartile range 4.5–10.1 years), 67 (10.3%) patients had PeAF. Multivariable analysis showed the following independent predictors of future PeAF: ischemic stroke or transient ischemic accident history (hazard ratio [HR] 2.03, 95% confidence interval [CI] 1.03–3.50, p = 0.040), atrial fibrillation/flutter history (HR 1.80, 95% CI 1.01–3.20, p = 0.046), sinus node disease (HR 2.24, 95% CI 1.16–4.35, p = 0.016), left atrial enlargement (>45 mm, HR 2.14, 95% CI 1.26–3.63, p = 0.005), and time in automatic mode switching >1% at first follow-up interrogation (HR 2.58, 95% CI 1.51–4.42, p < 0.001). An integrated scoring model combining these predictors showed good discrimination performance at the seven-year follow-up. (C-statistic 0.716, 95% CI 0.629–0.802, p < 0.001). Significantly greater seven-year PeAF incidences were seen in patients with higher scores (2–5) than in those with lower scores (0–1) (22.8% ± 3.8% vs. 5.3% ± 1.7%, p < 0.001). In conclusion, an integrated scoring model combining clinical, echocardiographic, and electrocardiographic characteristics is useful for predicting future PeAF in patients with a dual-chamber PM.

Newer algorithms in bradycardia management

Permanent cardiac pacemakers (PPM) are effective in the treatment of bradycardia in a growing number of clinical scenarios. An appreciation of the capacity of PPMs to result in negative hemodynamic and proarrhythmic effects has grown alongside clinical experience with permanent pacing. Such experience has necessitated the development of algorithms aimed at optimizing device functionality across a broad spectrum of physiologic and pathologic conditions. This review highlights recent device-based algorithms used in automated threshold testing, reduction of right ventricular pacing, prevention and treatment of pacemaker-mediated tachycardia, mode switching for atrial tachyarrhythmias, rate-modulated pacing, and advances in arrhythmia storage and remote monitoring.

Does atrial fibrillation detected by cardiac implantable electronic devices have clinical relevance?

The precise role atrial fibrillation (AF) plays in increasing the risk of stroke is less well understood; this is especially true for the implanted device population. Current cardiac implanted electronic devices have a very high sensitivity and specificity for true AF detection. It does not seem to matter if the AF episode is proximal to the stroke event, and risk seems to be increased by relatively brief AF episodes. The appearance of new atrial high-rate episodes increases thromboembolic event rates. Until larger trials or registries are conducted, it is important to follow established guidelines regarding anticoagulation.

Use of an atrial lead with very short tip-to-ring spacing avoids oversensing of far-field R-wave

Objective

The AVOID-FFS (Avoidance of Far-Field R-wave Sensing) study aimed to investigate whether an atrial lead with a very short tip-to-ring spacing without optimization of pacemaker settings shows equally low incidence of far-field R-wave sensing (FFS) when compared to a conventional atrial lead in combination with optimization of the programming.

Methods

Patients receiving a dual chamber pacemaker were randomly assigned to receive an atrial lead with a tip-to-ring spacing of 1.1 mm or a lead with a conventional tip-to-ring spacing of 10 mm. Postventricular atrial blanking (PVAB) was programmed to the shortest possible value of 60 ms in the study group, and to an individually determined optimized value in the control group. Atrial sensing threshold was programmed to 0.3 mV in both groups. False positive mode switch caused by FFS was evaluated at one and three months post implantation.

Results

A total of 204 patients (121 male; age 73±10 years) were included in the study. False positive mode switch caused by FFS was detected in one (1%) patient of the study group and two (2%) patients of the control group (p = 0.62).

Conclusion

The use of an atrial electrode with a very short tip-to-ring spacing avoids inappropriate mode switch caused by FFS without the need for individual PVAB optimization.

Trial Registration

ClinicalTrials.gov NCT00512915

Electrophysiological characteristics associated with symptoms in pacemaker patients with paroxysmal atrial fibrillation

PURPOSE

The purpose of this study is to identify the electrophysiological factors affecting symptoms in paroxysmal atrial fibrillation (PAF) using patients with paroxysmal atrial fibrillation and pacemakers with advanced atrial fibrillation (AF) diagnostics.

METHODS

Seventy-nine patients (age 71.0 +/- 8.2, 54.4% male) with symptomatic PAF and AF burden of 1% to 50% with DDDRP pacemakers implanted were assessed for 6 months. Patients recorded symptom onset and duration and these were correlated with device-derived electrophysiological data.

RESULTS

Of 2,638 AF episodes, 333 were symptomatic and 2,305 asymptomatic, with 194 non-atrial tachyarrhythmia symptomatic episodes giving a sensitivity of 12.6% and a positive predictive value of 63.2% for specific AF symptoms. Symptomatic AF episodes were 3.8 times more common diurnally than nocturnally (p < 0.001). Diurnally, symptomatic AF was significantly associated with a shorter AF cycle length (CL; p = 0.04), faster ventricular rate (p = 0.004), shorter PR interval (p < 0.001), faster preceding heart rate (p = 0.001) and increased early recurrence of AF (p < 0.04). Nocturnally, a significantly longer AF CL (p = 0.04) and PR interval (p < 0.001) prior to AF onset predicted symptomatic AF.

CONCLUSIONS

Symptoms in PAF are predicted by changes in AF episode duration, ventricular rate during AF, preceding sinus heart rate, AV nodal conduction and AF cycle length but not ventricular irregularity. Excess diurnal sympathetic tone and excess nocturnal vagal tone predispose to symptomatic PAF. These findings may have relevance for therapies for symptom control of PAF.

Registry of Atrial Tachycardia and Atrial Fibrillation Episodes in the cardiac rhythm management device population: the RATE Registry design

Most atrial fibrillation is asymptomatic. In patients with implanted pacemakers and defibrillators, accurate documentation of asymptomatic episodes provides the opportunity to better understand atrial fibrillation burden and its clinical consequences. The Registry of Atrial Tachycardia and Atrial Fibrillation Episodes in the cardiac rhythm management device population (RATE) is designed to follow 5,000 patients with pacemakers, defibrillators, and resynchronization devices for 2 years. Demographic and initial clinical data will be correlated with atrial fibrillation burden and with other outcome measures relating to therapies and adverse events. The hypothesis of the RATE Registry is that there exists a definable burden of atrial fibrillation episodes in the RATE population that will be predictive of important clinical outcomes, including progression from asymptomatic to symptomatic atrial fibrillation (if any) or to sustained atrial fibrillation, heart failure, and risk of stroke.

Atrial Arrhythmias in long-QT syndrome under daily life conditions: a nested case control study

BACKGROUND

The long-QT syndromes (LQTS) are inherited electrical cardiomyopathies characterized by prolonged ventricular repolarization and ventricular arrhythmias. Several genetic reports have associated defects in LQTS-causing genes with atrial fibrillation (AF). We therefore studied whether atrial arrhythmias occur in patients with LQTS under daily-life conditions.

METHODS

We systematically assessed atrial arrhythmias in LQTS patients and matched controls using implanted defibrillators or pacemakers as monitors of atrial rhythm in a nested case-control study. Twenty-one LQTS patients (3 male; 39 +/- 18 years old; 18 on beta blocker, ICD therapy duration 6.3 +/- 2.7 years; 4 LQT1, 6 LQT2, 2 LQT3) were matched to 21 control subjects (13 male; 50 +/- 19 years old; 3 on beta blocker; pacemaker therapy duration 8.5 +/- 5.5 years; 19 higher-degree AV block, 2 others). LQTS patients were identified by a systematic search of the LQTS patient databases in Münster and Munich.

RESULTS

One-third (7 of 21) of the LQTS patients developed self-terminating atrial arrhythmias (atrial cycle lengths <250 ms). Only one control patient developed a single episode of postoperative AF (P < 0.05 vs LQTS).

CONCLUSIONS

LQTS patients at high risk for ventricular arrhythmias may develop short-lasting atrial arrhythmias under daily-life conditions, suggesting that prolonged atrial repolarization may contribute to the initiation of AF.

Diagnostic tools for atrial tachyarrhythmias in implantable pacemakers: a review of technical options and pitfalls

BACKGROUND

Correct pacemaker (PM) diagnosis of paroxysmal atrial tachyarrhythmias is crucial for their prevention and intervention with specific atrial pacing programmes. The PM mode switch to only ventricular pacing after detection of atrial tachyarrhythmias is often used as the parameter to quantify the 'burden' of atrial tachyarrhythmias.

OBJECTIVES

This review addresses potential errors in the detection and diagnosis of atrial tachyarrhythmias, sometimes resulting in incorrect mode switches. The interpretation of PM-stored data of patients with atrial tachyarrhythmias and the results of trials of pace prevention and intervention can be better appreciated with more insight into the technical options and pitfalls.

RESULTS

Literature and clinical experience demonstrate that the correctness of PM-derived diagnosis of atrial tachyarrhythmias depends on 1) the sensitivity setting to detect the onset and perpetuation of atrial tachyarrhythmias frequently characterised by variable and low-voltage signals, 2) the rejection of far-field R wave sensing by the atrial sense amplifier, 3) the facility for verification of mode switches by a high-quality intracardiac registration of the nonmodified atrial electrogram. The configuration of the atrial lead also contributes to the diagnostic performance of the PM.

CONCLUSION

Not only pacing algorithms and diverse technical PM features but also the atrial lead configuration are currently the limiting factors to the fully reliable, automated detection and diagnosis of atrial tachyarrhythmias. If these technical shortcomings can be improved, better signal processing will result. Then atrial pacing to prevent or suppress atrial tachyarrhythmias will be more justified. (Neth Heart J 2008;16:201-10.).

The role of pacing in rhythm control and management of atrial fibrillation

Atrial fibrillation is the most common sustained cardiac arrhythmia and is increasing in prevalence with an ageing population. As the arrhythmia is often asymptomatic the true prevalence is likely even higher. Largely because of stroke this arrhythmia places a huge financial burden on the health economy. Despite this, large studies assessing rate versus rhythm control have been equivocal. Because of the ineffectiveness of pharmacological therapy much research effort has been undertaken in device and ablative approaches to rhythm management. Although catheter ablation has gained favour because of the high success rates the technique requires considerable expertise and still has a significant complication profile maintaining interest in pacing therapies for atrial fibrillation. Dual chamber versus single-chamber ventricular pacing has been shown to significantly reduce the incidence of atrial fibrillation. Research is currently underway to see if minimising the deleterious effects of right ventricular apical pacing could further increase the benefits of atrioventricular synchronous pacing. Several studies show some (albeit variable) reduction in AF burden with anti-AF algorithms in the setting of bradycardia. Antitachycardia pacing, on the other hand, has not been shown to treat AF in a randomised trial despite the successful termination of co-existent atrial tachycardias. There is increasing evidence that alternative atrial pacing sites may treat AF by improving atrial function. Furthermore, these strategies coupled with other therapies in a 'hybrid approach' have also showed promising results.