The role of rate hysteresis pacing in the hypersensitive carotid sinus syndrome

Long-term follow-up of patients treated with VVI pacing and sequential pacing with special reference to VA retrograde conduction

The aim of this prospective study is comparing long-term prognosis in patients implanted with a VVI pacemaker (group A) with those implanted with a sequential pacing device, AAI or DDD, (group B). Both groups of 45 patients each, were comparable as regards to age, sex, pacing indications, underlying heart disease, and technical conditions of implantation and were followed-up over 55 months. Atrial arrhythmias (A.A.) incidence was higher in group A: 24.4% than group B: 8.8% (P less than 0.05). Arterial embolisms (A.E.) occurred in group A patients only. Worsening or occurrence of exercise limitation was more frequent in group A: 35.6% as compared to group B: 13.3% (P less than 0.05) and deaths related to these complications, occurred in seven cases in group A versus four cases in group B. In group A, all patients who experienced a worsening or occurrence of an A.A. or an A.E., had a ventriculoatrial conduction (VAC). No statistical difference was observed in worsening or occurrence of exercise limitation between patients with VAC and those without VAC: nine (42.8%) and seven (29.2%) but they respectively experienced at least one complication in 16 cases (76.2%) and seven cases (29.2%) (P less than 0.01). In conclusion, long-term prognosis in patients implanted with VVI pacing as compared to patients implanted with sequential pacing is poorer. The presence of VAC in patients treated with permanent VVI pacing is a major factor for complications and deaths related to A.E. and cardiac failure. Thus VVI pacing should be avoided in patients with VAC.

Mixed carotid sinus hypersensitivity: successful therapy with pacing, ephedrine, and propranolol

Three forms of carotid sinus hypersensitivity are recognized clinically (cardio-inhibitory, vasodepressor, and mixed). The cardio-inhibitory form has been managed successfully with pacemaker therapy. The vasodepressor element has been difficult to manage clinically whether in its pure form or in combination with the cardio-inhibitory type. We review the various pharmacologic methods previously reported and present our experience with a new pharmacologic alternative, which is the combined use of ephedrine and propranolol to induce unopposed alpha stimulation.

Carotid sinus hypersensitivity: beneficial effects of dual-chamber pacing

Three types of carotid sinus (CS) syndrome have been described: cardioinhibitory, vasodepressor and mixed. For the treatment of symptomatic patients with associated significant cardioinhibition, permanent ventricular demand pacing systems are often implanted. Even with this pacing modality, some patients remain symptomatic because of continued (and at times aggravated) vasodepression. This study assesses the effects of loss of atrial preloading and orthostasis after carotid massage in patients with CS hypersensitivity. Eleven patients were studied using constant intra-arterial pressure measurements during either ventricular (VVI) or atrioventricular sequential (DVI) pacing in both supine or upright positions. The measurements performed included the magnitude of decrease in arterial blood pressure (BP), the rate of decrease of BP and the percent change in BP from baseline values. After carotid massage, all 11 patients had greater hemodynamic change with the VVI than DVI pacing mode, whether in the supine or upright position. The decreases in systolic BP were: DVI (supine) 29 mm Hg, VVI (supine) 48 mm Hg, DVI (upright) 37 mm Hg, and VVI (upright) 59 mm Hg (mean group values, p less than 0.001). The rates of decrease of systolic BP were: DVI (supine) 2.9 mm Hg/s, VVI (supine) 5.7 mm Hg/s, DVI (upright) 4.1 mm Hg/s, and VVI (upright) 8.3 mm Hg/s (mean group values, p less than 0.001). VVI pacing, particularly in the upright position, resulted in a significant increase in the incidence of patient symptoms (p = 0.03). Thus, in CS hypersensitivity, VVI pacing results in significant hemodynamic deterioration compared to DVI mode. This aggravation of the vasodepressor component results in increased patient symptoms, and therefore, DVI is the optimal pacing mode.