VDD Pacing:

Comparison of a Novel, Single-Lead Atrial Sensing System With a Dual-Chamber Implantable Cardioverter-Defibrillator System in Patients Without Antibradycardia Pacing Indications

Background—

Supraventricular tachyarrhythmias are the main cause for inappropriate therapy by implantable cardioverter-defibrillators (ICDs). For better rhythm discrimination, an atrial electrogram is helpful and usually obtained from an additional atrial lead, even in the absence of sinus node or atrioventricular nodal disease. An A+-ICD system with integrated atrial sensing rings mounted 15 to 18 cm from the tip of an ICD lead may obviate the need to implant a separate atrial lead. The aim of the study was to compare the novel A+-ICD and a conventional dual-chamber (DR)-ICD.

Methods and Results—

Two hundred forty-nine patients with standard ICD indications but no requirement for antibradycardia pacing were randomized to receive an A+-ICD (n=124) or a DR-ICD (n=125). Implantation details, need for ICD system revision, long-term sensing, documented arrhythmia episodes, and the respective rhythm discrimination during follow-up were analyzed. The implantation time was significantly shorter in the A+-ICD group (67±30 vs 79±30 minutes, P =0.003). Mean P-wave amplitudes were 3.5±0.8 mV (A+-ICD) and 3.2±0.6 mV (DR-ICD) and remained stable during the follow-up period of 12 months. Surgical revision was necessary in 13 patients in the DR-ICD and 10 in the A+-ICD group. All 593 ventricular tachyarrhythmia episodes were correctly discriminated. Sensitivity and specificity of supraventricular tachyarrhythmia discrimination were not different between the study groups.

Conclusions—

The novel A+-ICD system can be implanted faster and is equivalent to a standard DR-ICD with regard to the detection of ventricular tachyarrhythmias and supraventricular tachyarrhythmias. It represents a useful alternative to obtain atrial sensing.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00324662.

Unusual VDD-pacing

The case of an 80-year-old woman who underwent permanent VDD-pacemaker implantation for recurrent syncope in the presence of second-degree type 2 AV-block is reported. During follow-up, low atrial sensing with AV-synchrony of only 58-73% was noted. Four years after the pacemaker implantation, the patient was hospitalized for non-cardiac reasons and the chest radiograph showed displacement of the atrial dipole into the right ventricular outflow tract (RVOT). It is hypothesized that AV-synchrony was maintained by left atrial sensing due to the anatomic proximity of the RVOT to the left atrial appendage.

Upgrading of VVIR pacemakers with nonfunctional endocardial ventricular leads to VDD pacemakers in adolescents

BACKGROUND

In some children with ventricular rate responsive demand (VVIR) pacemakers (PM), transvenous leads fail for technical reasons or patient's growth.

AIM

The aim of this study is to describe our experience in adolescents with a nonfunctional ventricular lead in whom the lead was abandoned and an additional VDD lead was implanted. Of the 136 children who received a VVIR PM with an endocardial lead in our center, seven patients aged 7 (0.3-12) years [median (range)] at initial implantation, after 10 (5-15) years showed lead malfunction and underwent atrial synchronous ventricular inhibited pacing (VDD) PM upgrading at 16 (10-20) years.

RESULTS

The VDD lead was inserted through the ipsilateral subclavian vein in five patients, the contralateral in two (venous occlusion in one and for operator choice in the first patient). The tip was positioned into the right ventricular apex, the atrial dipole along the lateral atrial wall. Fluoroscopy times were not significantly different from those measured in SSI PM implantation and in VVIR dual-chamber demand pacing (VVIR-DDD) upgrading. There were no intraprocedural complications. Follow-up duration is 12 (6-62) months. The VDD PM showed good function, no undersensing or oversensing. Tricuspid damage, new venous occlusion, and "twisting" of the two leads at x-ray were not documented. The first patient showed an infection of the old PM pocket after 1 year, local pain after 3 years, and endocarditis of the leads after 5 years.

CONCLUSION

The upgrading of VVIR PM to VDD PM with the abandonment of the nonfunctional lead is feasible, with no intraprocedural complications and good PM function. Lead endocarditis occurred in one patient.

Seguridad y eficacia de los sistemas de estimulación VDD monosonda

INTRODUCTION AND OBJECTIVES

Single-lead VDD pacing provides the physiological benefits of atrioventricular synchrony with the convenience of a single-lead system. However, concern remains about the method's safety and effectiveness.

METHOD

In total, 700 patients with single-lead VDD pacemakers were evaluated retrospectively. The following parameters were recorded: age, sex, etiology, the symptoms and electrocardiographic diagnosis that justified pacemaker implantation, the venous access route used for implantation, atrial sensing at implantation, atrial undersensing at follow-up, the occurrence of supraventricular tachyarrhythmias, and final pacing mode.

RESULTS

Third-degree atrioventricular block was the main indication for pacemaker implantation (66.4%). The most commonly used venous access route was via the right cephalic vein (49.1%). At implantation, the mean atrial signal was 1.8 (4 1.15) mV. During follow-up, significant atrial undersensing occurred in 7.7% of patients; in 1.9%, it could not be corrected by device reprogramming. Uncontrollable supraventricular arrhythmias were observed in 6.4% of patients. Symptomatic sinus node disease was rare. By the end of follow-up, 91.4% of patients were still on VDD pacing, while, in 8.3%, the pacemaker had to be reprogrammed to the VVI mode. Only 0.3% required atrial lead implantation for DDD pacing. Left-side venous access during implantation was a independent predictora of atrial undersensing at follow-up. Low values of atrial detection at implant did not reach statistical signification although it showed a remarkable trend.

CONCLUSIONS

Single-lead VDD pacing seems to be safe and effective when appropriately indicated. Our findings are consistent with those of previously published studies.

VDD pacemaker replacement is safe and reliable independently of the previously implanted lead: a prospective and controlled study

Theoretically, replacement of a VDD device requires using a similar pacemaker to provide the best match between the filtering characteristics of the pacemaker and the atrial dipole of the lead. This study evaluated the performance of newly implanted Vitatron VDD pacemakers connected to dedicated leads and compared the results with those of the same Vitatron pacemakers used as replacement but connected to a variety of nondedicated leads.

METHODS

23 consecutive patients (15 M, 8 F, 78 +/- 6 years) in Group 1 underwent pacemaker replacement with a VDD(R) Saphir 3 (Vitatron BV, Arnhem, The Netherlands) device designed for an 8.6 mm atrial dipole. Atrial dipoles of the previously implanted leads ranged from 5 to 30 mm. Another 22 consecutive patients (14 M, 8 F, 80 +/- 7 years) in Group 2 received a Saphir 3 pacemaker with the related dedicated lead.

RESULTS

P-wave amplitude measured by the same Pacing Sensing Analyzer (PSA) at the first implantation was 1.7 +/- 0.8 vs. 1.7 +/- 0.5 mV (P = NS) in groups 1 and 2 respectively. P-wave amplitudes measured at 1 month follow-up after replacement in Group 1 and at 1 month follow-up after implantation in Group 2 were 0.69 +/- 0.5 vs. 0.85 +/- 0.3 mV (P = NS) respectively. The percentage of atrial sensing at the same follow-up was 97 +/- 3 vs. 95 +/- 5% (P = NS) in groups 1 and 2 respectively.

CONCLUSIONS

Replacement of VDD pacemakers with the Saphir 3 model designed for a short dipole is safe and reliable when used in combination with previously implanted nondedicated leads.

Cardiac resynchronization therapy using a VDD lead

In heart failure patients with normal sinus node function, cardiac resynchronization therapy can be achieved with only two leads, one VDD type, and one left ventricular. This reduces the number of venous punctures, implanted leads, and possibly operation and fluoroscopic times and complication rates. We present two cases and discuss the advantages and limits of such a procedure.

Optimal Side of Implant for Single-Lead VDD Pacing: Right-Sided Versus Left-Sided Implantation

BACKGROUND

Atrial undersensing occurs in a considerable number of patients with single-lead VDD pacing. This study tried to determine the role of implant side in maintenance of the VDD mode in patients with isolated atrioventricular (AV) block.

METHODS

Eighty-two patients with isolated AV block (46 females; mean age, 58 +/- 17 years) received a single-lead VDD pacemaker (Medtronic Kappa, n = 70 and St. Jude Medical Affinity, n = 12). The patients were randomly assigned to one of two implantation groups (group I: right-sided VDD and group II: left-sided VDD). In each group, the P-wave amplitudes were determined at implantation, predischarge, 2-month, and 6-month follow-up. At each follow-up visit, stored event histograms of pacemaker were also retrieved. The atrial sensing measurements were compared between two groups.

RESULTS

Implantation was easier from right side (1.7 +/- 1.0 vs 2.8 +/- 1.7 attempts, P = 0.001). Implant P-wave was higher in group I compared to group II (4.2 +/- 1.7 vs 2.7 +/- 1.0 mV, P < 0.0001). During follow-up, higher P-wave amplitudes were obtained in group I both at predischarge (2.6 +/- 1.3 vs 1.4 +/- 1.1 mV, P < 0.0001), 2-month (2.8 +/- 1.8 vs 1.3 +/- 1.0 mV, P < 0.0001), and 6-month (2.9 +/- 1.7 vs 1.3 +/- 0.9 mV, P < 0.0001) evaluations but remained stable throughout the 6 months in both groups. After implantation, VDD function was better maintained in group I than group II (100% vs 90%, P = 0.026). Incidence of atrial undersensing was lower in group I than group II (P = 0.026) in last follow-up visit.

CONCLUSIONS

Implant side has a significant influence on atrial sensing performance in single-lead VDD pacing. Thus, right-side implantation should be the preferred approach for the implantation of VDD single-lead systems.