Dual chamber sequential pacing management of sinus node dysfunction: Advantages over single-chamber pacing

doi:10.1016/0002-8703(82)90162-4

American Heart Journal

Volume 104, Issue 6, December 1982, Pages 1319-1327

https://doi.org/10.1016/0002-8703(82)90162-4 Get rights and content

Abstract

Sixty-nine patients receiving atrioventricular sequential (DVI) pacemakers are compared to 67 patients receiving ventricular demand (VVI) pacemakers for control of the symptoms of sinus node dysfunction. The populations were similar with comparable prepacing incidences of each assayed symptom and number of symptoms per patient (symptom density). Syncope was well controlled by both DVI and VVI pacing. DVI pacing was better than VVI pacing for control of all other symptoms. Symptom density response: DVI pre, 3.3 ± 0.95; post, 0.43 ± 0.63; VVI pre, 3.2 ± 0.97; post 1.75 ± 1.44 (p < 0.000). Atrial electrode problems were encountered in five (7.3%) of the DVI patients and one (0.74%) ventricular electrode required repositioning.

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Neurologic complications of arrhythmia treatment
2014, Handbook of Clinical Neurology
Citation Excerpt :
The stroke risk in sick sinus syndrome before cardiac pacemaker insertion is substantial and probably remains so after pacemaker insertion (Fisher et al., 1988). The precise stroke risk after cardiac pacemaker insertion remains uncertain, but strokes have been observed in 4.5–23% of paced sick sinus syndrome patients who are followed for 2–3 years (Stone et al., 1982; Rosenqvist et al., 1986; Fisher et al., 1988). Data from long-term follow-up of paced sick sinus syndrome patients indicates that the incidence of stroke is 3% at 1 year, 5% at 5 years, and 13% at 10 years (Sgarbossa et al., 1993).
An arrhythmia is defined as an abnormal heart rhythm. Certain arrhythmias have much higher rates of neurologic complications, including stroke, cognitive impairment, and dementia. The purpose of this paper is to review both the direct and indirect causes of neurologic problems caused by arrhythmias. Direct complications from arrhythmia can include stroke, transient ischemic attack (TIA), and varying disorders of cognition. According to the Stroke Data Bank, which divided potential direct causes of cardioembolic stroke into strong and weak sources, both atrial fibrillation and sick-sinus syndrome were considered to be strong sources of this type of ischemic stroke. Indirect causes of neurologic complications include cardiopulmonary resuscitation, medications, cardiology procedures, and cardiac surgical procedures used to treat arrhythmias.
Sick sinus syndrome
2002, Clinics in Geriatric Medicine
Prospective randomised trial of atrial versus ventricular pacing in sick-sinus syndrome
1994, The Lancet
Summary
In patients with sick-sinus syndrome, single-chamber atrial pacing has been reported, in retrospective studies, to be associated with lower frequencies of atrial fibrillation, thromboembolism, heart failure, and mortality than ventricular pacing; although single-chamber ventricular pacing is most commonly used.
We did a prospective randomised trial in 225 consecutive patients (142 women, 83 men; mean age 76 years) with the sick-sinus syndrome, randomised to atrial (n=110) or ventricular (n=115) pacing and followed for up to 5 years (mean 40 [SD 18] months). During follow-up, the frequency of atrial fibrillation was higher in the ventricular group, except at the first follow-up at 3 months. Thromboembolic events (stroke or peripheral arterial embolus) occurred in 20 patients in the ventricular group and in 6 patients in the atrial group (p=0·0083). 25 patients died in the ventricular group compared with 21 in the atrial group (p=0·74). Heart failure estimated by the New York Heart Association classification and by the daily doses of diuretics did not differ between the two groups. Atrioventricular block occurred in 2 patients in the atrial group.
Patients with sick-sinus syndrome should be treated with atrial pacing rather than ventricular pacing because atrial pacing is associated with lower frequencies of atrial fibrillation, thromboembolic complications, and a low risk of atrioventricular block.
Natural history of sinus node disease treated with atrial pacing in 213 patients: Implications for selection of stimulation mode
1992, Journal of the American College of Cardiology
Objectives. This study was designed to analyze the incidence and determinants of complications and long-term survival in sinus node disease treated with atrial pacing.
Background. Knowledge of the natural history of sinus node disease treated with different pacing modes is imperfect, and controversy exists regarding the optimal pacemaker therapy.
Methods. A consecutive series of 213 patients with sinus node disease initially treated with atrial pacing was studied for a median follow-up period of 60 months. The end points studied were permanent atrial fibrillation, high grade atrioventricular (AV) block, P wave undersensing, pacing mode change, reoperation and death. Several prognostic factors were evaluated statistically and the survival rate was compared with that of a matched general population.
Results. The incidence rate of permanent atrial fibrillation during follow-up was 7% (1.4%/year). The risk of this arrhythmia increased substantially with age ≥ 70 years at pacemaker implantation. Only 2 of the 15 patients who developed permanent atrial fibrillation required ventricular pacing. High grade AV block occurred in 8.5% (1.8%/year) and its incidence was much greater in patients with complete bundle branch block or bifascicular block (35%) than in patients without such conduction disturbances (6%).
A change to ventricular or dual-chamber stimulation was necessary in 14% of all patients, primarily because of early lead dislodgment or high grade AV block. Surgical intervention with maintenance of atrial pacing was required in 7% of patients.
The survival rates of 97% at 1 year, 89% at 5 years and 72% at 10 years did not differ significantly from those of a matched general population.
Conclusions. In sinus node disease, atrial pacing can be successfully applied during long-term follow-up. Patients with complete bundle branch or bifascicular block in addition to sinus node disease should initially receive a dual-chamber pacemaker, but routine application of dual-chamber stimulation does not appear to be warranted.
An analysis of symptoms in patients with permanent ventricular pacemakers
1992, Journal of Clinical Epidemiology
The prevalence and severity of symptoms of the “pacemaker syndrome” were investigated in 64 patients with VVI pacemakers and compared, in the same patients, to a series of control symptoms, unrelated to pacemaker function. Symptoms were also compared in patient groups unlikely to have the “pacemaker syndrome” (atrial fibrillation), most likely to have such symptoms (retrograde atrial activation) and in an intermediate group (competitive paced and sinus rhythms). There was a linear relationship between the frequency and severity of “pacemaker” symptoms and control questions in all groups and no preponderance of “pacemaker” symptoms in any group. The study provides an estimate of the number and severity of symptoms in patients with VVI pacemakers, demonstrates the non-specificity of the “pacemaker syndrome” and shows no evidence of a sub-clinical “pacemaker syndrome” in the patients observed.
Septal ventricular pacing in the immature canine heart: A new perspective
1991, American Heart Journal
Cardiac pacing initiated from epicardial or transvenous apical right ventricular electrodes causes asynchronous ventricular contraction. This alters myocardial stress vectors and results in adverse cellular and subcellular changes in the experimental animal. Clinically, such changes may contribute to the adverse hemodynamics reported with long-term ventricular pacing. To determine the feasibility of direct stimulation of the ventricular specialized conduction systems and therefore the potential for maintenance of normalized depolarization patterns, 13 beagle puppies were studied. Baseline ventricular activation and contraction patterns were obtained using intracardiac electrograms and multigated nuclear acquisition (MUGA) imaging. Septal electrode insertion from the aortoatrial groove was accomplished by use of two-dimensional echocardiography and continuous electrocardiographic (ECG) monitoring of the surface ECG during pacemaker implantation in five puppies. Standard right ventricular epicardial electrodes were implanted in five additional animals, with three remaining as age-matched non-paced controls. After 4 months of observation, repeat MUGA imaging and intracardiac electrograms demonstrated nearly normal biventricular activation and contraction patterns among the septal-paced group. Histopathologic examination illustrated normal cellular morphology in the septal-paced animals. This study demonstrates that pacing electrode insertion into the proximal interventricular septum is feasible and results in utilization of the normal ventricular conduction pathway. Such an approach to initiation of ventricular stimulation may attenuate the adverse effects of long-term ventricular pacing.

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