Comparative Evaluation of Acute and Long‐Term Clinical Performance of Two Single Lead Atrial Synchronous Ventricular (VDD) Pacemakers: Diagonally Arranged Bipolar Versus Closely Spaced Bipolar Ring Electrodes

Abstract

Floating P wave sensing can be derived from bipolar atrial electrodes with different electrode configurations, although the relative clinical efficacy of these methods of atrial sensing has not been studied. We evaluated 32 sex and age matched patients with advanced AV block who received AV synchronous pacers using either a single lead with diagonally arranged bipole (Unity VDDR, Model 292, Intermedics Inc.) or closely spaced bipolar complete ring electrodes (Thera VDD, Model 8948, Medtronic Inc.). The total surface area of the atrial electrodes were 17.2 and 25 mm2, and the highest programmable atrial sensitivities were 0.1 and 0.25 mV, respectively. Atrial electrogram amplitude and sensing threshold were evaluated at implant and at each follow-up clinic visit (1, 3, and 6 months). Stability of atrial sensing was assessed during physical maneuvers, treadmill exercise test, and Holter recording. Atrial electrogram amplitude at implantation was higher in the Thera VVD (2.08 +/- 0.79 vs 1.45 +/- 0.59 mV in Unity VDDR; P < 0.05), but the value of atrial sensing threshold was lower during follow-up than Unity VDDR. P wave undersensing was additionally observed with both pacemakers during physical maneuvers and exercise testing (6%-19% of patients). Two and four patients had atrial undersensing on Holter in the Unity VDDR and Thera VDD, respectively, and the percentage P wave undersensing were 0.88% +/- 2.41% versus 3.63% +/- 8.16%, respectively. Reprogramming of the atrial sensitivity in the Unity VDDR and the use of investigational software allowing 0.18 mV atrial sensitivity to be programmed in the Thera VDD substantially reduced the percentage of P wave undersensing on Holter to 0.46% +/- 1.67% and 0.10% +/- 0.24%, respectively. Beginning at discharge with a programmed atrial sensitivity level at least twice the sensing margin, the mean atrial sensitivity level was reprogrammed from 0.29 to 0.26 mV for Unity VDDR and 0.33 to 0.24 mV for Thera VDD at 6 months. There was no incidence of atrial oversensing. Despite differences in atrial amplitudes at implantation between the diagonally arranged bipole and closely spaced full ring single lead systems, the clinical performances of atrial sensing were similar at an appropriately high atrial sensitivities. The absence of atrial oversensing suggests that single pass VDD pacemakers should probably be programmed at the highest available atrial sensitivity to ensure adequate P wave sensing as guided by physical maneuvers and Holter recording to minimize the need of subsequent reprogramming.

The Impact of the Distance between the Atrial Electrode and the Atrial Wall on Atrial Undersensing in Patients with VDD Pacemakers: Long‐Term Follow‐Up

“…5,[7][8][9] Overall incidence of AUS was 22%. In spite of some methodological differences and vigorousness in the assessment of AUS, our results are comparable to previous reports.…”

“…8,12 In a study in which all the atrial sensitivities were programmed to the most sensitive levels, Hunziker et al reported that maximum programmable atrial sensitivity was a predictor of loss of AV synchrony. This was not surprising as it has been well known that the higher the programmed atrial sensitivity, the higher the atrial sensing capability.…”

Different Automatic Mode Switching in DDDR Pacemakers

“…Further studies will be required to compare the incidence of VDD versus DDD pacing in suppressing AF. (30) …”

“…Although reprogramming to a non-tracking mode (such as DVI, DDI or DDIR) prevents this clinical event, these modes do not provide appropriate AV synchrony if the sinus rate exceeds the programmed lower rate. (26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37) Limitation of the upper tracking rate only partly addresses this problem and may compromise exercise capacity or lead to symptoms from pacemaker Wenckebach behaviour at relatively slow rates. In response to this clinical dilemma, a variety of mode-switching algorithms has been devised that are meant to prevent tracking of pathological atrial tachy-arrhythmias while allowing ventricular pacing that is synchronous with the atrial electrocardiogram during sinus rhythm [17][18][19].…”

Atherosclerosis and myocardial infarction

“…[4][5][6] Today, multiple VDD pacing systems are on the market and their clinical performance is such that usually more than 98% of all beats are correctly sensed in the atrium and used for triggered ventricular pacing in patients with AV block. [7][8][9][10] Although the sensed atrial signals from floating electrodes are always smaller and more variable than signals from leads with fixed atrial wall contact, the mean P wave amplitudes remain very stable over time. In combination with dedicated VDD pulse generators that oVer a higher atrial sensitivity than conventional DDD pacemakers, the atrial sensing safety margins typically are 4-6 times higher than the corresponding atrial sensing threshold.…”