Overdrive Ventricular Pacing in Pacemaker Recipients with Permanent Atrial Fibrillation and Sleep Apnea

Abstract

Study Objectives: Cardiac pacing is ineffective in obstructive sleep apnea (SA), but it can alleviate central SA/CheyneStokes respiration (CSA) in patients with heart failure (HF). We examined whether overnight overdrive ventricular pacing (OVP) has an effect on SA in pacemaker recipients with permanent atrial fi brillation (AF). Methods: An apnea-hypopnea index (AHI) ≥ 15 was confi rmed in 28/38 patients screened by fi nger pulse oximetry during overnight ventricular pacing at a backup rate of 40 bpm (BUV40). These patients (23 men, 77.9 ± 7.6 y, BMI 27.6 ± 5.1 kg/m 2 ) were randomly assigned to 2 consecutive nocturnal ventilation polygraphies with BUV40 versus OVP at 20 bpm above the mean nocturnal heart rate observed during screening. Results: During BUV40 versus OVP, (1) mean heart rate was 49 ± 8 versus 71 ± 8 bpm (p < 0.0001) and percent ventricular pacing 36% ± 38% versus 96% ± 6% (p < 0.0001); (2) AHI was 35.4 ± 11.9 versus 32.5 ± 15.5 (p = ns), central AHI 23.9 ± 11.8 versus 19.1 ± 12.7 (p < 0.001), and obstructive AHI 11.6 ± 13.1 versus 13.5 ± 15.9 (p = ns). In 15/28 patients without HF, mean left ventricular ejection fraction (LVEF) was 51% ± 17%, AHI was 37.6 ± 11.0 during BUV40 and 39.0 ± 11.5 during OVP, versus 32.8 ± 12.9 and 24.9 ± 16.5 in 13/28 patients with HF (p = 0.02) and mean LVEF 35% ± 15% (p = 0.01). Between the 2 subgroups, (1) central AHI was 23.6 ± 12.4 during BUV40 and 21.5 ± 14.0 during OVP versus 24.1 ± 11.6 and 16.2 ± 10.7 (p = 0.05); (2) obstructive AHI was 14.0 ± 13.7 during BUV40 and 17.6 ± 16.5 during OVP versus 8.8 ± 12.3 and 8.7 ± 14.3 (p = ns). Conclusions:The prevalence of SA, predominantly central, was high in our pacemaker recipients with permanent AF. In those with HF, a single overnight OVP resulted in modest improvement in central events. keywords: Heart failure, sleep apnea, atrial fi brillation, cardiac pacing Citation: Bordier P; Maurice-Tison S; Ramana NK. Overdrive ventricular pacing in pacemaker recipients with permanent atrial fi brillation and sleep apnea. S C I E N T I F I C I N V E S T I g A T I O N SA fter a fi rst report suggesting that cardiac pacing might alleviate sleep apnea (SA), subsequent studies have yielded confl icting results.1,2 An increase in pacing rate by overdrive atrial pacing, using a dual chamber pacemaker implanted for the treatment of bradycardia, has no effect on obstructive SA (OSA) in patients without history of heart failure (HF). In contrast, cardiac resynchronization therapy (CRT) does alleviate central SA/Cheyne-Stokes respiration (CSA), a breathing disorder present in > 30% of patients with stable HF and associated with a decreased survival rate. 3-14The aim of this study was to compare the effects of overnight overdrive ventricular pacing (OVP) versus overnight ventricular pacing at a low backup rate on SA in recipients of permanent pacemakers suffering from permanent atrial fi brillation (AF). The comparison was also made in separating the patients depending on whether they suffered from HF or not. Those patients were chosen ...

Atrial arrhythmogenesis in obstructive sleep apnea: Therapeutic implications

“…One study has reported a high proportion of CSA (79%) in a group of pacemaker recipients with permanent AF [86]; this was probably a result of a high rate of heart failure and depressed left ventricular ejection function in this study population. Another study in AF patients with normal left ventricular function showed prevalence rates of 31% for CSA and 43% for OSA [87]. Future studies are needed to clarify mechanisms responsible for AF in CSA and whether adaptive servo ventilation is helpful to prevent AF and to improve symptoms and decrease mortality in heart failure AF-patients.…”

Arrhythmia Risk Associated with Sleep Disordered Breathing in Chronic Heart Failure

“…Although initial proof of concept work appeared to demonstrate improvement in central and obstructive apnea with an overdrive pacing intervention 86 , subsequent studies have failed to show consistent findings 46 . Recent data, however, suggest that in those with moderate to severe SDB, overdrive pacing at a rate 20 bpm above the mean nocturnal heart rate resulted in a statistically significant reduction in central apnea burden, however, it is unclear whether this burden reduction translates into clinical significance (central apnea hypopnea index of 23.9 ± 11.8 versus 19.1 ± 12.7) 87 . Unlike the disappointing results of overdrive pacing, cardiac resynchronization therapy (biventricular pacing) appears to be an effective strategy in improving SDB in HF likely because it improves left ventricular EF, increases cardiac output, reduces pulmonary venous pressure and therefore reduces the tendency towards hyperventilation and hypocapnia.…”

Principles of practice parameters for the treatment of sleep disordered breathing in the elderly and frail elderly: the consensus of the International Geriatric Sleep Medicine Task Force

“…A recent randomised cross-over trial showed in 28 patients with a mean age of 77.9 years that an overpacing of 20 beats per min over the sensored mean heart rate resulted in a significant reduction of central events [87] (table 5). The only age-stratified study compared CRT and atrial overpacing (AOP) in 15 subjects (mean age 74 years), and found that AOP resulted in a higher reduction of all apnoea events, but not hypopneas, compared to a lower fixed heart rate (mean apnoea index 18 with AOP versus 24 with fixed lower rate coming from a mean baseline of 35 events per h).…”