Skip Navigation

Europace 2007 9(1):76-77; doi:10.1093/europace/eul141
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Schumann, J.
Right arrow Articles by Rickenbacher, P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Schumann, J.
Right arrow Articles by Rickenbacher, P.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

© The European Society of Cardiology 2007. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

PACING

Unusual VDD-pacing

Jörg Schumann1, Stephanie Kiencke1, Stefan Osswald2 and Peter Rickenbacher1,*

1 Cardiology Division, Internal Medicine University Department, Kantonsspital Bruderholz, H-4101 Bruderholz, Switzerland; 2 Cardiology Division, University Hospital Basel, Switzerland

Manuscript submitted 9 August 2006. Accepted after revision 2 October 2006.

* Corresponding author. Tel: +41 61 436 2220; fax: +41 61 436 3670. E-mail address: peter.rickenbacher{at}ksbh.ch


   Abstract
Top
 Abstract
Introduction
 Case report
 Discussion
 References
 
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.

Key Words: VDD pacing, P-wave sensing, Atrial undersensing


   Introduction
Top
 Abstract
 Introduction
Case report
 Discussion
 References
 
VDD-pacemakers are indicated for patients with AV-block if they have normal sinus node function and no need for atrial pacing.1Go Inappropriate atrial sensing due to the floating atrial lead remains a potential limitation of VDD pacing. We report the case of a patient with a VDD-pacemaker and atrial sensing due to an unusual mechanism.


   Case report
Top
 Abstract
 Introduction
 Case report
Discussion
 References
 
A 80-year-old woman with a history of type-2 diabetes and arterial hypertension underwent permanent pacemaker implantation for recurrent syncope in the presence of second-degree type-2 AV-block. An endocardial pacing lead (Vitatron VDD 65/15.5 cm) was placed in the right ventricular apex with the atrial dipole in the right atrium through the right subclavian vein and the pulse generator (Vitatron Saphir 3 VDD(R) Mod. 640; Vitatron BV, Arnhem, NL) was positioned subcutaneously in the right pectoral region (Figure 1). After implantation, the P-wave amplitude was 2.8 mV, the R-wave amplitude 18.8 mV, and the ventricular pacing threshold was 0.4 V at 0.5 ms. At 3 months and during late follow-up, low atrial sensing (0.1–0.3 mV) with AV-synchrony in the range of 58–73% according to the event counter was noted, whereas the ventricular measurements were stable. The P-wave amplitude was not susceptible to breathing manoeuvres or different body positions. Since the patient remained asymptomatic, atrial sensitivity was programmed to 0.1 mV, but no other action was taken.


Figure 1411
View larger version (67K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 1 (A) Posterior–anterior and (B) lateral chest radiograph after pacemaker implantation showing correct position of the VDD lead with the atrial dipole in the right atrium.

 
Four years after the pacemaker implantation, the patient was hospitalized for urinary tract infection and dehydration. The chest radiograph (Figure 2) showed displacement of the atrial dipole into the right ventricular outflow tract (RVOT). The atrial dipole position was confirmed by echocardiography. At that time, the P-wave amplitude was 0.2 mV and the ventricular pacing threshold was 1.05 V at 0.4 ms, whereas the R-wave amplitude could not be measured because of complete AV-block with no underlying ventricular escape rhythm. In Figure 3, the intracardiac marker channel of the pacemaker is depicted demonstrating correct atrial sensing and pacing in the VDD mode. Repositioning of the electrode was discussed, but was refused by the patient.


Figure 1412
View larger version (75K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 2 (A) Posterior–anterior and (B) lateral chest radiograph 4 years after pacemaker implantation showing displacement of the atrial dipole into the RVOT.

 


Figure 1413
View larger version (79K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 3 Pacemaker marker channel confirming VDD-mode pacing with atrial sensing from the RVOT. Note that the atrial marker channel shows late atrial sensing in relation to the surface P-wave, a finding which is typical for left atrial appendage sensing.

 

   Discussion
Top
 Abstract
 Introduction
 Case report
 Discussion
References
 
Long-term performance of VDD pacing systems has been addressed in a number of studies. Although intermittent loss of P-wave sensing occurs in a considerable percentage of Holter-monitored patients, high mean AV-synchrony rates > 90% have been reported in most of the studies.2Go–5Go Available evidence suggests that inappropriate atrial sensing is clinically silent in most patients,6Go,7Go but 1.7–3.8% of patients with VDD devices are reprogrammed to VVI(R) mode or undergo operative revision due to symptomatic atrial undersensing.8Go,9Go Atrial undersensing due to complete displacement of the atrial dipole, as in the present case, seems to be rare.5Go Lead displacement in the present case occurred due to inadequate fixation at the venous entry site. Left atrial sensing seems to be the most likely explanation for continued atrial sensing. This is supported by the bipole location towards the left atrium. Although effective long-term left atrial sensing and pacing has been achieved with leads placed in the coronary sinus,10Go to our knowledge, left atrial sensing via the RVOT, as in the present case, has not been described to date. Given the current attempts to pace the right ventricle from the RVOT,11Go this case might be of interest, since interference from left atrial signals might be detected by leads positioned in the RVOT.


   References
Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
[1] Gregoratos G, Abrams J, Epstein AE, et al. ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices. Circulation 2002; 106: 2145–61.

[2] Pitts CJC. European multicenter prospective follow-up study of 1002 implants of a single lead VDD pacing system. The European Multicenter Study Group. Pacing Clin Electrophysiol 1991; 14: 1742–4.[CrossRef][Medline]

[3] Antonioli GE, Ansani L, Barbieri D, et al. Italian multicenter study on single lead VDD pacing system using a narrow atrial bipole. Pacing Clin Electrophysiol 1992; 15: 1890–3.[CrossRef][Medline]

[4] Naegeli B, Osswald S, Pfisterer M, et al. VDD(R) pacing: short- and long-term stability of atrial sensing with a single lead system. Pacing Clin Electrophysiol 1996; 19: 455–64.[CrossRef][Medline]

[5] Ovsyshcher IE and Crystal E. VDD pacing: under evaluated, undervalued and underused. Pacing Clin Electrophysiol 2004; 27: 1335–8.[CrossRef][Medline]

[6] Van Campen CMC, de Cock CC, Huijgens J, Visser CA. Clinical relevance of loss of atrial sensing in patients with single lead VDD pacemakers. Pacing Clin Electrophysiol 2001; 24: 806–9.[CrossRef][Medline]

[7] Wiegand UKH, Nowak B, Reisp U, et al. Implantation strategy of the atrial dipole impacts atrial sensing performance of single lead VDD pacemakers. Pacing Clin Electrophysiol 2002; 25: 316–23.[CrossRef][Medline]

[8] Wiegand UKH, Bode F, Schneider R, et al. Atrial sensing and AV synchrony in single lead VDD pacemakers: a prospective comparison to DDD devices with bipolar atrial leads. J Cardiovasc Electrophysiol 1999; 10: 513–20.[Web of Science][Medline]

[9] Ovsyshcher IE, Katz A, Rosenheck S, et al. Single lead VDD pacing: multicenter study. Pacing Clin Electrophysiol 1996; 19: 1768–71.[CrossRef][Medline]

[10] Mirza I, Holt P, James S. Permanent left atrial pacing: a 2-year follow-up of coronary sinus leads. Pacing Clin Electrophysiol 2004; 27: 314–7.[CrossRef][Medline]

[11] De Cock CC, Giudici MC, Twisk JW. Comparison of the haemodynamic effects of right ventricular outflow-tract pacing with right ventricular apex pacing. A quantitative review. Europace 2003; 5: 275–8.[Abstract/Free Full Text]


Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?



This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Schumann, J.
Right arrow Articles by Rickenbacher, P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Schumann, J.
Right arrow Articles by Rickenbacher, P.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?