Effect of Varying Atrial Sensitivity, AV Interval, and Detection Algorithm on Automatic Mode Switching

Automatic mode switching (AMS) is absolutely dependent on atrial tachyarrhythmia detection. The effects of programming several features that could influence tachyarrhythmia detection were assessed in 18 patients (six women; mean age 64 years) with pacemakers having AMS capability. The atrial electrogram amplitude in sinus rhythm at implant (SR-EGM), last measured atrial sensing threshold prior to tachycardia (A-SENS), and atrial sensing threshold for effective AMS during atrial tachyarrhythmia (AMS-SENS) were obtained. Additionally, ten patients had AV intervals increased from 60 to 200 ms, while seven patients had detection algorithms made more stringent from 5 beats at 150 beats/min to 11 beats at 200 beats/min to assess their effects on AMS efficacy. Results: Sensitivities: Mean SR-EGM = 3.55 mV; mean A-SENS = 2.06 mV; and mean AMS-SENS = 1.46 mV. Fourteen patients developed atrial fibrillation and four atrial flutter. Thirteen of 14 patients who developed atrial fibrillation sensed adequately at ≥ 1.0 mV in normal sinus rhythm (NSR), but only six patients had effective AMS at these settings in atrial fibrillation. Three of four patients who developed atrial flutter had effective AMS at ≥ 2.0 mV. AV Interval: AMS was effective in eight of ten patients at AV intervals up to 200 ms. One patient lost AMS at an AV interval of 120 ms. Algorithm: In two of seven patients, AMS was not effective if the detection algorithm was more stringent than five beats at 150 beats/min. Conclusions: (1) In atrial fibrillation, effective AMS requires more sensitive atrial settings than in NSR: (2) AV intervals as short as 120 ms can interfere with AMS function; and (3) More stringent detection algorithms may be inappropriate for effective AMS function.     

Initial Experience with a New Algorithm for Automatic Mode Switching from DDDR to DDIR Mode

Implantation of dual chamber devices in patients with paroxysmal atrial tachyarrhythmias who require permanent pacemakers may lead to significant complications due to an inappropriately triggered ventricular response. VVI/VVIR units cause loss of AV synchrony in the presence of sinus activity. A new DDDR device (THERA DR, model 7940), with an automatic mode switching (AMS) algorithm, was evaluated. When the mean atrial rate is > 182 beats/min, atrial tachyarrhythmia is detected, and AMS is activated. Twenty-three patients (12 males, mean age 71 ± 7 years) underwent implantation of a THERA DDDR device with the AMS algorithm. Seventeen patients had AV block and/ or sick sinus syndrome (SSS) and atrial arrhythmias, and 6 patients (2 with hypertrophic obstructive cardiomyopathy) had SSS and paroxysmal atrial fibrillation (PAF). The follow-up period was from 1–9 months. During follow-up, Holter monitoring and treadmill tests were performed. Results : Eighty-seven episodes of AMS were recorded. Telemetered AMS recordings demonstrated episodes in which the DDDR mode switched to the DDIR mode in the presence of PAF, and reverted to DDDR when sinus rhythm returned. Paroxysmal supraventricuiar arrhythmias with a heart rate < 182 beats/min did not activate tbe mode switch. Conclusions : This early, short-term clinical experience with a DDDR device capable of AMS from DDDR to DDIR demonstrated appropriate clinical function and response to PAF. These preliminary results suggest that DDDR pacemakers with AMS to DDIR may significantly extend the current indications for dual chamber pacing.     

Specificity of Atrial Mode Switching in Detecting Atrial Fibrillation Episodes:

The number of automatic mode switch (AMS) has been used to measure the efficacy of atrial pacing in limiting atrial fibrillation (AF). We investigated the impact of length and contiguity on the specificity of AMS in detecting AF episodes in 24 recipients of dual chamber pacemakers with sick sinus syndrome and paroxysmal AF. An AMS algorithm and intracardiac electrogram recordings (IEGM) were activated in all patients to distinguish true arrhythmic events from unnecessary AMS. The length of AMS and the contiguity, that is, the probability of occurrence of another AMS within 5 minutes before or after AMS were examined to increase the specificity of the AMS. During a mean follow-up of 5 ± 3 months, 250 AMS were collected. The IEGM analysis confirmed a true AF episode in 193 of 250 AMS (77.2%). Using the contiguity criterion, 47 of 57 (82.5%) inappropriate AMS episodes were isolated (there were no other AMS within 5 minutes), whereas 54 of 193 (27.9%) appropriate AMS episode were isolated. Adopting both length and contiguity criteria the specificity of AMS in detecting true AF episodes increased from 77.2% to 93.2% at the cost of 11.9% loss of original sensitivity. Combining the length and contiguity criteria, we were able to improve the specificity of the AMS in the detection of AF.     

The "Automatic Mode Switch" Function in Successive Generations of Minute Ventilation Sensing Dual Chamber Rate Responsive Pacemakers

Automatic mode switch (AMS) from DDDR to VVIR pacing is a new algorithm, in response to paroxysmal atrial tachyarrhythmias. With the 5603 Programmer, the AMS in the Meta DDDR 1250 and 1250H (Telectronics Pacings Systems, Inc.) operates when VA is shorter than the adaptable PVARP. With the 9600 Programmer, an atrial protection interval can be defined after the PVARP. The latest generation, Meta DDDR 1254, initiates AMS when 5 or 11 heart cycles are > 150, 175, or 200 beats/min. From 1990 to 1993, 61 patients, mean age 61 years, received a Meta DDDR: in 24 a 1250, in 12 a 1250H and in the remaining 25 a 1254 model. Indication for pacing was heart block in 39, sick sinus syndrome in 15, the combination in 6, and hypertrophic obstructive cardiomyopathy in 1. Paroxysmal atrial tachyarrhythmias were present in 43. All patients had routine pacemaker surveillance, including 52 Holter recordings. In 32 patients, periods of atrial tachyarrhythmias were observed, with proper AMS to VVIR, except during short periods of 2:1 block for atrial flutter in 4. In two others, undersensing of the atrial arrhythmia disturbed correct AMS. With the 1250 and 1250H model, AMS was observed on several occasions during sinus rate accelerations in ten patients. This was never seen with the 1254 devices. Final programmation was VVIR in 2 (chronic atrial fibrillation), AAI in 1 (fracture of the ventricular lead), VDDR in 1 (atrial pacing during atrial fibrillation), DDD in 5, and DDDR in 53, 48 of whom had AMS programmed on. The AMS detection algorithm in the successive models of the Meta DDDR appears to have become more specfic.     

Diagnosis of Atrial Undersensing in Dual Chamber Pacemakers: Impact of Autodiagnostic Features

Atrial undersensing occurs in a considerable number of patients, both with single lead VDD pacemakers and with DDD devices. The aim of this study was to investigate the diagnostic efficacy of electrocardiographic methods and autodiagnostic pacemaker features to detect atrial sensing dysfunction. Two hundred and thirty-one patients with AV block received single lead VDD pacemakers or DDD devices. Atrial sensitivity was programmed to 0.1 or 0.18 in VDD devices and to 0.5 mV in DDD devices; the rate limits were set to 40 and 160 beats/min. Twelve-lead ECG recording for 1 minute during deep respiration and change of body position, 24-hour Holter ECG recording, and treadmill exercise were performed 2 weeks and 15 months after pacemaker implantation. AV synchrony and, if available, P wave amplitude histogram were sampled by autodiagnostic pacemaker features and compared to electrocardiographic findings. Atrial undersensing was assumed, if AV synchrony was below 100% or if minimal P wave amplitude (PWA) was equal to the programmed atrial sensitivity. Intermittent atrial undersensing occurred in 20.7% of patients. The diagnostic sensitivities of the various methods used to detect atrial sensing failures were: 24-hour Holter monitoring 97.5%, P wave amplitude histogram 90.0%, stored AV synchrony 68.0% without significant difference between the various devices, treadmill exercise testing 58.8%, and 12-lead ECG recording 21.3%. In one patient, atrial undersensing was exclusively detected by exercise testing. In conclusion, autodiagnostic pacemaker features facilitate the evaluation of atrial sensing performance. However, to exclude intermittent atrial malsensing, routine Holter monitoring and treadmill exercise are still needed .     

Is the Atrial High Rate Episode Diagnostic Feature Reliahle in Detecting Paroxysmal Episodes of Atrial Tachyarrhythmias?

The atrial high rate episode diagnostic in The Thera® pacemaker reports frequency, duration, and date/time of atrial tachyarrbytbmias according to programmed criteria. The aim of The study was to validate The atrial high rate episode diagnostic feature. Episodes of atrial fibrillation recorded by Holter monitoring were compared to episodes detected by the pacemaker. Eorty five ambulatory (Holter) recordings were used for evaluation. Thirty of 45 ambulatory (Holter) recordings showed sinus rhythm. On 4 of these 30 ambulatory (Holter) recordings, The Thera® detected 12 episodes of atrial tachyarrbythmias as false-positives (sinus rhythm was detected as atrial tacbyarrbytbmia). The main reason was far-field R and T wave oversensing. On 15 of 45 ambulatory (Holter) recordings, 125 episodes of atrial tachyarrhytbmias were recorded. Ninety-three of these events also were detected by the pacemaker, while for 32 events the Thera® reported sinus rhythm. The main reason was that the episodes were of too short duration. Therefore, the Thera® (programmed with detection rate 160 beats/min, detection beats 40, termination beats 10) was unable to detect atrial tachycardias. Software simulation of The diagnostic algorithm under several programming settings using the digitized Holter files demonstrated highly reliable detection of atrial tachyarrhythmias (sensitivity 98%, specificity 100%) when programmed as follows: detection rate 220 beats/min, detection beats 10, termination beats 20. It can be concluded that Thera®'s high rate episode monitor is a reliable tool for detection of a trial tachyarrhythmias, if programmed as recommended.     

Is Atrial Sensing of Ventricular Far-Field Signals Important in Single-Lead VDD Pacing?

In single-lead VDD pacing the atrial sensitivity frequently is programmed to sensitive values. Atrial sensing of ventricular far-field signals should be reduced by differential atrial sensing. The aim of the study was to evaluate the effectiveness of this approach. Methods: The study included 10 patients with a single-lead VDD pacemaker (Thera 8948, Lead 5032). The atrial sensitivity was set to its most sensitive value of 0.18 mV and the telemetered intraatrial EGM was continuously recorded. After atrial tracked ventricular pacing, VVI pacing was performed with pacing rates from 100 to 160 beats/min in steps of 10 beats/min and up to 165 beats/min. The peak-to-peak amplitudes of P waves (P) and ventricular far-field signals (VFFS) were measured from the recordings. The ratio P/VFFS that defines the atrial signal-to-noise ratio was calculated, and the time from stimulus to maximum of the far-field signals amplitude (Tmax) was measured. Results: P measured 0.98 ± 0.76 mV. A VFFS was visible in the atrial channel in all patients with an amplitude of 0.45 ± 0.25 mV (range 0.01–1.0 mV), independent of the pacing rate. The ratio P/VFFS was 3.9 ± 4.2 (range 0.9–21.0). Tmax measured 99.4 ± 15.2 ms during sinus rhythm. A rate dependent shortening of Tmax to 92.7 ± 11.2 ms at 140 beats/min was observed (P = 0.001). At rates above 140 beats/min no further shortening occurred. Conclusion: Ventricular far-field signals are measurable in the atrial channel of VDD systems and may reach considerable amplitudes, which are not rate dependent. Although differential sensing provides favorable P waves to ventricular far-field signal ratios, refractory periods are needed to avoid far-field sensing. The rate dependent shortening of the ventricular signal can be detected in the atrial channel in VDD pacing.     

Sinus and paced P wave duration and dispersion as predictors of atrial fibrillation after pacemaker implantation in patients with isolated sick sinus syndrome

The aim of this study was to prospectively evaluate the sinus and the paced P wave duration and dispersion as predictors of AF after pacemaker implantation in patients with isolated sick sinus syndrome (SSS). The study included 109 (69 women, mean age 72 +/- 11 years) patients with SSS, 59 with bradycardia-tachycardia syndrome (BTS). A 12-lead ECG was recorded before pacemaker implantation and during high right atrial and septal right atrial pacing at 70 and 100 beats/min. The ECGs were scanned into a computer and analyzed on screen. The patients were treated with AAIR (n = 52) or DDDR pacing. The P wave duration was measured in each lead and mean P wave duration and P wave dispersion were calculated for each ECG. AF during follow-up was defined as: AF in an ECG at or between follow-up visits; an atrial high rate episode with a rate of > or =220 beats/min for > or =5 minutes, atrial sensing with a rate of > or =170 beats/min in > or =5% of total counted beats, mode-switching in >/=5% of total time recorded, or a mode switching episode of > or =5 minutes recorded by the pacemaker telemetry. The ECG parameters were correlated to AF during follow-up. Mean follow-up was 1.5 +/- 0.9 years. None of the ECG parameters differed between patients with AF and patients without AF during follow-up, nor was there any difference between groups after correction for BTS and age. BTS was the strongest predictor of AF during follow-up (P < 0.001). P wave duration and dispersion measured before and during pacemaker implantation were not predictive of AF after pacemaker implantation in patients with isolated SSS.     

Improved Efficacy of Mode Switching During Atrial Fibrillation Using Automatic Atrial Sensitivity Adjustment

Automatic mode switching (AMS) during atrial fibrillation (AF) in a dual chamber pacemaker is dependent on the accurate detection of an atrial electrogram. As atrial amplitude is often reduced during AF compared with sinus rhythm, this may result in failure of the AMS and a rapid ventricular response. In addition, undersensing of AF may result in competitive atrial pacing that sustains AF. We hypothesize that the use of automatic atrial sensitivity adjustment (ASA) may enhance AF sensing in a dual chamber pacemaker. We studied the AMS response with and without ASA of the Marathon DDDR (model 294–09, Intermedics, Inc.) pacemaker in 10 patients with paroxysmal AF. Intracardiac atrial electrograms during sinus rhythm and induced AF were recorded onto an analog tape recorder. They were replayed into the pacemaker to assess the AMS response at various starting atrial sensitivities from 3.5 to 0.8 mV with ASA activated and without. Atrial amplitude was reduced during AF. The higher the initial atrial sensitivity, the better is the AMS response and the lower the incidence of AF undersensing. The percentage of AMS before ASA ranged from 2.1% at an atrial sensitivity 3.5 mV to 95.6% at highest sensitivity of 0.5 mV (P < 0.05). After 10 minutes of ASA, the AMS response was improved from 1.7% to 50.6% and from 9.5% to 50.9% at starting atrial sensitivities of 3.5 mV and 2.5 mV, respectively (P < 0.05 in both instances). Undersensing during AF was also significantly reduced after ASA from 70% to 10% at a sensitivity of 3.5 mV and from 33.8% to 10.8% at 2.5 mV. There was no increase in oversensing. In four patients with paroxysmal AF with an implanted pacemaker, ASA improved AMS response in patients with a low implant atrial amplitude. In conclusion, efficacy of mode switching and AF sensing are dependent on the programmed atrial sensitivity, which can be enhanced with the use of ASA, particularly when P wave sensing during AF is borderline.     

Reliability of an Automatic Sensing Algorithm

Automatic adaptation of the atrial sensitivity was evaluated in 18 patients with dual chamber pacemakers (Intermedics, Inc., Relay) in the unipolar mode. After atrial sensitivity was stabilized in the upright position, patients underwent a 1.0 W/kg body weight exercise for 5 minutes. A 24-hour Holter EGG was recorded, and the maximum and minimum atrial sensitivity values reached were stored in the memory of the pulse generator. In a second series of 12 patients, Holter ECGs were recorded twice, starting with the same sensitivity but with automatic adaptation alternately switched "on" or "off." Results of the exercise test: mean atrial sensitivity declined from 2.30 ± 0.77 mV to 2.03 ± 0.68 mV. There was no change in five patients, a slight increase in two patients, and lowering of the atrial sensitivity was observed in 11 patients, the difference ranging from 0.2 to 1.0 mV. A total of two P waves in two patients were missed by the atrial amplifier. The minimum and maximum sensitivity reached during Holter monitoring averaged 2.31 ± 0.67 mV versus 1.72 ± 0.71 mV (difference 0-1.7 mV). Normal pacemaker function was found in six patients, including one patient without any intrinsic atrial activity. Malsensing of less than five P waves occurred in four patients. More than 50 sensing defects resulted from ectopic atrial beats (four patients). We observed atrial oversensing in three cases; one patient showed atrial over- and undersensing. The comparison between fixed and variable sensitivity did not reveal any superiority of automatic adaptation. Conclusion: earlier findings of atrial signal variation during daily life are confirmed. Although quite reliable during exercise studies, automatic adaptation of atrial sensitivity is not able to compensate for sudden changes in atrial electrogram or to sufficiently suppress extracardiac noise.     

Comparison of Bipolar Atrial Electrogram Amplitude in Sinus Rhythm, Atrial Fibrillation, and Atrial Flutter

Automatic mode switching pacemakers revert to non-atrial tracking modes in response to sensed atrial tachyarrhythmias. It is unclear how atrial electrogram amplitudes in sinus rhythm compare to those during atrial tachyarrhythmias. In this study, peak-to-peak bipolar atrial electrogram amplitudes were measured during sinus rhythm and either atrial fibrillation or atrial flutter in 69 patients. The mean atrial electrogram amplitudes were 1,59 ± 1.36 m V during sinus rhythm and 0.77 ± 0,58 mV during atrial fibrillation (P < 0.0001) for 25 patients with atrial fibrillation and 1.81 ± 2.07 mV during sinus and 1.5 ± 1.81 mV(P < 0.0001) for 44 patients with atrial flutter. The mean electrogram amplitudes during both atrial fibrillation and flutter correlated significantly with amplitudes during sinus rhythm (R = 0.79, R = 0.94. respectively, both P < 0,0001). The coefficient of variance of individual electrogram amplitudes was greater in atrial fibrillation than sinus (P < 0.0001). By comparing 20th percentile electrogram amplitudes in atrial fibrillation and flutter to mean sinus amplitudes, intermittent very low electrogram amplitudes (< 0.3 mV) were more likely during atrial fibrillation and flutter if the mean sinus electrogram amplitudes were < 1.5 mV and < 0.5 mV, respectively (P < 0.01). Eightieth percentile electrogram amplitude values in atrial fibrillation and flutter were equally likely to exceed mean sinus amplitude values in respective patients, in conclusion, mean atrial electrogram amplitudes during atrial fibrillation and flutter are less than but correlated to sinus rhythm electrogram amplitudes. Very low amplitude individual electrograms during these atrial arrhythmias are associated with low mean sinus rhythm electrogram amplitudes. These findings may have implications for the programming of permanent dual chamber pacemakers in patients with paroxysmal atrial fibrillation and flutter.     

Incidence of atrial tachyarrhythmias in pacemaker patients: results from the Balanced Evaluation of Atrial Tachyarrhythmias in Stimulated patients (BEATS) study

OBJECTIVES: The prospective Balanced Evaluation of Atrial Tachyarrhythmias in Stimulated patients (BEATS) study compared atrial tachyarrhythmia (AT) detection by means of serial ECG recordings versus device detection. BACKGROUND: The annual incidence of AT in patients with dual-chamber pacemakers may be significantly underestimated based on ECG and Holter recordings. METHODS: A DDD(R) device capable of AT-triggered dual-channel electrogram (EGM) storage was implanted in 254 patients (70 +/- 11 years, 159 men) with a class I pacing indication. Patients were seen at 6, 26, and 52 weeks after pacemaker implantation. At all visits, symptoms were checked, surface ECGs were recorded including a 24-hour Holter recording at 6 weeks, and the pacemakers were interrogated. Primary study endpoint was AT documentation by surface ECG/Holter versus stored EGMs. Secondary endpoints consisted of the association between patients' symptoms and AT documentation, and of the AT incidence depending on pacing indication and a history of AT. RESULTS: ATs were documented by ECG/Holter recordings in 37 patients (15%) and by stored EGMs in 137 patients (54%) (P < 0.0001). Symptoms were absent in 108 of 137 patients (79%) with device-documented AT but present in 70 of 117 patients (60%) without AT documentation. AT documentation was more frequent in patients with a history of AT but not in patients with sinus node compared to AV node disease. CONCLUSION: ATs occur in pacemaker patients significantly more frequently than estimated by ECG/Holter recordings. Only the analysis of device-stored EGMs allows reliable assessment of the AT burden.     

Continuous Holter telemetry of atrial electrograms and marker annotations using a common Holter recording system: impact on Holter electrocardiogram interpretation in patients with dual chamber pacemakers

The impact of continuous telemetry of atrial electrogram and marker annotations on Holter ECG interpretation was assessed in 98 patients with bipolar dual chamber pacemakers (VDD pacemakers n = 29, DDD(R) systems n = 69). Atrial electrogram and marker annotations were continuously sampled by a telemetry coil that was externally positioned on the pacemaker pocket, amplified, and transduced to a three-channel Holter ECG recorder in addition to an ECG recording. Holter tapes were analyzed by two experienced investigators for quality of P wave recognition and episodes suspicious of pacemaker dysfunction. Initially, only the ECG channel was analyzed. Thereafter, results were compared to those achieved on the basis of the complete recording including atrial electrogram and marker annotations. Recognition of atrial rhythm was markedly improved by Holter telemetry. During 99.3% of recording time telemetry showed a satisfying quality, whereas ECG alone allowed a reliable P wave recognition only during 84.4% of recording time (P < 0.001). One hundred twenty-nine episodes suspicious of pacemaker malfunction occurred in 17 of 98 patients. By analysis of ECG, only 78.3% of episodes were concordantly classified by the investigators. However, 98.4% of all episodes were properly identified when atrial electrogram and marker annotations were added to the analysis (P < 0.001). In particular, discrimination between atrial undersensing, sinus bradycardia, and atrial sensed events within the refractory periods was facilitated. Holter telemetry of atrial electrogram and marker annotations facilitates the analysis of Holter ECGs in pacemaker recipients and improves the detection of pacemaker dysfunctions.     

Efficacy and Safety of Bipolar Sensing with High Atrial Sensitivity in Dual Chamber Pacemakers

In dual chamber pacemakers, atrial sensing performance is decisive for maintenance of AV synchrony. Particularly, the efficacy of mode switching algorithms during intermittent atrial tachyarrhythmias depends on the sensitive detection of low potential amplitudes. Therefore, a high atrial sensitivity of 0.18 mV, commonly used in single lead VDD pacemakers, was investigated for its efficacy and safety in DDD pacing. Thirty patients received dual chamber pacemakers and bipolar atrial screw‐in leads for sinus node syndrome or AV block; 15 patients suffered from intermittent atrial fibrillation. Pace makers were programmed to an atrial sensitivity of 0.18 mV. Two weeks, 3, 9, and 15 months after implantation, P wave sensing threshold and T wave oversensing thresholds for the native and paced T wave were determined. The myopotential oversensing thresholds were evaluated by isometric contraction of the pectoral muscles. Automatic mode switch to DDIR pacing was activated when the mean atrial rate exceeded 180 beats/min. The patients were followed by 24‐hour Holter monitoring. Two weeks after implantation, mean atrial sensing threshold was 1.81 ± 0.85 mV (range 0.25–2.8 mV) without significant differences during further follow‐up. Native T wave sensing threshold was < 0.18 mV in all patients. In 13% of patients, paced T waves were perceived in the atrial channel at the highest sensitivity. This T wave sensing could easily be avoided by programming a postventricular atrial refractory period exceeding 300 ms. Myopotential oversensing could not be provoked and Holter records showed no signs of sensing dysfunction. During a 15‐month follow‐up, 1,191 mode switch events were counted by autodiagnostic pacemaker function. Forty‐two of these events occurred during Holter monitoring. Unjustified mode switch was not observed. In DDD pacemakers, bipolar atrial sensing with a very high sensitivity is efficient and safe. Using these sensitivity settings, activation of the mode switch algorithm almost completely avoids fast transmission of atrial rate to the ventricle during atrial fibrillation.     

P Wave Recognition and Atrial Stimulation with Fractally Iridium Coated VDD Single Pass Leads

The bottleneck of VDD systems is the reliable detection of the small atrial signals by a floating atrial electrode. Fractally iridium coated electrodes offer excellent sensing and pacing performance. In this study, the performance of such a floating atrial lead in P wave sensing and synchronous ventricular stimulation was examined. Atrial pacing was also used as a test of atrial wall contact. Patients and Methods : A fractally iridium coated VDDlead was implanted in 18 patients. In 15 patients it was interfaced with a VDD pacemaker and in 3 patients with a DDD system depending on the P wave amplitude measured acutely (≥ 2 mV). Simultaneous recordings of the surface ECG and pacemaker telemetry were used to analyze P wave amplitudes and AV synchrony in different body positions, and during normal and deep breathing. Additionally, exercise tests based on daily life activities and 24-hour ECG monitoring were performed to test the pacemaker function. Results : During implantation P wave amplitudes were 1.86 mV ± 1.08 mV (range 0.5–4.9 mV) and during follow-up (6.6 ± 5.6 weeks) 0.18–3.8 mV. Holter recordings revealed reliable P wave sensing at a sensitivity setting of 0.5 mV (95.5%). P wave sensing was further improved by a higher atrial sensitivity. AV synchronous pacing ± 99.9% was achieved in all patients. In 7 patients the atrial electrode could be positioned close to the atrial wall enabling atrial stimulation thresholds at an average of 4.3 volts. Conclusion : This fractally iridium coated VVD lead allowed consistent and reliable P wave sensing at an atrial sensitivity as low as 0.5 mV in selected patients.     

Age and Gender Influences on Rate and Duration of Paroxysmal Atrial Fibrillation

The influence of age and gender on the character of paroxysmal atrial fibrillation (PAF) has not been described. Methods: The heart rate (HR) during PAF in patients receiving placebo or antiarrhythmic therapy was analyzed. Data from 177 24-hour Holter recordings were analyzed to mark the onset and termination of PAF and converted into RR interval files. PAF episodes lasting at least 2 minutes and containing ± 20% noise were included. HR during the first 30-second segment versus during the remainder of the episode, and the duration of PAF episodes were compared among groups of different ages and sex (Wilcoxon test). Results: 236 episodes from 55 recordings in 32 patients (all patients: 61.4 ± 12.8 years; men (19): 58.5 ± 12.6 years; women (13) 65.5 ± 12.4 years, P = ns for difference in age) fulfilled the inclusion criteria. Women had a higher mean heart rate at AF onset (123 ± 35 beats/min vs 115 ± 20 beats/min, P = 0.02) and during the remainder of the episode (120 ± 25 beats/min vs 112 ± 22 beats/min at the start, P = 0.01, and 116 ± 26 beats/min vs 108 ± 18 beats/min subsequently, P = 0.01). Episodes tended to be longer in women (mean 89.8 min vs 50.5 min, P = NS) and in the aged (mean 83.8 min vs 46.9 min, P = NS). Conclusion: PAF episodes are associated with faster heart rates and last longer in women, which may reflect differing autonomic responses to AF. A slower ventricular rate during PAF in older patients probably reflects an increasing prevalence of impaired atrioventricular conduction.     

Impact and Prevention of Far-Field Sensing in Fallback Mode Switches

BORDACHAR, P., et al.: Impact and Prevention of Far-Field Sensing in Fallback Mode Switches. Far-field oversensing (FFOS) promoted by high atrial sensitivity and short atrial refractory periods induces false positive mode switches. We evaluated the incidence of ventricular FFOS in a population of DDD paced patients. Methods: One hundred thirty-seven patients (   71 ± 10   years, 76 men) implanted with a Talent DR pacemaker were studied. Before discharge, an analysis of internal data stored in the memories of the PM was performed by the specific software incorporated in the programmer in parallel with a 24-hour Holter recording. Data were validated by a panel of experts. One and 4 months follow-up was based only on the data stored in the PM memories. Results: Pacing indications were atrioventricular block   (n = 75)   , sinus node dysfunction   (n = 57)   , and other   (n = 5)   . Sustained far-field oversensing was observed in 12/137 patients (9%). Out of a total of 3,511 triggered mode switch episodes, FFOS accounted for 20% and 7% of a 311 days cumulative time in mode switch. Inappropriate mode switch episodes induced by far-field were more numerous but shorter than episodes prompted by atrial arrhythmias. Atrial sensitivity was increased in eight patients, successfully in four. Reprogramming of the atrial refractory period   (156 ± 11 ms)   was successful in five of six patients. Conclusions: A 9% rate of ventricular FFOS was observed in an unselected population, easily and automatically diagnosed using the internal memory function and the automatic analysis provided by the programmer. Prolongation of the atrial refractory period was more effective than resetting of the atrial sensitivity in eliminating FFOS. (PACE 2003; 26[Pt. II]:206–209)     

Successful Results of a Bipolar Active Fixation Lead for Atrial Application: An Interim Analysis

Adequate atrial lead performance consists of stable sensing and pacing properties. To evaluate whether the CPI 4269 bipolar lead, covered with mannitol (Sweet Tip), in the atrial position encounters these properties, we performed a prospective study of this lead. After complete dissolution of the mannitol helix, mapping of the atrium to obtain the highest electrogram and lowest threshold was followed by screw-in into the endocardium. Intraoperative measurements were performed and long-term follow-up was scheduled every 6 to 12 months to measure threshold and perform an intracardial electro-gram. Between February 1993 and December 1996, a total number of 73 leads in the atrial position in a consecutive series of patients was implanted. Implantation was performed in 28 patients receiving an AAIR and 45 patients a DDDR pacemaker. Reason for pacemaker implantation was a third-degree AV block in 37% of patients, type II second-degree AV block in 25%, sick sinus syndrome in 35%, and drug refractory paroxysmal atrial fibrillation following His-bundle ablation in 3%. The intraoperative bipolar atrial electrogram had a mean voltage of 4.25 ± 2.1 mV. The acute atrial bipolar threshold was 0.63 ± 0.43 V, and current was 1.35 ± 0.81 mA at a 1.0-ms pulse duration. The mean acute resistance of the lead was 572 ± 86 Ohm. After a mean follow-up of 18.3 months, the bipolar intracardial electrogram was 3.37 ± 2.00 mV, the mean atrial threshold measured at the last outpatient clinic visit was 0.99 ± 0.74 V and the mean impedance was 640 ±127 Ohm. A sensing problem due to traction of the atrial lead occurred in only one patient. Acute and late dislodgement did not occur. The CPI 4269 (Sweet Tip) lead is manufactured with a dissolvable capsule covering the helix tip electrode, permitting a safe passage through the venous system. This interim analysis shows that this lead in the atrial position has favorable acute and chronic results.     

Specificity of atrial mode switching in detecting atrial fibrillation episodes: roles of length and contiguity

The number of automatic mode switch (AMS) has been used to measure the efficacy of atrial pacing in limiting atrial fibrillation (AF). We investigated the impact of length and contiguity on the specificity of AMS in detecting AF episodes in 24 recipients of dual chamber pacemakers with sick sinus syndrome and paroxysmal AF. An AMS algorithm and intracardiac electrogram recordings (IEGM) were activated in all patients to distinguish true arrhythmic events from unnecessary AMS. The length of AMS and the contiguity, that is, the probability of occurrence of another AMS within 5 minutes before or after AMS were examined to increase the specificity of the AMS. During a mean follow-up of 5 +/- 3 months, 250 AMS were collected. The IEGM analysis confirmed a true AF episode in 193 of 250 AMS (77.2%). Using the contiguity criterion, 47 of 57 (82.5%) inappropriate AMS episodes were isolated (there were no other AMS within 5 minutes), whereas 54 of 193 (27.9%) appropriate AMS episode were isolated. Adopting both length and contiguity criteria the specificity of AMS in detecting true AF episodes increased from 77.2% to 93.2% at the cost of 11.9% loss of original sensitivity. Combining the length and contiguity criteria, we were able to improve the specificity of the AMS in the detection of AF.