DDD Pacing Research Articles

Long-term Effect of Dual-chamber Pacing on Pressure Gradient at Left Ventricular Outflow Tract in Hypertrophic Obstructive Cardiomyopathy

A 60‐year‐old man with hypertrophic obstructive cardiomyopathy (HOCM) was implanted dual‐chamber ICD for the purpose of both the left ventricular outflow tract (LVOT) gradient reduction by ventricular pacing and the primary prevention of ventricular tachyarrhythmia. Because the LVOT gradient reduction and improvement of symptoms by pacing were insufficient, however, a new pacing lead was inserted in the right ventricular apex at a different position 1.5 cm away from the site of the defibrillation lead, and the LVOT gradient greatly declined from 108 to 30 mmHg. This DDD pacing was continued over seven years. On this occasion, he was referred to our hospital because of battery depletion, and a cardiac catheterization study was performed after ICD replacement. The LVOT gradient was 10 mmHg in sinus rhythm. After administration of isoproterenol (0.02γ), the gradient was increased to 92 mmHg in sinus rhythm. DDD pacing using a newly placed ventricular pacing lead significantly decreased the gradient to 36 mmHg. This case study indicated that DDD pacing from a suitable location in the right ventricular apex caused a marked early reduction in the LVOT gradient, and at long‐term follow up a further significant effect was obtained, also in sinus rhythm.

The recent therapeutical effects of septal pacing on the cardiac arrhythmia

ObjectiveTo investigate the therapeutical effects of septal pacing on the cardiac arrhythmia.Methods62 patients with sick sinus syndrome and (or) high/third degree A-V block were implanted with pacemaker in right atrial...

Rate responsive pacing using cardiac resynchronization therapy in patients with chronotropic incompetence and chronic heart failure

Chronotropic incompetence (CI) is a common finding in patients with advanced chronic heart failure (CHF) and is associated with a worse functional capacity. Whether rate responsive pacing with cardiac resynchronization therapy (CRT) would acutely improve exercise performance in patients with advanced CHF and severe CI (<70% age-predicted maximum heart rate) is unknown. Patients (n = 13) with CHF, a CRT device, and severe CI were randomized in a double-blind crossover pilot study to either DDD (control) or DDDR (rate responsive) pacing. Six minutes walk test (6MWT) distance, oxygen consumption at anaerobic threshold (VO(2) @ AT), and maximal oxygen consumption (VO(2) max) were measured. One week later, testing was repeated in the alternate pacing mode. Rate responsive pacing commenced with standard settings in only 9 of 13 (69%) patients. In these 9 subjects, 6MWT distance improved acutely from 358.5 ± 40.7 to 376.8 ± 24.5 m with DDDR pacing (P< 0.05). VO(2) max did not improve with DDDR pacing (14.0 ± 3.2 mL/kg/min) compared with DDD pacing (13.9 ± 3.0 mL/kg/min; P= 0.69). VO(2) @ AT tended towards improvement with DDDR pacing (10.8 ± 2.9 mL/kg/min) compared with DDD pacing (9.6 ± 1.8 mL/kg/min; P= 0.29). There was a linear relationship between the increase in heart rate at minute 3 during rate responsive pacing and improvement in VO(2) @ AT (r = 0.83, P< 0.05). When rate responsive pacing using a CRT device is achieved in patients with advanced CHF and severe CI, parameters of aerobic exercise performance improve acutely. Routine exercise testing to ensure successful restoration of heart rate response may be beneficial to optimize CRT settings in this patient population.

Postshock AAI pacing associated with asystole despite programming postshock DDD pacing

Postshock AAI pacing associated with asystole despite programming postshock DDD pacing

Isoelectric Atrioventricular Interval during DDD Pacing: What is the Mechanism?

Pacing and Clinical ElectrophysiologyVolume 34, Issue 6 p. 764-766 DEVICE ROUNDS Isoelectric Atrioventricular Interval during DDD Pacing: What is the Mechanism? MAREK JASTRZEBSKI M.D., Ph.D., MAREK JASTRZEBSKI M.D., Ph.D. First Department of Cardiology and Hypertension, University Hospital, Krakow, PolandSearch for more papers by this author MAREK JASTRZEBSKI M.D., Ph.D., MAREK JASTRZEBSKI M.D., Ph.D. First Department of Cardiology and Hypertension, University Hospital, Krakow, PolandSearch for more papers by this author First published: 05 January 2011 https://doi.org/10.1111/j.1540-8159.2010.02984.xCitations: 2 Address for reprints: Marek Jastrzebski, M.D., Ph.D., I Department of Cardiology and Hypertension, ul. Kopernika 17, 31-501 Krakow, Poland. Fax: 048-124247320; e-mail: mcjastrz@cyf-kr.edu.pl Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume34, Issue6June 2011Pages 764-766 RelatedInformation

Long-term Effect of Dual-chamber Pacing on Pressure Gradient at Left Ventricular Outflow Tract in Hypertrophic Obstructive Cardiomyopathy

A 60-year-old man with hypertrophic obstructive cardiomyopathy (HOCM) was implanted dual-chamber ICD for the purpose of both the left ventricular outflow tract (LVOT) gradient reduction by ventricular pacing and the primary prevention of ventricular tachyarrhythmia. Because the LVOT gradient reduction and improvement of symptoms by pacing were insufficient, however, a new pacing lead was inserted in the right ventricular apex at a different position 1.5 cm away from the site of the defibrillation lead, and the LVOT gradient greatly declined from 108 to 30 mmHg. This DDD pacing was continued over seven years. On this occasion, he was referred to our hospital because of battery depletion, and a cardiac catheterization study was performed after ICD replacement. The LVOT gradient was 10 mmHg in sinus rhythm. After administration of isoproterenol (0.02γ), the gradient was increased to 92 mmHg in sinus rhythm. DDD pacing using a newly placed ventricular pacing lead significantly decreased the gradient to 36 mmHg. This case study indicated that DDD pacing from a suitable location in the right ventricular apex caused a marked early reduction in the LVOT gradient, and at long-term follow up a further significant effect was obtained, also in sinus rhythm.

Permanent Left Atrium Pacing via Coronary Sinus

Atrial pacing is effective in sick sinus patients. In high threshold right atrium, however, atrial pacing is difficult. Left atrium muscle exists around coronary sinus. Left atrium pacing is enabling via coronary sinus. Patients: From 2008 to 2010, four SSS patients and two A-V block patients received permanent left atrium pacing via coronary sinus. There were three men and three women. Patient’s mean age was 67 years old (43–83). One patient was post MVR. Other patient became reoperation since atrial lead placed upper atrial septum was floated. Methods and Results: Pacing lead was placed via left subclavian vein with cut down technique. Screw-in lead was used. First right atrium upper septum was attempted, next right atrium appendage, finally lower septum or coronary sinus. Lead placed site was proximal position in 5 patients and distal in one patient. Atrial threshold is 0.5–1.25 V at proximal and 3 mV at distal. Atrial sensing is 0.5–4.3 mV. Lead impedance is 464–583 Ω. Post operative chest lateral Xp showed atrial lead in coronary sinus. Negative P wave was showed in ECG 2 lead. There were no complications of infection, coronary sinus thrombosis, hemorrhage, or trauma. All patients alive and DDD pacing was maintained at last examination. Conclusion: Left atrium pacing via coronary sinus is a safe and feasible technique.

Complex percutaneous extraction of a 15-year-old atrial lead dislodged into the subclavian vein

We present a case of a 50-year-old patient with DDD pacing failure who underwent atrial lead extraction. The lead was implanted 15 years ago, and 4 months ago it dislodged into the subclavian vein following a fracture. The lead was removed via the femoral vein approach using a Cook Medical device (Byrd Femoral Workstation, Dotter basket) and pigtail catheter.

A Case of Cardiac Amyloidosis Whose Exercise Intolerance Was Caused by Loss of Bi-Ventricular Pacing after Atrial Contractions within Pacemaker Refractory Period

A 68-year-old man presented with congestive heart failure (NYHA III) with QRS morphology of left bundle branch block. Systemic amyloidosis with cardiac involvement was pointed out 7 years ago. A Medtronic CRT-D device was implanted because of dyssynchronous left ventricular motion. Four months after implantation, the patient had recurrent episodes of faintness during exercise. Faintness was coincident with sudden prolongation of a P-P interval from 600 ms to 1100 ms at the peak exercise. It was due to sinus pause followed by a back-up pacing of nonrate responsive DDD pacing at 60/min with rate adaptive AV delay (280 ms to 180 ms). The pacing parameters were changed so that the symptom was resolved. Sixteen months later, the patient developed general fatigue during exercise. Exercise intolerance was apparently due to bi-ventricular pacing failure, but this was not shown at rest. Intra-cardiac ECG during exercise showed a premature atrial contraction and/or a non-competitive atrial pacing (NCAP) within post-ventricular atrial refractory period (PVARP), followed by aborted ventricular pacing. Conducted own QRS appeared to resume ventricular dyssynchrony. Symptom was improved after NCAP was turned off and PVARP was shortened. This case is unique because of exercise-induced loss of bi-ventricular pacing, which was not due to shortening of own AV conduction. It was useful to examine intra-cardiac ECG during exercise in detail.

Future easy and physiological cardiac pacing

The right atrial appendage (RAA) and right ventricular apex (RVA) have been widely considered as conventional sites for typical dual-chamber atrio-ventricular cardiac (DDD) pacing. Unfortunately conventional RAA pacing seems not to be able to prevent atrial fibrillation in DDD pacing for tachycardia-bradycardia syndrome, and the presence of a left bundle branch type of activation induced by RVA pacing can have negative effects. A new technology with active screw-in leads permits a more physiological atrial and right ventricular pacing. In this review, we highlight the positive effects of pacing of these new and easily selected sites. The septal atrial lead permits a shorter and more homogeneous atrial activation, allowing better prevention of paroxysmal atrial fibrillation. The para-Hisian pacing can be achieved in a simpler and more reliable way with respect to biventricular pacing and direct Hisian pacing. We await larger trials to consider this "easy and physiological pacing" as a first approach in patients who need a high frequency of pacing.

Differential Effect of Biventricular and Right Ventricular DDD Pacing on Coronary Flow Reserve in Patients With Ischemic Cardiomyopathy

CRT and Coronary Flow Reserve. Cardiac resynchronization therapy (CRT) has become a mainstay in heart failure management. There are also indications that upgrading of existing pacemakers to CRT systems may be of benefit. The aim of this study was to assess the effect of biventricular (BiV), compared with right ventricular (RV), pacing, on coronary flow reserve (CFR), in patients with ischemic cardiomyopathy. From our database of heart failure patients implanted with BiV pacemakers, 20 patients (10 responders and 10 non-responders to CRT) were randomly selected. Left anterior descending artery coronary flow reserve was measured invasively, under BiV and RV pacing, using intracoronary adenosine to induce hyperemia. In all the 20 patients, there was a significant difference in the pairwise comparison between CFR recorded during BiV and RV pacing (mean difference 0.15, 95% confidence interval 0.07-0.23, P = 0.001). When comparing responders to non-responders, there was a significant difference as to the effect of BiV, compared with RV, pacing on CFR: mean difference (BiV minus RV CFR) was 0.26 ± 0.06 (95% confidence interval 0.13-0.39; P = 0.002), while in non-responders the difference was 0.04 ± 0.03 (95% confidence interval -0.02 to 0.10; P = 0.168). BiV pacing is overall associated to higher CFR, compared with RV DDD pacing. This difference is almost exclusively attributable to the beneficial effect of CRT on coronary flow reserve in CRT-responders. This effect may contribute to the beneficial action of resynchronization in the failing heart and can be viewed in the context of reports of the usefulness of upgrading RV pacemakers to CRT systems.

Cardiac memory in humans: vectocardiographic quantification in cardiac resynchronization therapy

"Cardiac memory" (CM) refers to a change in repolarization induced by an altered pathway of activation. The effects of biventricular pacing on CM induction have not been investigated. To investigate the development of CM during cardiac resynchronization therapy (CRT) through vectorcardiography (VCG). Eleven patients undergoing CRT were enrolled. VCG was acquired during spontaneous ventricular activation at baseline and during AAI and DDD pacing immediately after and 7, 14, 21 and 60days after the implantation. At 1-week follow-up, during AAI pacing T vector angles significantly changed (azimuth 23±19°; p=0.002; elevation 23±27°; p=0.019) and magnitude significantly increased (baseline 1.13±0.69mV; 7days: 1.77±1.27mV; p=0.026). T angle changes remained stable throughout the follow-up period while a further significant increase in magnitude was observed at 60days (2.21±1.50mV; p=0.01 vs. baseline and p=0.04 vs. 7days). Paced T vector magnitude at implant (2.24±1.25mV) decreased significantly at 7days (1.64±1.26mV; p=0.030) with a further significant decrease at 60days (1.40±1.18mV; p=0.003 vs. baseline; p=0.02 vs. 7days). CRT induces a significant change in T vector magnitude, azimuth, and elevation after resumption of spontaneous ventricular activation after 7days from implantation. While further changes in T vector angle were not observed, after 2months of CRT a significant decrease of paced T vector magnitude and a significant increase of spontaneous T vector magnitude were observed.

Current Density Distribution by Ring and Diagonally Arranged Half-Ring Electrodes in Bipolar and Overlapping Biphasic Impulse Stimulation

We have studied the acute and long-term efficacy of overlapping biphasic impulse (OLBI) stimulation for atrial pacing with VDD pacemakers and demonstrated the feasibility of DDD pacing in OLBI with diagonally arranged half-ring (Half-Ring) electrodes. We made two three-dimensional computational analysis models to verify our clinical studies. Model I was composed of a heart, a pacemaker, and a human body. Model II was a cube with dimensions of 20 by 20 by 20 mm quarried from Model I for the detailed study of current density distributions. Laplace's equation was solved using the finite element method and the current density J was calculated. For Model I, the distal and proximal voltages were -10 V, 0 V in bipolar and -5 V, +5 V in OLBI, using Ring electrodes. In Model II, the actual measurements of electrode impedances obtained from the clinical study (1,180 Ω for Ring and 630 Ω for Half-Ring) were added to the analysis conditions. Model I showed that OLBI produced more concentrated current density distributions than those by bipolar. According to Model II, at the atrial myocardium position current density produced by Half-Ring was larger than that by Ring electrodes, 70 μA/mm(2) versus 30 μA/mm(2) in OLBI configuration. It also indicated that even if electrode impedances were equal between Half-Ring and Ring electrodes, the maximum current density produced by Half-Ring would be greater than that by Ring electrodes. It was considered that OLBI configuration with Half-Ring electrodes provides more effective current density distributions.

A Case of Hypertrophic Obstructive Cardiomyopathy, in which the Left Ventricular Pressure Gradient was Disappeared After Cessation of Long-Term DDD Pacing

A Case of Hypertrophic Obstructive Cardiomyopathy, in which the Left Ventricular Pressure Gradient was Disappeared After Cessation of Long-Term DDD Pacing

Atrial undersensing in VDD pacing: should we blame calcium-channel blockers?

Single-lead VDD pacing is an attractive alternative to DDD pacing in patients with high-degree AV block and normal sinus node function. It provides physiological AV synchronous stimulation with a single lead. Owing to easier implantation, VDD systems have shorten the operation time by up to 40% and reduce the intraoperative fluoroscopy time by up to 55%. Additionally, they showed a trend towards a reduction in perioperative complications compared with DDD systems, and also showed a reduction in cost. 1 Therefore, why are single-lead VDD systems used infrequently in patients with isolated high-degree AV block? First, concerns exist about testing for sinus node dysfunction and development of sinus bradycardia during long-term follow-up. Sinus bradycardia during VDD pacing may result in VVI stimulation or necessitate the implantation of an atrial lead. However, in properly selected patients, sinus node function remains stable in the vast majority of patients. 2 Secondly, scepticism exists about the reliability of atrial sensing, using a floating atrial dipole within the right atrium. When I (B.N.) personally had the first contact with single-lead VDD pacing at a presentation given by Seymour Furman in Munich in the year 1990, I asked him whether he really thought that this concept might work, he answered: ‘Just put it in, it works’. Many studies thereafter have shown that he was right. Reliable atrial sensing can be accomplished with the floating atrial dipole, achieving AV synchrony .99%, with the prerequisite that atrial sensitivity is programmed to very sensitive values. 3‐5

Long-Term Outcome of Single-Chamber Atrial Pacing Compared with Dual-Chamber Pacing in Patients with Sinus-Node Dysfunction and Intact Atrioventricular Node Conduction

PurposeThe optimal pacing mode with either single chamber atrial pacemaker (AAI or AAIR) or dual chamber pacemaker (DDD or DDDR) is still not clear in sinus-node dysfunction (SND) and intact atrioventricular (AV) conduction.Materials and MethodsPatients who were implanted with permanent pacemaker using AAI(R) (n = 73) or DDD(R) (n = 113) were compared.ResultsThe baseline characteristics were comparable between the two groups, with a mean follow-up duration of 69 months. The incidence of death did not show statistical difference. However, the incidence of hospitalization for congestive heart failure (CHF) was significantly lower in the AAI(R) group (0%) than the DDD(R) group (8.8%, p = 0.03). Also, atrial fibrillation (AF) was found in 2.8% in the AAI(R) group, which was statistically different from 15.2% of patients in the DDD(R) group (p = 0.01). Four patients (5.5%) with AAI(R) developed AV block, and subsequently switched to DDD(R) pacing. The risk of AF was lower in the patients implanted with AAI(R) than those with DDD(R) [hazard ratio (HR), 0.84; 95% confidence interval, 0.72 to 0.97, p = 0.02].ConclusionIn patients with SND and intact AV conduction, AAI(R) pacing can achieve a better clinical outcome in terms of occurrence of CHF and AF than DDD(R) pacing. These findings support AAI(R) pacing as the preferred pacing mode in patients with SND and intact AV conduction.

Possible acute and chronic synergistic effect of dual chamber pacing and disopyramide in obstructive hypertrophic cardiomyopathy: a case report

It remains unclear whether the combination of dual-chamber (DDD) pacing and disopyramide can achieve prolonged left ventricular outflow tract (LVOT) gradient reduction and symptom relief in patients with obstructive hypertrophic cardiomyopathy (HCM). In an HCM patient with a severe LVOT gradient, the combination of DDD pacing and disopyramide achieved marked improvement of gradient in the catheter laboratory and also after medium-term follow-up. The patient's severe dyspnoea was alleviated during the follow-up period. This combination might enable physicians to treat and manage elderly symptomatic obstructive HCM patients with a severe LVOT gradient more effectively and less invasively.

Ventricular pacing: to pace or not to pace

Pacing from the right ventricular apex has been the clinical standard for decades but has recently come into question with a growing trend towards reducing ventricular pacing as much as possible. The earliest devices provided asynchronous ventricular pacing in patients whose indication for pacing was asystolic complete heart block. RV apical pacing was literally the difference between life and death. Over the decades, as technology has advanced allowing the medical community to more closely model normal cardiac physiology, we have seen the progressive introduction of demand function, single-chamber atrial pacing, dual-chamber pacing, dual-chamber rate-modulated pacing, and in the past decade, cardiac resynchronization pacing. During this evolution, it has been noted that pacing from the right ventricular apex, even in the presence of high-grade AV block, may contribute to ventricular dysfunction associated with the disordered ventricular activation sequence associated with the paced left bundle branch block pattern. ‘Pacemaker syndrome’ or the adverse haemodynamics associated with a technically normal pacing system was rarely recognized in the late 1960s when complete heart block was the indication for implantation. Its recognition blossomed in the 1980s with the introduction of dual-chamber pacing systems and an increase in the relative indications for permanent pacing including individuals who only needed pacing on an intermittent basis or whose primary indication for pacing was sinus node dysfunction. Pacemaker syndrome was usually associated with a loss of appropriate atrial transport (atrioventricular synchrony) and was able to be corrected by upgrading a patient with a single-chamber VVI pacing system to a DDD pacing system.1–3 The standard location for the ventricular lead during the first four decades of cardiac pacing was the RV apex. The first generation of DDD pacemakers had limited AV delay programmability such that there was either full ventricular pacing or consistent ventricular fusion. On the … *Corresponding author. Tel: +1 818 493 2900, Fax: +1 818 362 2242, Email: plevine{at}sjm.com

DDD versus VVIR Pacing in Patients, Ages 70 and Over, with Complete Heart Block

Dual-chamber pacing is believed to have an advantage over single-chamber ventricular pacing. The aim of the study was to determine whether elderly patients with implanted pacemaker for complete atrioventricular block gain significant benefit from dual-chamber (DDD) compared with single-chamber ventricular demand (VVIR). The study was designed as a double-blind randomized two-period crossover study-each pacing mode was maintained for 3 months. Thirty patients (eight men, mean age 76.5 +/- 4.3 years) with implanted PM were submitted to a standard protocol, which included an interview, functional class assessment, quality of life (QoL) questionnaires, 6-minute walk test, and transthoracic echocardiographic examinations. QoL was measured by the SF-36. All these parameters were obtained on DDD mode pacing and VVIR mode pacing. Paired data were compared. QoL was significantly different between the two groups and showed the best values in DDD. Overall, no patient preferred VVIR mode, 18 preferred DDD mode, and 12 expressed no preference. No differences in mean walking distances were observed between patients with single-chamber and dual-chamber pacing. VVI pacing elicited marked decrease in left ventricle ejection fraction and significant enlargement of the left atrium. DDD pacing resulted in significant increase of the peak systolic velocities in lateral mitral annulus and septal mitral annulus. Early diastolic velocities on both sides of mitral annulus did not change. In active elderly patients with complete heart block, DDD pacing is associated with improved quality of life and systolic ventricular function compared with VVI pacing.

Optimizing Hemodynamics in Heart Failure Patients by Systematic Screening of Left Ventricular Pacing Sites: The Lateral Left Ventricular Wall and the Coronary Sinus Are Rarely the Best Sites

We sought to evaluate the impact of the left ventricular (LV) pacing site on hemodynamic response to cardiac resynchronization therapy (CRT). CRT reduces morbidity and mortality in heart failure patients. However, 20% to 40% of eligible patients may not fully benefit from CRT device implantation. We hypothesized that selecting the optimal LV pacing site could be critical in this issue. Thirty-five patients with nonischemic dilated cardiomyopathy referred for CRT device implantation were studied. Intraventricular dyssynchrony and latest activated LV wall were defined by tissue Doppler imaging analysis before the study. Eleven predetermined LV pacing sites were systematically assessed in random order: basal and mid-cavity (septal, anterior, lateral, inferior), apex, coronary sinus (CS), and the endocardial site facing the CS pacing site. For each patient, +dP/dTmax, −dP/dTmin, pulse pressure, and end-systolic pressure during baseline (AAI) and DDD LV pacing were compared. Two atrioventricular delays were tested. Major interindividual and intraindividual variations of hemodynamic response depending on the LV pacing site were observed. Compared with baseline, LV DDD pacing at the best LV position significantly improved +dP/dTmax(+31 ± 26%, p < 0.001) and was superior to pacing the CS (+15 ± 23%, p < 0.001), the lateral LV wall (+18 ± 22%, p < 0.001), or the latest activated LV wall (+11 ± 17%, p < 0.001). The pacing site is a primary determinant of the hemodynamic response to LV pacing in patients with nonischemic dilated cardiomyopathy. Pacing at the best LV site is associated acutely with fewer nonresponders and twice the improvement in +dP/dTmaxobserved with CS pacing.