Value of VDD-pacing systems in patients with atrioventricular block: Experience over a decade

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Abstract

Background

Even though current guidelines suggest the use of VDD pacemakers in patients with AV block and normal sinus node function, a DDD system is often preferred for fear of either long-term atrial undersensing or late sinus node dysfunction and the resultant need for system upgrades.

Methods

We evaluated the long-term follow-up of all VDD pacemakers implanted in our center between 1992 and 2001 regarding atrial sensing, maintenance of AV synchrony, incidence of atrial fibrillation (AF), or the need for system upgrade, respectively.

Results

320 consecutive patients (56% men, age 75 ± 13 years) received a VDD pacemaker for the following indications: third-degree AV block 54%, second-degree AV block 34%, fascicular block with first-degree AV block and syncope 6%, others 6%. 138 patients (43%) died during follow-up, 3.8 ± 2.3 years after implantation. Follow-up duration was 6.1 ± 2.5 years in the remaining patients. At the last follow-up, 268 pacemakers (84%) were programmed to the VDD mode, 47 pacemakers (15%) were permanently programmed to the VVI mode (AF 36, undersensing 7, others 4, respectively). In five patients a DDD upgrade was necessary for sinus node dysfunction (3) or lead defect (2). Lead revision was performed in 19 patients (6%) (ventricular lead dislocation 7, atrial undersensing 6, lead fracture 3, others 2, respectively).

Conclusion

VDD pacemakers have an excellent long-term performance in patients with AV block. They have a very low incidence of lead revisions for atrial undersensing (2%) and DDD upgrades for secondary sinus node dysfunction (1%).

Introduction

In patients with higher-degree atrioventricular (AV) block, both DDD pacing and VDD pacing allow the restoration of AV synchrony by triggered ventricular pacing. The use of VDD pacemakers, where atrial sensing is accomplished through a floating dipole of the single-pass ventricular lead, has been shown to offer shorter and less complicated implantation procedures as well as lower follow-up costs than the use of DDD pacemakers [1], [2]. Therefore, VDD pacemakers have become an alternative to DDD pacemakers and are suggested in patients with AV block and normal sinus node function in current ACC/AHA/NASPE guidelines [3]. Nevertheless, VDD pacemakers are underutilized in these patients for fear of appearance of either sinus node dysfunction or atrial undersensing during follow-up, which would require a subsequent upgrade to a DDD system [4]. In Switzerland, for example, only 8.6% of the pacing systems used in 2003 were VDD pacemakers, although AV block accounted for 43.8% of all indications for pacemaker implantation [5].

The limitation of previous studies that evaluated VDD pacing in patients with higher-degree AV block and normal sinus node function [6], [7], [8], [9], [10], [11], [12] was mainly their relatively short follow-up, which probably has underestimated the incidence of atrial fibrillation (AF) and secondary sinus node dysfunction. Therefore, we aimed to assess the long-term performance of VDD pacing in a consecutive series of patients who had a VDD pacemaker implanted at our center over a ten year period. In patients who survived until the end of the study period, follow-up was at least three and a half years.

Section snippets

Study population

Data from pacemaker implantation and pacemaker follow-up visits of all patients who had a VDD pacemaker implanted at our center between 1992 and 2001 were analyzed. In general, the indication for the implantation of a VDD pacemaker was based on the history of a symptomatic AV block. Intact sinus node function was determined clinically by means of patient history, stress tests and/or 24-hour-Holter ECG.

Implantation technique and devices

Pacemakers were implanted under local anesthesia using a standard implantation technique. The

Implantation and follow-up

Between 1992 and 2001, 1344 consecutive patients underwent pacemaker implantation at our institution. Of these, 348 patients (26%) received a VDD pacemaker (152 women, age 75 ± 13 years). Excluded from the analysis were 28 patients (8%) because they had died before their first pacemaker follow-up visit (10), did not attend the pacemaker clinic although alive (3), had been programmed to a backup VVI mode directly after pacemaker implantation (6), or were lost to follow-up (9), respectively.

The

Discussion

When selecting a pacemaker system for a patient with a symptomatic higher-degree AV block and normal sinus node function, the cardiologist can choose between a VDD and a DDD system. Both pacing modalities have their obvious advantages. VDD systems have been shown [2] to shorten the implantation time (44 versus 74 min, p < 0.001), tend to have less early and long-term complications and, at least in Germany, significantly less overall costs. On the other hand, atrial undersensing hardly occurs in

Conclusions

In daily clinical practice, VDD pacing has an excellent long-term performance in patients with AV block and presumably normal sinus node function. Of special note are the very low incidence of lead revisions for atrial undersensing (2%) and the even lower rate of DDD upgrades for secondary sinus node dysfunction (1%). The most common reason for reprogramming the pacemaker to the VVI mode was permanent AF with a similar incidence to previous large studies with DDD pacemakers.

Acknowledgements

The authors wish to thank T. Cueni, MD, Ph. Weiss, MD, M. Gutmann, MD and S. Kiencke, MD for their help in collecting the data presented here.

References (18)

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Both authors have contributed equally to this paper.

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