Value of VDD-pacing systems in patients with atrioventricular block: Experience over a decade
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.
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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.
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Cited by (20)
Response to atrial arrhythmias in an atrioventricular synchronous ventricular leadless pacemaker: A case report in a paroxysmal atrial fibrillation patient
2018, HeartRhythm Case ReportsCitation Excerpt :Nevertheless, VDD pacing is rarely used owing to the risk of atrial undersensing or the future need for atrial pacing. Recently, Schaer and colleagues showed that 2% of implanted VDD systems will need an upgrade to DDD systems owing to failure of the system or development of sinus node dysfunction.10 The Micra IDE trial and the postmarket registry have shown major complication rates of 4.0% at 1 year and 1.56% at 30 days follow-up, respectively, reducing the risk of major complications by 50% compared to the historical control of traditional pacing system.1,2,11
VDD vs DDD Pacemakers: A Meta-analysis
2014, Canadian Journal of CardiologyCitation Excerpt :In fact, some large studies have reported similar observations. Schaer et al.16 studied 320 consecutive patients who received VDD pacemakers. During a follow-up duration of up to 6.1 ± 2.5 years, only 2% of VDD recipients required system revision for atrial undersensing.
HRS/ACCF expert consensus statement on pacemaker device and mode selection
2012, Journal of the American College of CardiologyCitation Excerpt :Thus, they may reduce procedure time and some complications associated with dual-chamber implants. They are used infrequently because the atrial sensing ability of the lead has tended to degrade over time, and implanters are concerned about the potential need for atrial pacing if SND develops (95–96). However, a VDD pacing system can have a potential role in the management of the younger patient, such as the patient with congenital heart block who might expect multiple system revisions over decades of follow-up (see Recommendations Table 1).
HRS/ACCF expert consensus statement on pacemaker device and mode selection: Developed in partnership between the Heart Rhythm Society (HRS) and the American College of Cardiology Foundation (ACCF) and in collaboration with the Society of Thoracic Surgeons
2012, Heart RhythmCitation Excerpt :Thus, they may reduce procedure time and some complications associated with dual-chamber implants. They are used infrequently because the atrial sensing ability of the lead has tended to degrade over time, and implanters are concerned about the potential need for atrial pacing if SND develops.95–96 However, a VDD pacing system can have a potential role in the management of the younger patient, such as the patient with congenital heart block who might expect multiple system revisions over decades of follow-up (see Recommendations Table 1).
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Both authors have contributed equally to this paper.