Reduction of right ventricular pacing in patients with sinus node dysfunction through programming a long atrioventricular delay along with the DDIR mode

Abstract

Background: Right ventricular (RV) pacing increases the incidence of atrial fibrillation (AF) and hospitalization rate for heart failure. Many patients with sinus node dysfunction (SND) are implanted with a DDDR pacemaker to ensure the treatment of slowly conducted atrial fibrillation and atrioventricular (AV) block. Many pacemakers are never reprogrammed after implantation. This study aims to evaluate the effectiveness of programming DDIR with a long AV delay in patients with SND and preserved AV conduction as a possible strategy to reduce RV pacing in comparison with a nominal DDDR setting including an AV search hysteresis.

Methods: In 61 patients (70 +/- 10 years, 34 male, PR < 200 ms, AV-Wenckebach rate at > or =130 bpm) with symptomatic SND a DDDR pacemaker was implanted. The cumulative prevalence of right ventricular pacing was assessed according to the pacemaker counter in the nominal DDDR-Mode (AV delay 150/120 ms after atrial pacing/sensing, AV search hysteresis active) during the first postoperative days and in DDIR with an individually programmed long fixed AV delay after 100 days (median).

Results: With the nominal DDDR mode the median incidence of right ventricular pacing amounted to 25.2%, whereas with DDIR and long AV delay the median prevalence of RV pacing was significantly reduced to 1.1% (P < 0.001). In 30 patients (49%) right ventricular pacing was almost completely (<1%) eliminated, n = 22 (36%) had >1% <20% and n = 4 (7%) had >40% right ventricular pacing. The median PR interval was 161 ms. The median AV interval with DDIR was 280 ms.

Conclusions: The incidence of right ventricular pacing in patients with SND and preserved AV conduction, who are treated with a dual chamber pacemaker, can significantly be reduced by programming DDIR with a long, individually adapted AV delay when compared with a nominal DDDR setting, but nonetheless in some patients this strategy produces a high proportion of disadvantageous RV pacing. The DDIR mode with long AV delay provides an effective strategy to reduce unnecessary right ventricular pacing but the effect has to be verified in every single patient.