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. 2023 Jan;28(1):e13033.
doi: 10.1111/anec.13033. Epub 2022 Dec 19.

Potential triggering of repetitive nonreentrant ventriculoatrial synchrony by loss of atrial capture

Asli Inci Atar  1 , Ilyas Atar  2
Affiliations

Potential triggering of repetitive nonreentrant ventriculoatrial synchrony by loss of atrial capture

Asli Inci Atar et al. Ann Noninvasive Electrocardiol. 2023 Jan.

Abstract

Background: Data on the factors that trigger repetitive nonreentrant ventriculoatrial synchrony (RNRVAS) are limited. We hypothesize that loss of atrial capture may trigger RNRVAS. We aimed to use an atrial threshold test to observe the development of RNRVAS upon loss of atrial capture in patients with implantable cardiac electronic devices (CIED).

Methods: Patients with DDD mode CIEDs [177 patients, 67.5 ± 14.8 (70) years; 70 women] were included. Atrial threshold test was done in DDD mode at a rate at least 10 beats above the basal heart rate, with an AV delay of 300 ms (range 250-350). A multivariable logistic regression model was used to assess the independent predictors of RNRVAS.

Results: RNRVAS was observed in 69 of the 177 patients (39.0%) during atrial threshold test. In patients with VA conduction, incidence of RNRVAS increased to 76.7%. In univariate analysis, younger age (p = .038) and the presence of VA conduction (p < .001) were associated with an increased risk of RNRVAS, whereas complete AV block or any AV node conduction defect (p < .001) and the ventricular pacing ratio (p = .001) were inversely related to the risk of RNRVAS occurrence after loss of atrial capture. In multivariate analysis complete AV block (p = .009) and ventricular pacing ratio (p = .029) appeared as independent factors inversely related to the risk of RNRVAS development.

Conclusion: In this study, we demonstrated that loss of atrial capture results in RNRVAS in one-third of patients with a CIED in DDD mode, and in three-fourths of those with VA conduction under certain predisposing CIED settings.

Keywords: atrial capture test; cardiac implantable electronic device; endless loop tachycardia; loss of atrial capture; repetitive nonreentrant ventriculoatrial synchrony.

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Conflict of interest statement

None of the authors has associations that might pose a conflict of interest.

Figures

FIGURE 1
FIGURE 1
Description of flow of events leading to triggering of RNRVAS
FIGURE 2
FIGURE 2
Recording from St Jude medical device demonstrating commencement of RNRVAS during atrial threshold test with loss of atrial capture. Red arrow points to where atrial capture is lost and RNRVAS starts. Red stars point to atrial threshold test end and RNRVAS terminated. From top to bottom: (1) DII surface ECG, (2) marker channel and intervals, (3) atrial EGM, (4) near field ventricular EGM, (5) far field ventricular EGM. Recording sweep speed 12.5 mm/s. RNRVAS, repetitive nonreentrant ventriculoatrial synchrony; AP, Atrial pace; AS, Atrial sense; VS, ventricular sense; VP, ventricular pace; Ab, Atrial activity in Post ventricular atrial blanking period; AR, Atrial activity sensed in PVARP; BV, Biventriküler pace; Ar, atrial activity sensed in PVARP; bV, Biventriküler pace; PAC, Premature atrial contraction; RVS, Right ventricular sense; RVP, Right ventricular pace; LVS, Left ventricular sense; LVP, Left ventricular pace
FIGURE 3
FIGURE 3
Recordings demonstrating commencement of RNRVAS and ELT during atrial threshold test with loss of atrial capture. Red arrow points to where atrial capture is lost and RNRVAS starts. Red stars point to atrial threshold test end and RNRVAS terminated and ELT started. Recording from St Jude Medical device showing from top to bottom: (1) D1 surface ECG, (2) Marker channel and intervals (3) D2 surface ECG (4) Atrial EGM. Recording sweep Speed 12.5 mm/s. RNRVAS, repetitive nonreentrant ventriculoatrial synchrony; ELT, Endless loop tachycardia; AP, Atrial pace; AS, Atrial sens; VS, ventricular sens; VP, ventricular pace
FIGURE 4
FIGURE 4
Recording from a patient who was in RNRVAS when his pacemaker was interrogated during routine pacemaker control. Recording from St Jude Medical device showing from top to bottom: (1) DII surface ECG (2) Marker channel and intervals (3) Ventricular EGM (4) Atrial EGM. Recording sweep Speed 25 mm/s. RNRVAS, repetitive nonreentrant ventriculoatrial synchrony; AP, Atrial pace; AR, Atrial activity sensed in PVARP; VP, Ventricular pace
FIGURE 5
FIGURE 5
Recordings demonstrating commencement of RNRVAS during loss of atrial capture. (a) Development of RNRVAS with loss of atrial capture, (b) Activation of SIR response with loss of atrial capture and the start of RNRVAS. Red arrow points to where atrial capture is lost. Red stars point to SIR response. Recording from St Jude Medical device showing from top to bottom: (1) DII surface ECG, (2) Marker channel and intervals, (3) Ventricular EGM (4) Atrial EGM. Recording sweep Speed 25 mm/s. RNRVAS, repetitive nonreentrant ventriculoatrial synchrony; SIR, Sensor – indicated rate; AP, Atrial pace; AR, Atrial activity sensed in PVARP; VS, ventricular sens; VP, Ventricular pace
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