The atrial output was increased resulting in consistent atrial capture ( figure 2), and her oedema subsequently resolved completely over the following week, allowing for complete withdrawal of her intravenous diuretics. Chest radiography showed satisfactory lead integrity and positioning, with the ventricular lead sited at the cardiac apex. The atrial lead impedence was normal at 730 Ohms, ventricular lead parameters and battery function were satisfactory, and there was near continuous atrial and ventricular pacing.

Pacemaker interrogation was undertaken and confirmed an increased atrial threshold of 2.9 V at 0.4 ms, above the current output of 2.5 V. Increases in 24-hour BP values associated with higher cardiovascular risk These findings were consistent with loss of atrial capture resulting in atrioventricular dyssynchrony, suggesting that pacemaker syndrome had been responsible for her presentation.

Atrial sensing was intact, though, and there was no evidence of retrograde (VA) conduction. Close inspection revealed no identifiable P waves following the atrial pacing artefact ( figure 1 – dashed rings), and dissociated P waves at other points within the cardiac cycle. Although her electrocardiogram showed atrioventricular sequential pacing with what appeared to be the occasional tracking of sinus beats, there were some early paced ventricular beats and other periods of ventricular safety pacing. Her blood pressure was 95/60 mmHg and there were intermittent cannon waves on examination. High-dose intravenous diuretics were administered, but despite prolonged treatment over a 10-day period, she remained severely oedematous, and due to her lack of progress, she was referred for cardiology review. Previous echocardiography had demonstrated a small hypertrophied left ventricle with an end-diastolic diameter of 3.9 cm and good systolic function.Ī clinical diagnosis of cardiac failure was made and she was admitted under the medical team for in-patient treatment. A dual chamber pacemaker had been implanted 12 years earlier for complete heart block, and she had recently been prescribed amiodarone for paroxysmal atrial fibrillation. 5.An 86-year-old woman presented with a six-month history of severe peripheral oedema and limiting breathlessness. Developed in collaboration with the European Heart Rhythm Association (EHRA).

2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Kirchhof P, Blomstrom-Lundqvist C, Badano LP, Aliyev F, Bänsch D, Baumgartner H, Bsata W, Buser P, Charron P, Daubert JC, Dobreanu D, Faerestrand S, Hasdai D, Hoes AW, Le Heuzey JY, Mavrakis H, McDonagh T, Merino JL, Nawar MM, Nielsen JC, Pieske B, Poposka L, Ruschitzka F, Tendera M, Van Gelder IC, Wilson CM. Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Document Reviewers. If sinus node function is not intact and the patient has atrial arrhythmias:Ĭhronic Atrial Arrhythmias, e.g., Atrial Fibrillation or Atrial Flutter:īrignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, Cleland J, Deharo JC, Delgado V, Elliott PM, Gorenek B, Israel CW, Leclercq C, Linde C, Mont L, Padeletti L, Sutton R, Vardas PE, ESC Committee for Practice Guidelines (CPG). The first important question is if the sinus node function is intact? If the atrium is healthy, the clinician will want to maintain AV synchrony as much as possible. While selecting a pacemaker mode, the clinician will want to ensure that the patient has a viable atrial activity. The pacemaker utilizes its sensing ability with the aid of sensors that can sense motion or minute ventilation changes according to the activity and pace the heart at a required rate. Usually, there is a problem with SA node function. Chronotropic incompetence is defined as the inability of the heart to appropriately increase its rate with increased activity or metabolic demand that leads to exercise intolerance. Rate Response or Rate Adaptive Pacing is used in patients with chronotropic incompetence. DOO mode is asynchronous pacing and is usually used only in certain situations, such as when a magnet is placed over a pacemaker or sometimes when a patient is having surgery. This mode results in AV sequential pacing at the lower rate limit regardless of the heart's own intrinsic activity.

Pacemaker av sequential