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Non-physiological increase of AV conduction time in sinus disease patients programmed in AAIR-based pacing mode

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Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Purpose

The EVOCAVDS trial aimed to quantify the paradoxal atrioventricular (AV) conduction time lengthening in sinus node (SD) patients (pts) paced in AAIR-based pacing mode.

Methods

SD pts, implanted with dual-chamber pacemaker programmed in AAIR-based pacing mode, were randomized in two arms for a 1-month period: the low atrial pacing (LAP; basic rate at 60 bpm, dual sensor with minimal slope) and the high atrial pacing (HAP; basic rate at 70 bpm, dual sensor with optimized slope, overdrive pacing) arm. At 1 month, crossover was performed for an additional 1-month period. AV conduction time, AV block occurrence and AV conduction time adaptation during exercise were ascertained from device memories at each follow-up.

Results

Seventy-nine pts participated to the analysis (75 ± 8 years; 32 male; PR = 184 ± 38 ms; bundle branch block n = 12; AF history n = 36; antiarrhythmic treatment n = 53; beta-blockers n = 27; class III/Ic n = 18; both n = 8). The mean AV conduction time was significantly greater during the HAP (275 ± 51 ms) vs. LAP (263 ± 49 ms) period (p < 0.0001). Class III/Ic drugs were the only predictors of this abnormal behaviour. Degree II/III AV blocks occurred in 49 % of pts in the HAP vs. 19 % in the LAP period (p < 0.0001). Fifty-two patients (66 %) presented a lengthening of AV conduction time during exercise.

Conclusion

AAIR-based pacing in SD pts may induce a significant lengthening of pts’ AV conduction time, including frequent abnormal adaptation of AV conduction time during exercise.

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Acknowledgments

This study was sponsored by Sorin CRM SAS, Clamart, France. The authors thank Pierre-Henri Siot for his contribution to statistical analysis, and Pelle Stolt, PhD and Anne Rousseau-Plasse, PhD, for their assistance in the preparation of the manuscript.

Conflicts of interest

Philippe Mabo, MD, Jean-Pierre Cebron, MD, Aude Solnon, MD, Aude Tassin, MD, and Daniel Gras, MD, received research grant from Sorin CRM SAS for their participation to the EVOCAV DS study. Philippe Mabo, MD, received consulting fees from Sorin CRM SAS. Laurence Graindorge received a salary from Sorin CRM SAS as employee.

Participating investigators and institutions

The participating investigators and institutions are the following: for CHU Rennes—Christophe Leclercq, MD, PhD, Philippe Mabo, MD and Aude Solnon, MD; Nouvelles Cliniques Nantaises—Marc Burban, MD, Jean-Pierre Cebron, MD and Daniel Gras; CHU Nantes—Selim Abbey, MD and Gilles Landes, MD; and CHU Angers: Jean-Marc Dupuis, MD and Aude Tassin, MD.

Author information

Authors and Affiliations

  1. CHU Rennes, Rennes, France

    Philippe Mabo

  2. NCN Nantes, Nantes, France

    Jean-Pierre Cebron & Daniel Gras

  3. CHU Nantes, Nantes, France

    Aude Solnon

  4. CHU Angers, Angers, France

    Aude Tassin

  5. Sorin CRM SAS, Clamart, France

    Laurence Graindorge

  6. Service de Cardiologie et maladies vasculaires, CHU Pontchaillou, 2 Rue Henri Le Guilloux, 35033, Rennes, France

    Philippe Mabo

Authors
  1. Philippe Mabo
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  2. Jean-Pierre Cebron
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  6. Daniel Gras
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Corresponding author

Correspondence to Philippe Mabo.

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Editor’s note

This study examines the behaviour of the PR interval in patients with sinus node dysfunction who have functional AAIR pacing. The study has particular relevance at this time because of the current emphasis on avoidance of (right) ventricular pacing in dual-chamber pacing systems. The investigators randomized 79 patients to lower rate atrial pacing (60 bpm) with dual sensors (accelerometer and minute ventilation), minimal slope and higher rate atrial pacing (70 bpm) with dual sensor, optimized slope. Follow-up was at 1 month after which the patients were crossed over and followed for another month. Stored data within the device regarding AV conduction time, AV block point and AV conduction time adaptation during exercise were the parameters analyzed in a new mode (SafeR™, Sorin CRM SAS, Clamart, France) that allows AV conduction assessment through continuous analysis, with DDDR pacing programmed only after specific, but programmable, PR/AR durations and/or P waves not followed by QRS complexes. Patients in the higher atrial pacing arm had longer AV conduction times as well as greater incidence of development of AV blocks. The actual mechanism is not always immediately clear in any given patient, although there is an effect of beta-blockers, intra-atrial conduction delays, and AV nodal-His conduction abnormalities on the development of AV blocks at the higher atrial pacing rates.

The potential deleterious effects of AAIR pacing during exercise have been recognized previously and consist not only of the development of second and higher degrees of AV block but also inappropriately long AR conduction times, which could be hemodynamically detrimental if not actually destabilizing. The authors, by means of the algorithm described in this study have added data to existing literature and lead one to conclude that AAIR-based pacing can be detrimental in patients with sinus node dysfunction. The importance of this work is the revisiting of the “goal” of minimizing ventricular pacing at all costs, indicating that this may well not be universally warranted.

This investigation was not designed to determine clinical outcomes over time, and was quite small. Nonetheless, the data are highly provocative and warrant a larger study.

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Mabo, P., Cebron, JP., Solnon, A. et al. Non-physiological increase of AV conduction time in sinus disease patients programmed in AAIR-based pacing mode. J Interv Card Electrophysiol 35, 219–226 (2012). https://doi.org/10.1007/s10840-012-9703-4

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  • DOI: https://doi.org/10.1007/s10840-012-9703-4

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