Proarrhythmic effects from competitive atrial pacing and potential programming solutions.

Publisher: Futura Pub. Co. Country of Publication: United States NLM ID: 7803944 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1540-8159 (Electronic) Linking ISSN: 01478389 NLM ISO Abbreviation: Pacing Clin Electrophysiol Subsets: MEDLINE

Original Publication: Mount Kisco, N. Y. : Futura Pub. Co., c1978-

Algorithms* ; Defibrillators, Implantable* ; Pacemaker, Artificial*; Atrial Fibrillation/*physiopathology ; Cardiac Pacing, Artificial/*methods ; Heart Atria/*physiopathology ; Heart Ventricles/*physiopathology; Aged ; Aged, 80 and over ; Female ; Humans ; Male ; Middle Aged

Background: Programmed long AV delays and intrinsic long first degree AV block may increase risk for competitive atrial pacing (CAP) in devices without CAP avoidance algorithms.
Methods: Patients identified with CAP-induced mode switch episodes were followed clinically from September 2013 to August 2019. Attempts to avoid CAP included shortening of postventricular atrial refractory period (PVARP) or postventricular atrial blanking period (PVAB), or change to AAI or DDI modes. After observing associations with sensor-driven pacing, rate response was inactivated in a subset.
Results: Among 23 patients identified with CAP (22 St Jude Medical [Abbott]; one Boston Scientific Corporation devices), atrial fibrillation (AF) was induced in 12 (52%), lasting 10 seconds to 28 hours and 32 minutes. In one patient with an ICD CAP-induced AF with rapid ventricular rates that triggered a shock, inducing ventricular fibrillation, syncope, and another shock. Changing AV delays and shortening of PVARP failed to resolve CAP. After noting that all had CAP during sensor-driven pacing, rate response was inactivated in seven, resolving further device-induced AF in the three of seven that had prior CAP-induced AF. In two patients with intact AV conduction, AAI(R) pacing resolved further documentation of CAP.
Conclusions: CAP predominantly occurs during sensor-driven atrial pacing that competes with intrinsic atrial events falling in PVARP. Inactivation of the activity sensor or change to atrial-based pacing modes (AAI/R) appears to effectively prevent induction of device-induced atrial proarrhythmia. Ultimately, a corrective algorithm is needed to avoid CAP-induced proarrhythmia.
(© 2020 Wiley Periodicals LLC.)

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Keywords: atrial fibrillation; defibrillator shock; pacing; proarrhythmia

Date Created: 20200527 Date Completed: 20211005 Latest Revision: 20211005

20250114

10.1111/pace.13962

32452039