10 things you need to know about pacing modes to prevent unnecessary ventricular pacing

  1. there is extensive evidence demonstrating the deleterious effect of prolonged right ventricular pacing on left ventricular function; prolonged right ventricular pacing has been shown to induce deleterious ventricular remodeling with increased ventricular volumes and increased risk of atrial arrhythmia
  2. prevention of unnecessary ventricular pacing allows battery saving, prolongs the life of the device and may reduce the frequency of battery replacement
  3. high percentage of right ventricular pacing in a patient implanted for sinus node dysfunction with preserved AV conduction should alert the physician at the time of interrogation and elicit a discussion regarding the use of specific algorithms
  4. evaluation of the burden of ventricular pacing is an important follow-up component in a patient with sinus node dysfunction, with the aim of reducing to minimum any unnecessary ventricular pacing
  5. different strategies and algorithms have been designed by device manufacturers to mitigate unnecessary ventricular pacing without inducing symptoms or compromising safety, when AV conduction is interrupted
  6. permanent programming of long AV delays may prevent ventricular pacing but may also sacrifice optimal end-diastolic preload by the atria, increase the risk of PMT and favor the occurrence of 2:1 block during exercise
  7. the concept of AV hysteresis refers to intermittent prolongation of the AV delay to promote intrinsic activation; this method, introduced before the development of dedicated pacing modes, is still available in the newer platforms of all different manufacturers
  8. specific pacing modes ensuring transition between DDD to AAI/ADI modes have been developed by the different manufacturers; the modes are easy to set up and program but the general philosophy of each of these modes needs to be perfectly understood
  9. it is not uncommon to be called by a nurse who considers a tracing with blocked P wave as corresponding to a device dysfunction; it is therefore essential to understand the operating principles of these specific modes so as not to be surprised if intermittent, blocked P waves occur
  10. these modes should be avoided in patients with high-grade AV block
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