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Cardiac pacing 2012 and beyond

Session presentations
  • Current pacing and sensing algorithms. The clinical value and the cost of follow-up. Presented by Michele BRIGNOLE (Lavagna, IT) See the slides
  • Is remote follow-up of cardiac pacing the future? Presented by Philippe MABO (Rennes Cedex 09, FR) See the slides
  • Diagnostic capabilities of the implantable therapeutic systems. Presented by Pekka RAATIKAINEN (Tampere, FI) See the slides
  • Leadless pacing: technical challenges and concerns. Presented by Panagiotis VARDAS (Heraklion, GR) See the slides

This session comprehensively addressed several new technologies related to cardiac pacing.

Dr. M. Brignole (Italy) reviewed 5 crucial automatic pacing algorithms:

  • Rate-responsive pacing
  • Minimizing ventricular pacing (coexisting in sinus node disease and intermittent AV block)
  • Mode switching (in paroxysmal AF)
  • Rate drop response (in reflex syncope)
  • AV and VV optimization (with CRT)

Rate responsive pacing is based on a functional sensor, however no firm recommendation can be made when it comes to superiority of various technical designs (accelerometer, respiration, QT interval, peak endocardial acceleration or intracardiac impedance). There is little evidence to support superiority of any of them. However, there is overall agreement that dual-chamber pacing with fast mode switching is the pacing mode of choice for paroxysmal atrial fibrillation. As for the termination of atrial fibrillation, no benefit has been shown in 9 trials, which have demonstrated at the most a decrease of AF burden in 3 trials. As for the rate drop algorithms, there are currently no comparable studies that would show a clear clinical benefit of such algorithms.

It can be concluded that from the evaluated automatic pacing algorithms, only very few have true evidence to support their superior in terms of clinical benefit.

Prof. P. Mabo (France) reviewed the role of remote monitoring in patients with pacemakers. The objective of such an approach is at the same time improving patient care and cost effectiveness. The increasing volume of pulse generator de novo implantations and exchanges is directly reflected by a dramatic increase in workload for the follow-up visits. He reported the results of the COMPAS trial (Mabo P et al., Eur Heart J 2012, eurheartj.ehr419) which was a randomized trial to assess the efficacy of remote versus on-site PM follow-up in terms of occurrence of significant SAE. Overall, 538 patients were enrolled and the results showed that after 18 months, there was no difference in mortality between the active home monitoring group and the control group. It is of particular interest that SAE due to atrial arrhythmias and related strokes were reduced by 67% in the group with active remote monitoring. There was also a significant 36-56% decrease of on-site follow up visits. This observation is of clinical relevance and might help to reach a correct decision on anticoagulation. The trial further emphasizes the technical feasibility and excellent safety of remote monitoring.

Prof. P. Raatikainen (Finland) reviewed in detail the diagnostic capabilities of contemporary implantable therapeutic systems. The aim of these diagnostic features is to collect more and better information, both on the device and on the patient, and to alleviate the burden of the on-site follow up visits. These systems gather important background information on the integrity of the pacing system, as well as on the performance of the system and its longevity. They usually have the following diagnostic functions:

  • Event counters
  • P&R wave amplitude histograms
  • Rate histograms
  • Mode switch
  • Episodes of high rate (A and V)

Present experience suggests that it is important to use IEGM to confirm proper arrhythmia detection by the device. A recent publication on the occurrence of subclinical atrial fibrillation and the risk of stroke (Healey S et al, NEJM 2012; 366: 120-9) was reviewed in order to highlight a significant increase of the risk of stroke with any episode of atrial tachyarrhythmias longer than 6 minutes. This association is particularly strong with a CHADS2 score > 2. Thus, subclinical AF can be reliably detected using advanced PM diagnostics and the higher the risk score of the patient, the greater the clinical impact of shorter episodes of AF.

Furthermore, modern implantable devices have capabilities to inform about:

  • Patient activity and exercise
  • HR variability
  • Fluid retention by means of congestion monitoring
  • Ischemia occurrence by means of ST segment monitoring

Prof. P. Vardas (Greece) gave an overview on the history and future of leadless pacemakers. Up to now, cardiac pacing has been the only effective treatment for symptomatic bradycardia. The idea of leadless electronic intracardiac pacemakers was first introduced by V. Spickler (Spickler JW et al., J. Electrocardiology 1970; 3: 325-331). Vardas et al performed preliminary experimental studies in 1991. Among the potential advantages are the following:

  • Less invasive approach
  • Improved efficiency
  • Better cost effectiveness

Complex wireless communication, limited longevity and implant risks due to large diameter of necessary endovascular sheaths are among the disadvantages. The energy for leadless pacing can be derived from ultrasound transmission, from induction with magnetic field or via wireless electrical stimulation. A promising approach is biological pacemakers, which aim to create pacemaker cells from cells that previously did not have such an activity. Both gene therapy using adenoviruses or retroviruses as vectors and stem cell therapy might be used for this purpose. Potential for carcinogenicity, neoplasia and infectivity must be excluded in future research.




Cardiac pacing 2012 and beyond

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.