Identifying atrial arrhythmias versus pacing‐induced rhythm disorders with state‐of‐the‐art cardiac implanted devices

Abstract

Repetitive non‐reentrant ventriculo‐atrial synchrony (RNRVAS) is a pacemaker‐induced arrhythmia that must be distinguished from atrial fibrillation (AF). Pacemaker‐induced arrhythmias are commonly detected as atrial high rate episodes (AHRE) by implanted cardiac devices. Two main types of atrial oversensing are recognized: far‐field R‐wave (FFRW) oversensing and pacemaker‐induced arrhythmias, which include pacemaker‐mediated tachycardia and RNRVAS. The presence of ventriculo‐atrial conduction is required for both types of pacemaker‐induced arrhythmias. The incidence of RNRVAS can increase with the use of various device settings and functions, such as long atrioventricular (AV) interval programming, the rate‐adaptive mode, and the atrial overdrive pacing algorithm. The negative aspects of pacemaker‐induced arrhythmias, especially RNRVAS, include (1) loss of optimal AV delay, (2) inappropriate increase in ventricular pacing, (3) induction of atrial arrhythmias, and (4) inaccurate diagnosis of AHRE. We review the incidence of arrhythmias, electrophysiological mechanisms, and the clinical diagnosis of RNRVAS identified by using dual‐chamber implantable cardiac devices.

Pacemaker Detected Prolonged Atrial High Rate Episodes – Incidence, Predictors And Implications; A Retrospective Observational Study

“…Modern Atrial High Rate Episode (AHRE) detection algorithms integrated into pacemakers & other CIEDs allow detection of atrial tachyarrhythmias(AT) with high sensitivity and specificity [ 6 , 7 ]. In addition to ATs, AHRE algorithms may also pick up other events such as myopotentials, lead noise & pacemaker mediated arrhythmic events such as repetitive non-re-entrant ventriculoatrial synchrony (RNRVAS), endless loop tachycardia (ELT), far-field R wave (FFRW) [ 8 ] which are easily identifiable by evaluating device stored tracings. Various studies have defined thresholds for the rate and duration for AHRE episodes that help to differentiate prolonged AHREs from sinus tachycardia, slower & shorter atrial tachyarrhythmias which are of unknown clinical significance.…”

Troubleshooting Pacemaker Behavior: Consequence of Prolonged Ventriculoatrial Conduction

“…This means that the device will not respond to the retrograde activation and, because of the relatively long atrial effective refractory period, the device delivers a functional noncaptured atrial pacing impulse. At this point, the device reaches the paced AV delay limit, generating a ventricular pacing impulse that again propagates retrogradely to the atria via the intrinsic VA conduction, prompting the endless loop phenomenon 3 , 4 ( Figure 2 ) .…”

Can we rely on machines? Device-detected atrial high rates correspond well with atrial arrhythmias in cardiac resynchronization recipients

“…However, because this manoeuvre narrows the search window of atrial sensing, the lower rates of falsepositive detections (higher specificity) may be achieved at a cost of higher false-negative rates (leading to lower sensitivity). 16 Because the concordance between device-detected AHRs and true arrhythmic episodes seems not to be very high (34-82%, probably up to 89% for episodes lasting .5 min), careful verification of diagnosis by a detailed analysis of intracardiac EGMs stored in device memory or transmitted via remote monitoring is crucial. 10,17 -19 However, in many cases, EGMs are not available, underscoring the potential clinical utility of our results.…”