Leadless atrio-ventricular synchronous pacing in an outpatient setting - early lessons learned on factors affecting atrio-ventricular synchrony.

Neugebauer, Felix; Noti, Fabian; van Gool, Stephan; Roten, Laurent; Baldinger, Samuel H.; Seiler, Jens; Madaffari, Antonio; Servatius, Helge; Ryser, Adrian; Tanner, Hildegard; Reichlin, Tobias; Häberlin, Andreas (2022). Leadless atrio-ventricular synchronous pacing in an outpatient setting - early lessons learned on factors affecting atrio-ventricular synchrony. Heart rhythm, 19(5), pp. 748-756. Elsevier 10.1016/j.hrthm.2021.12.025

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BACKGROUND

Leadless pacemakers (PMs) capable of atrio-ventricular (AV) synchronous pacing have recently been introduced. Initial feasibility studies were promising, but limited to just a few minutes of AV synchronous pacing. Real-world long-term data on AV synchrony and programming adjustments affecting AV synchrony in outpatients are lacking.

OBJECTIVE

To investigate AV synchrony and influences of PM programming adjustments in outpatients with leadless VDD PMs.

METHODS

All patients who received a leadless VDD PM (Micra™ AV, Medtronic, US) between 07/2020 and 05/2021 at our center were included in this observational study. AV synchrony was assessed repeatedly postoperatively and during follow-up using Holter ECG recordings. AV synchrony was defined as a QRS complex preceded by a p-wave within 300ms. The impact of programming changes during follow-up on AV synchrony was studied.

RESULTS

816 hours of Holter ECG from 20 outpatients were analyzed. During predominantly paced episodes (≥80% ventricular pacing), median AV synchrony was 91% (IQR 34-100%) when patients had sinus rates 50-80/min. Median AV synchrony was lower when patients had sinus rates >80/min (33%, IQR 29-46%, p<0.001). During a stepwise optimization protocol, AV synchrony could be improved (p<0.038). Multivariate analysis showed that a shorter maximum A3 window end (p<0.001), a lower A3 threshold (p=0.046), and minimum A4 threshold (p<0.001) improved AV synchrony.

CONCLUSION

Successful VDD pacing in the outpatient setting during higher sinus rates is more difficult to achieve than can be presumed based on the initial feasibility studies. The devices often require multiple reprogramming to maximize AV sequential pacing.

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