1126
Guiqing Yao resolved immediately by reprogramming to
University of Birmingham
UK
Melanie J. Calvert
University of Birmingham
UK
John G.F. Cleland
Department of Cardiology
University of Hull
Castle Hill Hospital
Kingston upon Hull
UK
Lucinda Billingham
University of Birmingham
UK
Jean-Claude Daubert
Department of Cardiology
Hôpital Pontchaillou
Rennes
France
Stirling Bryan
University of Birmingham
UK
doi:10.1093/eurheartj/ehi803
Online publish-ahead-of-print 23 February 2006
Pacemaker selection: time for a
rethinking of complex pacing systems
The article by Musilli and Padeletti is a
thought-provoking challenge to the wide-
spread use of DDD pacing. They suggest
that single-chamber devices, AAI and VVI,
are a more rational choice in most cases of
sinus node disease (SND) and AV block,
respectively.
The authors advocate VVI systems instead
of DDD systems because of non-inferiority
with regard to stroke and mortality, as
shown by MOST, CTOPP, PASE, and UKPACE.
However, in patients paced for a slower
intrinsic rate, a significantly higher mortality
has been reported using VVI vs. DDD
systems.1 These studies also show that VVI
pacing increases the risk of developing
chronic atrial fibrillation (AF) by 20%. AF is
the leading arrhythmia cause of hospitaliz-
ation, increases the risk of stroke by five-
fold, and doubles mortality,2 but the
number needed to treat with a DDD system
(CTOPP) to prevent AF is nine. MOST
showed heart failure hospitalization
reduction of 27% with DDD pacing.
MOST and PASE show the incidence of
pacemaker syndrome (PMS) to be about
25–33%, which occurred early and was
2. Benjamin EJ, Wolf PA, D’Agostino RB,
DDD mode.3 It is likely that the lower inci-
dence of PMS reported in CTOPP is because
reoperation rather than reprogramming was
required biasing their results. If 30% of
patients require an upgrade to the DDD
mode early after implantation of a VVI
system, the effects on patients’ quality of
life and healthcare costs will be marked. A
recent meta-analysis showed that the cost
difference between single and dual-chamber
systems over 5 years is small—£700 more for
dual-chamber devices.4
The authors suggest AAI systems, by
reducing ventricular pacing, should be used
instead of DDD systems in patients with
SND because of ‘low’ requirement of
upgrade to DDD (0.6–8.4%). This is not insig-
nificant, and therefore, AAIR implantation
for SND is only 1–3% in the US and central
Europe. Manufacturers have addressed this
by developing algorithms that reduce
ventricular pacing to a minimum with a
‘pseudo-AAI’ mode with backup ventricular
pacing, if required. It is likely that the
benefits observed by Nielsen et al. with AAI
pacing can be extrapolated to these new
DDD devices. This is further supported by
the linear relationship of ventricular pacing
percentage and heart failure hospitalization
and risk of AF in MOST. Large studies with
these newer DDD systems may show superior-
ity over VVI pacing and should be awaited
before prematurily abandoning DDD pacing.
DDD devices also improve patient diagnos-
tics allowing accurate arrhythmia detection
and enhanced pacemaker programming and
can inform or monitor drug treatment and
need for anti-coagulation. AF episodes
recorded in this way have been shown to
predict stroke5 and improve treatment by
reducing AF-related hospitalizations.6 With
home telemetry of Holter data, these moni-
toring features are going to become a crucial
aspect of modern devices.
Technological advances in device therapy
will continue. With clearer identification of
treatment goals, for example, less arrhyth-
mia symptoms, reduced arrhythmia burden,
beneficial remodelling effects, improved
quality of life, or better exercise capacity,
we will understand whether increasing com-
plexity of device hardware is beneficial and
cost-effective. It is our opinion that these
objectives will not be met by the use of
simple systems.
Reference
1. Tang AS, Roberts RS, Kerr C, Gillis AM, Green MS,
Talajic M, Yusuf S, Abdollah H, Gent M,
Connolly SJ. Relationship between pacemaker
dependency and the effect of pacing mode
on cardiovascular outcomes. Circulation 2001;
103:3081–3085.
Letters to the Editor
Silbershatz H, Kannel WB, Levy D. Impact of
atrial fibrillation on the risk of death. The
Framingham heart study. Circulation 1998;98:
946–952.
3. Ellenbogen KA, Stambler BS, Orav EJ,
Sgarbossa EB, Tullo NG, Love CA, Wood MA,
Goldman L, Lamas GA. Clinical characteristics
of patients intolerant to VVIR pacing. Am J
Cardiol 2000;86:59–63.
4. Castelnuovo E, Stein K, Pitt M, Garside R, Payne E.
The effectiveness and cost-effectiveness of
dual-chamber pacemakers compared with
single-chamber pacemakers for bradycardia
due to atrioventricular block or sick sinus
syndrome: systematic review and economic
evaluation. Health Technol Assess 2005;9:1–262
5. Glotzer TV, Hellkamp AS, Zimmermann J,
Sweeney MO, Yee R, Marinchak R, Cook J,
Paraschos A, Love J, Radoslovich G, Lee KL,
Lamas GA. Atrial high rate episodes detected
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on December 16, 2016
by pacemaker diagnostics predict death and
stroke: report of the atrial diagnostics ancillary
study of the MOde Selection Trial (MOST).
Circulation 2003;107:1614–1619.
6. Padeletti L, Santini M, Boriani G, Botto G,
Gulizia M, Molon G, Luzzi G, Senatore G,
Giraldi F, Zolezzi F, Pieragnoli P, Pro F, Desanto
T, Grammatico A. Long-term reduction of
atrial tachyarrhythmia recurrences in patients
paced for bradycardia–tachycardia syndrome.
Hearth Rhythm 2005;2:1047–1057.
John Silberbauer
Department of Cardiology
Eastbourne General Hospital
Kings Drive
Eastbourne BN21 2UD
UK
Tel: þ44 1323 417400
Fax: þ44 1323 435821
E-mail address: johnsilberbauer@lycos.com
Neil Sulke
Eastbourne General Hospital
Eastbourne
UK
Carsten W. Israel
J.W. Goethe University
Frankfurt
Germany
Nils Edvardsson
Sahlgrenska University Hospital
Goethenborg
Sweden
Lluis Mont
Hospital Clinico y Provincial
Unidad de Arritmias y Electrofisiologia
Barcelona
Spain
Letters to the Editor
Josef Kautzner
Department of Cardiology
Institute for Clinical and
Experimental Medicine
Prague
Czech Republic
Phillippe Ritter
Cabinet de Cardiologie
Saint-Cloud
France
A. John Camm
Department of Cardiology
St George’s Hospital
London
UK
doi:10.1093/eurheartj/ehi804
Online publish-ahead-of-print 23 February 2006
Pacemaker selection: time for a
rethinking of complex pacing systems:
reply
We appreciate the interest in our article
expressed by Silberbauer and colleagues.
We are surprised to read that we ‘advocate
VVI systems instead of DDD systems
because of non-inferiority with regard to
stroke and mortality as shown by MOST,
CTOPP, PASE, and UKPACE.’ Indeed, we
never mentioned UKPACE trial,1 published
in July 2005, until the submission of our
article.
UKPACE trial (in which John Camm is one
of the top investigators) compared the clini-
cal effects of VVI(R) pacing and DDD(R)
pacing in elderly patients with high-grade
AV block. No significant differences were
observed between the two pacing modes in
the rates of deaths from all causes, atrial
fibrillation, heart failure, or a composite of
stroke, transient ischaemic attack, or other
thromboembolisms.1 This confirms exactly
what we wrote about the treatment of
patients with AV block.
Regarding the pacemaker syndrome, data
from CTOPP trial are totally confirmed by
UKPACE trial. The clinical significance of
this has been underlined by Toff et al. 1:
‘The low crossover rate (3.1%) from single-
chamber to dual-chamber pacing in our
study was similar to that in the CTOPP trial
(2.7%) suggesting that single-chamber
pacing is well tolerated.’
Moreover, in CTOPP, the percentage of
patients who crossed from DDD to VVI mode
at 5 years was 17.1%. If we consider that in
this group the annual rate of patients devel-
oping atrial fibrillation and consequently
crossed to ventricular pacing was 5.3%, the
difference in part or entirely is to be ascribed
to intolerance of dual chamber stimulation.2
Thus, we greatly appreciate what was
written by Toff et al.1: ‘Our results, supported
by the PASE and CTOPP trials, suggest that the
clinical benefits associated with dual-
chamber pacing for atrioventricular block
have been overestimated.’
This reply gives us the opportunity to
introduce an important point that we did
not consider in our article: the incidence of
perioperative complications in dual-chamber
pacing resulted significantly higher in both
UKPACE1 and CTOPP3 trials. The conse-
quence of this is a further increase of differ-
ence in costs between dual-chamber and
single-chamber devices.
Concerning the new DDD pacemakers
equipped with algorithms for minimizing
the ventricular pacing in patients with sinus
node disease (SND), we believe that: (i) in
the absence of data from large trials, it is
not scientifically correct to extrapolate the
benefits observed by Nielsen et al.4 with
atrial pacing to these new devices; (ii) the
percentage of patients with SND who
develop AV block is low even if not insignifi-
cant in some reports, as mentioned by
Silberbauer et al.; a strategy of routine
implantation of such a pacemaker whose
cost is higher by at least ]2000 to one SSIR
is totally unjustified; (iii) these new DDD
devices in the presence of advanced AV
block work just as the traditional ones; the
reasons why they may show superiority
over VVI pacing and furnish different
results from UKPACE1 and PASE5 trials
remain yet to be explained.
Reference
1. Toff WD, Camm AJ, Skehan JD. Single-chamber
versus dual-chamber pacing for high-grade
atrioventricular block. N Engl J Med 2005;
353:145–155.
2. Gilligan DM, Morillo CA, Wood MA, Ellenbogen
KA. Hemodynamics of pacing: new aspects and
unresolved issues. In: Barold SS, Mugica J, eds.
Recent Advances in Cardiac Pacing. Goals
for the 21st Century. Armonk, NY: Futura
Publishing Company, Inc.; 1998. p3–34.
3. Connolly SJ, Kerr CR, Gent M, Roberts RS, Yusuf
S, Gillis AM, Sami MH, Talajic M, Tang AS, Klein
GJ, Lau C, Newman DM. Effects of physiologic
pacing versus ventricular pacing on the risk of
stroke and death due to cardiovascular causes.
N Engl J Med 2000;342:1385–1391.
4. Nielsen JC, Kristensen L, Andersen HR,
Mortensen PT, Pedersen OL, Pedersen AK. A
randomized comparison of atrial and dual-
chamber pacing in 177 consecutive patients
with sick sinus syndrome: echocardiographic
and clinical outcome. J Am Coll Cardiol
2003;42:614–623.
5. Lamas GA, Orav EJ, Stambler BS, Ellenbogen
KA, Sgarbossa EB, Huang SK, Marinchak RA,
Estes NA III, Mitchell GF, Lieberman EH,
1127
Mangione CM, Goldman L. Quality of life and
clinical outcomes in elderly patients treated
with ventricular pacing as compared with dual-
chamber pacing. N Engl J Med 1998;338:
1097–1104.
Luigi Padeletti
Internal Medicine and Cardiology Institute
University of Florence
V.le Morgagni 85
50134 Florence
Italy
Tel: þ39 0557497634
E-mail address: lpadeletti@interfree.it
Nicola Musilli
Internal Medicine and Cardiology Institute
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on December 16, 2016
University of Florence
V.le Morgagni 85
50134 Florence
Italy
doi:10.1093/eurheartj/ehi805
Online publish-ahead-of-print 16 February 2006
Gatekeeper for coronary angiography
We would like to compliment Hoilund-Carlsen
and colleagues on their well-designed study
on myocardial perfusion scintigraphy (MPS)
as gatekeeper for coronary angiography.1
However, we have some doubts with regard
to the use of MPS in a not-low-risk popu-
lation. In this selection of patients scheduled
for coronary angiography, obstructive coro-
nary artery disease (CAD) was present in
half of the population. This is more than
twice the prevalence found in populations
screened for acute chest pain.2 In such
not-low-risk populations, it has been
advised to use a test with high sensitivity
to identify all patients with the most
severe forms of disease in order to improve
event-free survival and cost-effectiveness
at a long term.3 In our opinion, a sensitivity
of 81% for obstructive CAD and 94% for three-
vessel disease, as was found by Hoilund-
Carlsen and colleagues, is too low to
incorporate MPS as effective gatekeeper in
a pre-coronary angiography strategy.
Furthermore, we share their concern that
too many coronary angiographies are per-
formed in patients with normal coronary
arteries. A diagnostic test with a high-
negative predictive value could therefore
best serve as a filter for coronary angio-
graphy, but the estimated negative predic-
tive value of MPS for obstructive CAD was
only 82%. We suggest that other imaging
modalities, such as electron beam computed
tomography (EBCT), may better serve as an