Behavior of AV synchrony pacing mode in a leadless pacemaker during variable AV conduction and arrhythmias

Christophe Garweg, Surinder Kaur Khelae, Joseph Yat Sun Chan, Larry Chinitz, Philippe Ritter, Jens Brock Johansen, Venkata Sagi, Laurence M Epstein, Jonathan P Piccini, Mario Pascual, Lluis Mont, Rik Willems, Vincent Splett, Kurt Stromberg, Todd Sheldon, Nina Kristiansen, Clemens Steinwender, Christophe Garweg, Surinder Kaur Khelae, Joseph Yat Sun Chan, Larry Chinitz, Philippe Ritter, Jens Brock Johansen, Venkata Sagi, Laurence M Epstein, Jonathan P Piccini, Mario Pascual, Lluis Mont, Rik Willems, Vincent Splett, Kurt Stromberg, Todd Sheldon, Nina Kristiansen, Clemens Steinwender

Abstract

Introduction: MARVEL 2 assessed the efficacy of mechanical atrial sensing by a ventricular leadless pacemaker, enabling a VDD pacing mode. The behavior of the enhanced MARVEL 2 algorithm during variable atrio-ventricular conduction (AVC) and/or arrhythmias has not been characterized and is the focus of this study.

Methods: Of the 75 patients enrolled in the MARVEL 2 study, 73 had a rhythm assessment and were included in the analysis. The enhanced MARVEL 2 algorithm included a mode-switching algorithm that automatically switches between VDD and ventricular only antibradycardia pacing (VVI)-40 depending upon AVC status.

Results: Forty-two patients (58%) had persistent third degree AV block (AVB), 18 (25%) had 1:1 AVC, 5 (7%) had variable AVC status, and 8 (11%) had atrial arrhythmias. Among the 42 patients with persistent third degree AVB, the median ventricular pacing (VP) percentage was 99.9% compared to 0.2% among those with 1:1 AVC. As AVC status changed, the algorithm switched to VDD when the ventricular rate dropped less than 40 bpm. During atrial fibrillation (AF) with ventricular response greater than 40 bpm, VVI-40 mode was maintained. No pauses longer than 1500 ms were observed. Frequent ventricular premature beats reduced the percentage of AV synchrony. During AF, the atrial signal was of low amplitude and there was infrequent sensing.

Conclusion: The mode switching algorithm reduced VP in patients with 1:1 AVC and appropriately switched to VDD during AV block. No pacing safety issues were observed during arrhythmias.

Trial registration: ClinicalTrials.gov NCT03752151.

Keywords: AV synchrony; arrhythmias; atrial fibrillation; leadless pacing; paroxysmal AV block.

© 2021 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

Figures

Figure 1
Figure 1
Percentage ventricular pacing by rhythm. The two subjects with sinus bradycardia and high percentage pacing had sinus rate frequently less than 40 bpm, leading to ventricular pacing at lower rate (and mode switching to VDD mode). Percentage pacing varied during atrial arrhythmias depending upon conduction of the AF to the ventricles. Values represent median and interquartile range (in brackets). AF, atrial fibrillation; AVB, complete (third degree) AV block; NSF, normal sinus node function
Figure 2
Figure 2
(A) AV conduction mode switch in patient with third degree heart block. Initial mode switch to VVI‐40 does not find 1:1 AV conduction so pacing mode switches to VDD. Lower waveform shows accelerometer signal expanded out for one beat to show individual components of cardiac cycle and blanking (PVAB) and sensing (A3 Window and A4 Window) periods. (B) AV conduction mode switch in patient with 1:1 AV conduction (and first degree AVB). Mode switch to VVI‐40 finds 1:1 AV conduction, so mode remains VVI‐40. AS, atrial sense; MS, mode switch; VE, end of A3 (ventricular) window; VP, ventricular pace; VVI, ventricular only antibradycardia pacing
Figure 3
Figure 3
Reduction in percentage of ventricular pacing from VVI (Micra VR initial interrogation) to VDD mode with activated mode switch to VVI‐40. Values above each boxplot represent median and interquartile range. VVI, ventricular only antibradycardia pacing
Figure 4
Figure 4
Example behavior during PVCs. (A) shows minimal disruption in atrial sensing after a PVCs (arrow). (B) shows multiple beats are needed to re‐establish AV synchrony since sinus beat occurred after ventricular pace beats. AS, atrial sense; PVC, premature ventricular contraction; VE, end of A3 (ventricular) window; VP, ventricular pace
Figure 5
Figure 5
Example behavior during PACs. A late coupled PAC (left arrow) is tracked without loss of AV synchrony while an early coupled PAC (right arrow) is not tracked since it is in the blanking period (PVAB). AV, atrio‐ventricular; PAC, premature atrial contraction; PVC, premature ventricular contraction

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