European Heart Journal Advance Access originally published online on February 23, 2006
European Heart Journal 2006 27(9):1127; doi:10.1093/eurheartj/ehi804
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Pacemaker selection: time for a rethinking of complex pacing systems: reply
Internal Medicine and Cardiology Institute
University of Florence
V.le Morgagni 85
50134 Florence
Italy
Tel: +39 0557497634
E-mail address: lpadeletti{at}interfree.it
Internal Medicine and Cardiology Institute
University of Florence
V.le Morgagni 85
50134 Florence
Italy
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 clinical 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 developing 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 consequence of this is a further increase of difference 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 insignificant 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.
References
- 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.
[Abstract/Free Full Text] - 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.
- 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.
[Abstract/Free Full Text] - 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.
[Abstract/Free Full Text] - Lamas GA, Orav EJ, Stambler BS, Ellenbogen KA, Sgarbossa EB, Huang SK, Marinchak RA, Estes NA, Mitchell GF, Lieberman EH, 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.
[Abstract/Free Full Text]
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