Pulsed Doppler Verification of AtrialContribution to Ventricular Fillingin Sequential Pacing

MARINA PAULETTI, MAURIZIO RAUGI, GIANCARLO BINI.

PIETROPAOLO BELLI, and PASQUALE DEL BENE

From the Department of Gardiology, Hospital of Uvorno, Italy

PAULETTI, M., ET AL.: Pulsed Doppler verification of atrial contribution to ventricular filling in se-quential pacing. We have used puJsed Doppler to ascertain effective atrial contribulion to ventricularfilling in sequential pacemaker rhythm. The technique is parM'cuiaWy vaJuabie when eJectrocardiographicevidence of atrial capture is uncertain. (PACE, Vol. 10, March, 1987)

sequentiai pacing, pu/sed Doppier, atrial contraction, P wave

Introduction

The hemodynamic benefits of atrioventricu-lar synchrony are weil established.'"^ Atrial cap-ture, however, may be difficult to verify on ECGtracings. We used tbe pulsed Doppler techniqueto assess effective athal contribution to ventricularBlling.

Materials and Methods

We studied 15 patients with DDD pacemakersand predominating atrioventricular sequentialrhythm. Although different pacemaker modelswere used, atrial output was programmable in allunits.

In ail patients 12-lead ECG and pulsed Dop-pler echocardiography were simultaneously re-corded at different atrial outputs. Pulsed Dopplerecbocardiography was performed with an ultra-sonic pulsed Doppler flow meter incorporated ina real-time two-dimensional {2-D) ecbocardi-

ograph* with a mechanical sector scanner havinga 3.5 MHz probe. The Doppler signal was obtainedby placing the sample volume at the mitral levelusing an apical four-chamber 2-D echocardio-graphic view.

Results

When the output of the atrial channel wasabove tbe atrial pacing threshold, the pulsed Dop-pler recording showed the presence of a normalmitral flow, that is. a biphasic wave due to passiveventricular filling and to atrial contribution (Fig. 1).

In 13 out of 15 patients, simultaneous ECGrecording showed obvious atrial depolarizationfollowing an atrial spike. In 2 of 15 patients, elec-trocardiographic evidence of atrial capture wasequivocal, wbereas Doppier recording of mitralflow confirmed the presence of ventricular fillingdue to atria! contraction (Figs. 1. 2).

Absence of late diastolic peak flow velocityalways corresponded to a lack of atrial depolar-ization on an ECG tracing.

Address for reprints: P. Del Bene, MD. U.O. di Cardioangiologia,Spedali Riuniti di Livorno, viale V. Alfieri. 57100 Livomo. Italy.

Received March 24. 1986; accepted May 1, 1986. • Honeywell (Ultra-imager).

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Discussion

Atrial depolarization in sequential pacing isdifficult to ascertain on ECG tracings {Fig. 2). evenwhen all leads are recorded. Some manufacturerssuggest that there is reliahle atrial capture onlywhen the atrial spike is followed by a spontaneousQHS,* which is oflen impossible to obtain evenprolonging the AV delay to the highest values.However, the ECG may give indirect informationon atrial capture. If atrial sensing is present andatrial pacing is ineffective, a ventricular arrhyth-mia may ensue (Fig. 3); when there is no atrialcapture, retrograde P waves may be present (Figs.4, 5). If favorable conditions are present, pace-maker-mediated tachycardia may occur.^ In anycase, the evidence of atrial electrical activity fol-

lowing the pacing spike does not give adequateinformation on the effectiveness of atrial me-chanics.

The recording of mitral valve^ and right atrialmotion with TM echocardiography' allows betterassessment of atrial dynamics but gives no infor-mation about atrioventricular flow.

Doppler techniques^""* permit direct record-ing of such flow, which appears to be biphasic intbe case of effective atrial contraction. Examina-tion of the Doppler pattern allows certain identi-fication of atriai contribution to ventricular fillingand is particularly valuable when ECG tracingsare difficult to interpret (Figs. 6, 7). This techniquefacilitates the choice of atrial output in pacemakerpatients in order to ensure optimal hemodynamicsat lower energy consumption.

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Figure 2. Same pa(ienl as in Figure I at the same atrial output. Standard leads I. II. III. Electro-cardiographic evidence of atrial capture is equivocal.

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ATRIAL CONTRIBUTION TO VENTRICULAR FILLING

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ATRIAL CONTRIBUTION TO VENTRICULAR FILLINC

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References1. Benchimol A, Ellis IG, Dimond EG. Hemodynamic

consequences of atrial and ventricular pacing inpatients with normal and abnormal hearts. Am I 7.Med 1965:39:911.

2. Ogawa S. Dreifus LS. Sheney PN. et al. Hemody-namic consequences of atrioventricular and ven-triculoatrial pacing. PACE 1978; 1:8. 8.

3. Kristensson BE, Arnman K. Smedgard P. et al.Physiological versus single-rate ventricular pacing:a double blind cross-over study, PACE 1985; 8:73.

4. The Cordis guide to interpretation of DDD pacerECGs. Gordis Gorporation. 1984. Part 3. p. 10.

5. Bertholet M. Materne P, Dubois G. et al. Artificial 9.circus movement tachycardias: incidence, mech-anisms, and prevention. PAGE 1985; 8:415. 10.

6. Nanda NG, Gondi B. Falkoff MD. et al. Two-di-mensional echocardiographic evaluation of pacing

function. In GA Feruglio (Ed.): Cardiac Pacing.Piccin Medical Books. Padova. 1982, p. 817.Drinkovic N. Ferek B. [ursic M. Subcostal M-modeechocardiography of the rigbt atrial wall in eval-uation of cardiac arrhythmias and pacing. PAGE1985; 8:110.Baker DW. Two-dimensional echo imaging andpulsed Doppler blood flow detection: A compre-hensive approach to cardiovascular diagnosis. InP Hanrath. W Bleifold, I Souquet (Eds.): Gardio-vascular diagnosis by ultrasound, Martinus Nijhoff.The Hague, 1982, p. 97,Schuster AH. Nanda NC. Doppler echocardiogra-phy and cardiac pacing. PAGE 1982; 5:607.Nanda NG. Bhandari A. Barold SS. et al. Dopplerechocardiographic studies in sequential atrioven-tricuiar pacing. PAGE 1983; 6:811.

At a meeting of the N A S P E Board of Trus tees on January 11,1987. NASPE adopteda portion of a new generic pacen\aker code to supersede the 5-po5ition ICHD Co<le.

The following modifications recommended by the NASPE Mode Code Committeewere adopted: the addition of "0" ("none") in Position I. the deletion of "R" ("reverse")in Position III. and the addition of "R" ("rate modulation") in Position IV. It was alsodecided to eliminate the optional comma after Position III. and to require a minimum offour positions (examples: VOOO, DVIM. W I R ) . Further changes are being consideredand a detailed report will be issued in the near future.

Alan D. Bernstein. Eng.Sc.D.Secretary. NASPE Mode Code Committee

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