22 / 60
CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 1, January/February 2021
20
AFRICA
of pacemaker for SND should not be guided by the risk of
subsequent AF alone.
This study showed no difference in the rate of device infection
between the two groups (1.9% in the AAIR versus 1.6% in the
DDDR group,
p
= 1.00). These findings are similar to those
observed in the DANPACE trial, which showed no difference
in device infection between AAIR and DDDR pacing (0.4% in
both groups,
p
= 0.98).
6
This study also showed no difference
in the need for lead/s revision (7.4% in AAIR versus 3.2% in
DDDR group,
p
= 0.42). Similar findings were observed in
the DANPACE trial where no differences in the need for lead
revision were found between the two groups (5.2% in the AAIR
versus 4.2% in the DDDR groups,
p
= 0.42).
6
The DANPACE
trial reported that subsequent lead revision was associated with a
high complication rate. This study had only six lead revisions and
no complications were noted in any of these six patients.
Study limitations
This was a retrospective study from a single institution with a
relatively small number of patients. The conclusions are therefore
hypothesis generating. However, the results reflect real-world
practice in a contemporary South African population. Larger
randomised trials using AV nodal functional testing as required
need to be adopted. The interpretation of ECGs showing AF was
made by cardiac technologists who routinely perform pacemaker
device interrogations in the device clinic. It is possible that the
technologists may not have recognised AF and may have under-
reported episodes of AF. This study has all the limitations of a
retrospective study, including missing information. It is possible
that patients in the AAIR group who developed AV block may
have been lost to follow up or died. However, the numbers of
deaths between the two groups were similar.
Conclusion
In this typical elderly populationwho presentedwith symptomatic
SND, we found functional AV nodal testing with atrial pacing at
the time of pacemaker implantation to be a useful tool to help
guide the implanter about the choice of AAIR or DDDR pacing.
Patients who underwent AAIR pacing had a low subsequent risk
of AF, AV block or lead revision. In resource-limited settings,
AAIR pacing should be considered as an alternative to DDDR
pacing. Patients with AAIR pacemakers should be counselled
regarding future symptoms of AV block, and device follow up
may be required on a six-monthly basis to rule out the need for
ventricular pacing. Randomised trials are required to further
define the role of AV nodal functional testing.
We acknowledge the Department of Medicine, University of Cape Town
for their enormous support, as well as all the staff in the Medical Records
Department and Catheterisation Laboratory pacing unit at GSH for provid-
ing relevant documents, which were used for data collection.
References
1.
Rubenstein JJ, Schulman CL, Yurchak PM, Desanctis RW. Clinical
spectrum of the sick sinus syndrome.
Circulation
1972;
XLVI
(46): 5–13.
2.
Nielsen JC. Pacing mode selection in patients with sick sinus syndrome.
Dan Med Bull
2007;
54
(1): 1–17.
3.
Mond HG, Irwin M, Morillo C, Ector H. The World Survey of Cardiac
Pacing and Cardioverter Defibrillators: Calendar Year 2001. Vol. 27,
PACE – Pacing and Clinical Electrophysiology. 2004: 955–964.
4.
Brignole M, Auricchio A, Baron-Esquivias G,
et al
. 2013 ESC guidelines
on cardiac pacing and cardiac resynchronization therapy.
Eur Heart J
2013;
34
: 2281–2329.
5.
Gregoratos G, Abrams J, Epstein AE,
et al.
ACC/AHA/NASPE 2002
guideline update for implantation of cardiac pacemakers and antiar-
rhythmia devices: summary article. A report of the American College
of Cardiology/American Heart Association Task Force on Practice
Guidelines (ACC/AHA/NASPE committee)
Circulation
2002;
106
(16):
2145–2161.
6.
Nielsen JC, Thomsen PEB, Højberg S,
et al
. A comparison of single-
lead atrial pacing with dual-chamber pacing in sick sinus syndrome.
Eur
Heart J
2011;
32
(6): 686–696.
7.
Masumoto H, Ueda Y, Kato R,
et al.
Long-term clinical performance
of AAI pacing in patients with sick sinus syndrome: A comparison with
dual-chamber pacing.
Europace
2004;
6
(5): 444–450.
8.
Bonny A, Ngantcha M, Jeilan M, Okello E, Kaviraj B, Talle MA,
et
al
. Statistics on the use of cardiac electronic devices and interventional
electrophysiological procedures in Africa from 2011 to 2016: Report of
the Pan African Society of Cardiology (PASCAR) Cardiac Arrhythmias
and Pacing Task Forces.
Europace
2018;
20
(9): 1513–1526.
9.
Brandt J, Anderson H, Fåhraeus T, Schüller H. Natural history of sinus
node disease treated with atrial pacing in 213 patients: Implications for
selection of stimulation mode.
J Am Coll Cardiol
1992;
20
(3): 633–639.
10. Swiatecka G, Sielski S, Wilczek R, Jackowiak D, Kubica J, Raczak G.
Atrioventricular conduction disturbances in patients with sinoatrial
node disease and atrial pacing.
Pacing Clin Electrophysiol
1992;
15
(11
II): 2074–2076.
11. Rosenqvist M, Obel IWP. Atrial pacing and the risk for AV block: is
there a time for change in attitude?
Pacing Clin Electrophysiol
1989;
12
(P1): 97–101.
12. Andersen HR, Nielsen JC, Thomsen PEB, Thuesen L, Vesterlund T,
Pedersen AK,
et al
. Atrioventricular conduction during long-term
follow-up of patients with sick sinus syndrome.
Circulation
1998;
98
(13):
1315–1321.
13. Kristensen L, Nielsen JC, Pedersen AK, Mortensen PT, Andersen HR.
AV block and changes in pacing mode during long-term follow-up
of 399 consecutive patients with sick sinus syndrome treated with an
AAI/AAIR pacemaker.
PACE – Pacing Clin Electrophysiol
2001;
24
(3):
358–365.
14. Fahy G, Pinski S, Miller D, McCahe N, Pye C, Walsh M,
et al
. Natural
history of isolated bundle branch block.
Am J Cardiol
1996;
77
(14):
1185–1190.
15. Brandt NH, Kirkfeldt RE, Nielsen JC,
et al.
Single lead atrial vs. dual
chamber pacing in sick sinus syndrome: Extended register-based follow-
up in the DANPACE trial.
Europace
2017;
19
(12): 1981–1987.