Diagnostic value of stored electrograms in single-lead VDD systems

Evaluation of the quality of atrial sensing is indispensable to monitor the performance of VDD single-lead systems. In addition to counters, a new VDD system offers storage of intracardiac electrograms (EGMs). The clinical contribution of stored EGMs in a VDD pacemaker was prospectively examined in a multicenter study, and the reliability of its counters was evaluated on the basis of EGM information.

A VDD system (Pulsar 870, Guidant Co.) was implanted in 46 patients with atrioventricular block. EGM storage was activated upon detection of ventricular tachycardia (VT), recurrent premature ventricular complexes (PVCs), and mode switch ("atrial tachy reaction," ATR). Stored EGMs were retrieved before discharge of the patients from the hospital, and at 6-week, 3-month, and 6-month follow-up.

A total of 440 stored EGMs were retrieved and analyzed. Of 30 VT episodes detected, 2 (7%) were confirmed, and all others were attributable to ventricular oversensing. One postmortem interrogation documented VT as the cause of sudden death. Of 175 EGMs stored upon detection of PVCs, 43 episodes (25%) were confirmed and 124 (70%) showed intermittent atrial undersensing with spontaneous AV conduction; in 8 episodes (5%) no abnormality was observed. Of 235 episodes stored upon ATR, 82 (35%) were confirmed and 153 were due to atrial oversensing.

(1). Stored EGMs indicated a high percentage (69%) of event misdiagnosis by the pacemaker. Thus, pacemaker counter information without the availability of stored EGMs should be interpreted with caution. (2). Misclassified events are of high clinical importance since they unmask otherwise unsuspected intermittent under- or oversensing.