Functional atrial undersensing associated with switching to a tracking mode of pacing

We have previously demonstrated that contemporary St. Jude devices (pacemakers and implantable cardioverter-defibrillators [ICDs]; St. Jude Medical, Sylmar, CA, USA) are designed to generate an extended postventricular atrial refractory period (PVARP) of 475 ms at the termination of conventional automatic mode switching (AMS) in response to atrial tachyarrhythmias . This response may cause functional atrial undersensing . A similar PVARP response unrelated to conventional AMS was found in four St. Jude devices (three ICDs and one pacemaker) whenever a nontracking pacing mode switched to a tracking DDD(R) mode. PVARP extension and functional atrial undersensing were observed when the VOO, VVI, and the DDI(R) modes (unrelated to conventional AMS) switched to the DDD(R) mode . In one patient the switch from the OOO mode (in the programmed noise reversion mode) to the DDD mode occurred after cessation of electromagnetic interference disturbing the ventricular channel. In this case PVARP extension was seen only in the corresponding markers because no P waves occurred coincidentally with the extended PVARP. The PVARP extension caused by a mode switch to the tracking function was designed to prevent sensing of a retrograde P wave on the first cycle of the reestablished tracking mode. The observed functional atrial undersensing is a normal manifestation of device function and must not be misinterpreted as a true atrial undersensing problem.