Noise reversion of a dual chamber pacemaker without noise

Three patients are reported whose DDD pacemakers reverted to the asynchronous mode in the absence of skeletal muscle or electromagnetic (EMI) interference. In all three cases, the basic cardiac rhythm was atrial fibrillation with fast ventricular response due to intrinsic AV conduction. Noise reversion was triggered by the patients' own ventricular activity at cycle lengths shorter than the ventricular refractory period of the pulse generator. In one patient, asynchronous AV sequential pacing during atrial fibrillation was noted shortly after resuscitation from ventricular fibrillation; however, the initiation of the malignant ventricular arrhythmia by the pacemaker remains unproven. The mechanism of noise reversion by rapid cardiac activity and possible solutions to the problem by adequate pacemaker design are discussed.