Pseudo repetitive non-reentrant ventriculoatrial synchrony: Current challenges

Area of Science:

• Cardiology
• Electrophysiology
• Medical Devices

Background:

• A novel pacemaker-mediated arrhythmia, pseudo-RNRVAS, mimics repetitive non-reentrant ventriculoatrial synchrony (RNRVAS) but can occur in patients with ventriculoatrial (VA) block.
• This arrhythmia arises from sinus P-waves trapped in the post-ventricular atrial refractory period (PVARP), mimicking VA conduction and potentially triggering atrial fibrillation (AF) due to subsequent atrial pacing.
• Recognition and differentiation of pseudo-RNRVAS from RNRVAS are challenging as most cardiac implantable electronic devices (CIEDs) do not store these events.

Purpose of the Study:

• To illustrate the practical challenges in assessing pseudo-RNRVAS.
• To provide safe and effective programming strategies for preventing pseudo-RNRVAS and mitigating the risk of RNRVAS in patients with CIEDs.

Main Methods:

• Case illustration of 10 patients with pseudo-RNRVAS, detailing its characteristics and treatment.
• Follow-up assessment of pseudo-RNRVAS recurrence at 6 months.
• Implementation of pacing parameter adjustments, including shortening PVARP, inactivating/reducing rate response, and lowering basic pacing rate.

Main Results:

• Inappropriate atrial pacing during pseudo-RNRVAS led to AF in six patients.
• Adjustments to pacing parameters successfully prevented or reduced pseudo-RNRVAS in nine out of ten patients.
• One patient developed permanent AF, while pseudo-RNRVAS was avoided in eight and reduced in one patient.

Conclusions:

• Pseudo-RNRVAS is a significant pacemaker-mediated arrhythmia that can occur without VA conduction and precipitate AF.
• The study demonstrates that specific programming adjustments to CIEDs are safe and effective in preventing pseudo-RNRVAS.