SSS and Afib/ADOPT A

Hi everybody:
I have posted on here before about having had a pacemaker before my ablation. I start passing out when I was 13. Finally got a pacemaker when I was 45. It was removed during my ablation, because the tip had perforated my right ventricle. I have had one sudden drop blackout in the last few months, and again am thinking about having the pacemaker replaced. I have posted on here before some discussions about atrial burst or overdrive pacing for those of us with SSS and Afib. I have also talked about atrial defibrillators. I found this stury interesting. It was a trial for implanted pacemakers with overdrive pacing capabilities. ADOPT stands for Atrial Dynamic Overdrive Pacing Trials.
I know some of you share this problem with me - SSS and afib. What do you think of this? Or, does anyone know anything further about it?

[www.pslgroup.com]

Pam

What is SSS?

Will,

Sick Sinus Syndrome.

Pam,

What an interesting article. I have cross referenced to another that has copious footnoting for further investigation. According to the quick review of literature I did, this pacing is certainly cutting edge and most Doctor's hold this technique with high hopes, especially for PAF.

Seems most articles on the web are referencing the article you highlighted though.

Please see the following article:

[www.cacr.ca]

Joe

Pam,

Here is another abstract about ADOPTA that is very current.

Joe

Pacing and Clinical Electrophysiology
Volume 26 Issue 9 Page 1841 - September 2003
doi:10.1046/j.1460-9592.2003.t01-1-00278.x


Effect of Right Atrial Overdrive Pacing in the Prevention of Symptomatic Paroxysmal Atrial Fibrillation:
A Multicenter Randomized Study, the PAF-PACE Study
STEFAN WIBERG*, STEFAN LÖNNERHOLM, STEEN M. JENSEN, PER BLOMSTRÖM, IVAR RINGQVIST* and CARINA BLOMSTRÖM-LUNDQVIST

The aim of this study was to assess if right atrial overdrive pacing can suppress symptomatic episodes of paroxysmal atrial fibrillation (PAF) in patients without bradyarrhythmias. Forty-two patients with frequent and symptomatic PAF without other pacing indication had a pacemaker implanted after a 4-week run-in period, during which the frequency of symptomatic PAF episodes and the mean heart rate were objectively documented. Depending on the mean heart rate recorded during run-in, the pacemaker was programmed in random order to right atrial AAI pacing at 10-19 beats/min > mean heart rate (medium overdrive [MO]), at 20-29 beats/min > mean heart rate (high overdrive [HO]) and to no pacing (OAO mode) for 4-12 weeks each using a crossover design. In the 35 patients who completed the protocol, the number of symptomatic episodes of PAF (>30-second duration) per week was significantly lower during MO pacing (median 0.88, P = 0.001, n = 35) and during HO pacing (median 0.75, P = 0.002, n = 20) than during OAO (median 2.02 and 2.04, respectively). There was no difference between MO and HO pacing in the 20 patients paced at both rates (0.97 vs 0.75, P = 0.33). Seven patients did not complete the protocol due to persistent atrial fibrillation (n = 4), angina pectoris requiring surgery (n = 1), and unwillingness to continue the study due to improvement (n = 1) or worsening (n = 1) of symptoms during the study periods. Right atrial overdrive pacing can reduce the number of symptomatic PAF episodes in patients with frequent and drug refractory PAF but without bradyarrhythmias. (PACE 2003; 26:1841-1848)

Joe:
I think in Greek Pisan, or Pisano means friend? Thanks for the links. It seems like a promising alternative to PVA. I think the longevity of improvement or absence of afib in PVA has yet to be documented. Overdrive pacing seems to carry less risk as well. All the studies seem to be using patients who don't otherwise require pacing, although they used subjects who had bradycardia. What a great idea for those who are recommended for pacemakers anyway, and have afib. The studies I have seen don't talk about burst pacing for converting PAF though. I heard that was in the works as well.
I can remember many years ago (15 or 18 years) in working in CCU, having cardiac patients who had temporary pacemakers and went into uncontrolled afib. The temporary pulse generator was lying on their chest much like a telemetry pack. If their afib rate took off with a ventricular rate of 140, we could just pick up the pulse generator with its controlls, and dial the rate up to 160 for 5 minutes or so and slowly start to dial the rate back down, at maybe 3 beats every 5 minutes and almost always were able to recapture the sinus node. I remember very well doing that.
It will be interesting to see where this goes. After what happened to me during PVA, and given that I may have to get a pacemaker anyway, I'm going to be watching the progress of this.

Pam

Pam,

My name comes from the Italian word Pisan, which you correctly indicates means friend. The O is inflective of the language's male gender. There are many variations of the name... Pisana, Pisani, Pisanolo, etc.

I was born in America, as were my parents, but I come from a very typical Italian Family, Large, Loving and very Family Oriented all the way out to the 3rd and 4th cousins!. It is nice.

Thanks for noticing.

Joe

Pam:

A few years ago they were talking about a pacer to override AF, some people have this feature on their pacers I don't know if it works for them, this may be something different however. I had my pacemaker implanted in 1999, it is a dual pacer but doesn't have the ability that the article you submitted talks about.

If this works, I already have dual leads, perhaps the controls could be changed. They said I have SSS, I don't know about that for certain, the only times that I had a problem with almost blacking out was when I would go from being in AF to converting back into NSR. In fact, the 6 months before I started to have this problem I was hypo (low thyroid) and was taking 25 mg. of a beta blocker, ambien and ativan, as I look back that was a very bad mix. I was hypo and these downers either gave me SSS or acted like it. I peeked at my chart when I was in my EPs office and it noted that the SSS could have been caused by the beta-blocker. I don't know if I would have recovered after getting my thyroid levels where they should be and getting off the downers or if the damage was permanent.

Thanks for the post Pam, the next time I see my EP I am going to talk to him about this.

Liz H. (there are two of us now, but, I am Liz H. and have been on this board for about a year and a half)

Pam,

I am an MT(ASCP) and don't have anywhere near the direct patient-care clinical knowledge and experience that you do, considering all of your years of CCU. I basically understand the articles and your questions and find it very interesting. Thank you. I certainly hope it is something that will be of benefit in your case. I don't have SSS (that I know of), although I had three different episodes of partial black-out during the 'recovery' period (which really wasn't) after my first ablation (for Afib.) when my heart rate would go over 200. CC basically explained it as the usual heart irritability during the recovery period. Then I went into persistent flutter, had a second ablation, and haven't experienced it since.

My question: During the second ablation toward the end of the (approx. 3 to 3.5 hrs.), as they were finishing I experienced a very painful kind of thumping sensation...about 4-5 times. I know I moaned because it hurt a lot, in spite of the anesthetic! Someone said something like, "hold on a moment, we're pacing." I know this was not done during the first procedure. Do you have any idea why they would they do this then, and not the first time?. I didn't get a chance to ask an EP nurse or Dr. Natale after the procedure.

Char:
One of the leads they put in during an ablation is a pacing wire or electrode. In trying to induce arrhythmias, they pace you at a rapid rate and high voltage, just as is done in an EP study. You would feel it as a hard thumping, and the higher the voltage, the more you might perceive it as a thumping pain which could certainly make you moan.
How goes it these days Char? Are you still a free bird?

Pam

As usual, I’m late to the party but I'll add my 2 cents anyway. I note that J. Pisano used data from another study, the "PAF-PACE" study that excluded brady-arrhythmias.

Pam's ADOPT-A trials showed positive results with brady-arrhythmias -- that is those with SSS. Sick Sinus Syndrome is a sinus node dysfunction characterized by slow HR. My cardio is suspicious of my HR, as it's around 50 in NSR. Although I was fairly athletic for a number of years, this doesn't usually drop the HR that much and those with HR in high 40's or low 50's should always be "considered" as being a SSS candidate. Because of my normal low HR I’ve been reluctant to take B-Blockers as they drop my HR down into the 40’s – then Pac’s happen then AF……..

Although the pacing algorithm shows 25% improvement in PAF, it only seems to have been applied to pacing in the RH atrium and I’m not sure what that means for those with dual pacing in both atria. I think it can be applied to dual pacing (one lead in RH atrium, one in RH ventricle) as I think they have independent functions.

Thanks for the info as I’m studying ICD/PM implant vs. ablation of AFib & VT.

Anton

Pam,
Thanks so much for the reply. It didn't occur to me that they were trying to induce arrythmia since it was right before they finished (?). (Probably checking to see if there were any other potentials they missed?) I was almost totally awake by then so it didn't occur to me that they would be doing it then. That must be the effect you would also feel at a cardioversion without the anesthetic to dull it.

I wish I could say I am a 'free bird'...(you made me laugh and I needed a laugh). I'm not though. It lasted for two weeks and three days. Last Thurs. night I went into the familiar flutter...at 160 this time. I took 180 mg. of diltiazem and an ativan, went to sleep, and it was gone by morning. It's Sunday night and it started again an hour ago...at 165. I was probably being too cocky about the whole thing. It really teaches humility and I guess I have more to learn. Char

I had a St, Judes over ride pacemaker for a year. It really did not seem to help since i had so much fib. i had it done at Shand's hospital in Florida, and it was donated to prove that it would work in severe cases a AFib. What it does is when it senses PAC's or flutter or eeven fib, it tries to make your pulse go faster to keep ahead of the fib. Around a year later, I started to have to use oxygen, and found out that it was probably because I was in heart failure from so much fib and from the pacer speeding me up so frequently. They shut that portion of the pacer off, and my oxygen need decreased to nothing within several weeks. Now i am scheduled for the ablation, and a little apprehensive to say the least.

Bob G