Journal of Arrhythmia 30 (2014) 115118

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Journal of Arrhythmia
journal homepage: www.elsevier.com/locate/joa

Case Report

Automatic switching between the AAI and the DDD algorithm can
prevent repetitive non-reentrant ventriculoatrial synchrony
Takeshi Kitamura, MDa,n, Seiji Fukamizu, MDa, Masahiro Nauchi, MDa, Takuro Nishimura, MDa,
Tomohiko Watanabe, MDa, Jin Iwasawa, MDa, Hiroshi Shimada, MDa, Tae Ishikawa, MDa,
Noriko Matsushita, MDa, Tomomi Abe, MDa, Rintaro Hojo, MDa, Takekuni Hayashi, MDa,
Kota Komiyama, MDa, Yasuhiro Tanabe, MDa, Tamotsu Tejima, MD, PhDa,
Mitsuhiro Nishizaki, MD, PhDb, Harumizu Sakurada, MD, PhDc, Masayasu Hiraoka, MD, PhDd
a

Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan

Department of Cardiology, Yokohama Minami Kyosai Hospital, Yokohama, Kanagawa, Japan
c
Tokyo Metropolitan Health and Medical Treatment Corporation, Ohkubo Hospital, Tokyo, Japan
d
Tokyo Medical and Dental University, Tokyo, Japan
b

art ic l e i nf o

a b s t r a c t

Article history:
Received 21 January 2013
Received in revised form
6 April 2013
Accepted 2 May 2013
Available online 29 July 2013

A 67-year-old man with non-obstructive hypertrophic cardiomyopathy had received an implantable

cardioverter-debrillator (ICD) for an unstable, sustained ventricular tachycardia (VT) induced by programmed
stimulation during an electrophysiological study 5 years earlier. An intracardiac electrogram recorded by the ICD
revealed repetitive, non-reentrant ventriculoatrial synchrony (RNRVAS) associated with hypotension. Electrophysiologic and hemodynamic studies indicated that RNRVAS was induced and reproducibly termed by a single
ventricular extrastimulus from the right ventricular apex. Following attainment of the elective replacement
indicator, we replaced the ICD with another having managed ventricular pacing, which automatically switched
AAI and DDD, thereby avoiding unnecessary ventricular pacing. Thus far, the patient has not experienced further
RNRVAS. Thus, we believe that automatic switching between AAI and DDD can prevent RNRVAS.
& 2013 Japanese Heart Rhythm Society. Published by Elsevier B.V. All rights reserved.

Keywords:
Repetitive non-reentrant ventriculoatrial
synchrony
Managed ventricular pacing mode
Pacemaker tachycardia
Implantable cardioverter-debrillator

1. Case report
A 67-year-old man with non-obstructive hypertrophic cardiomyopathy had received a dual-chamber implantable cardioverterdebrillator (ICD) (7278 Maximos DR, Medtronic, Minneapolis, MN,
USA) 5 years earlier for an unstable, sustained ventricular tachycardia
(VT) induced by programmed stimulation during an electrophysiological study (EPS). The ICD was programmed to provide atrial overdrive
suppression for paroxysmal atrial brillation and to avoid unnecessary
ventricular pacing. The electrophysiological study (EPS) record during
ICD implantation revealed a maximum sinus node recovery time of
11,100 ms; moreover, the patient's 12-lead electrocardiogram (ECG)
showed rst-degree atrioventricular block (DDIR) with a lowered
heart rate of 80 beats/min (bpm). The atrioventricular (AV) delay after
atrial pacing was 350 ms. The postventricular atrial refractory period
(PVARP) was maintained at 310 ms for containing retrograde ventriculoatrial (VA) conduction, with a VA conduction time of
n
Correspondence to: Department of Cardiology, Tokyo Metropolitan Hiroo
Hospital, 2 34 10 Ebisu, Shibuya-ku, Tokyo, Japan. Tel.: +81 3 3444 1181;
fax: +81 3 3444 3196.
E-mail address: take1124@hotmail.co.jp (T. Kitamura).

approximately 190 ms. In addition, we prescribed 160 mg/day sotalol

to prevent ventricular tachycardia.
In our clinic, the intracardiac electrogram recorded by the ICD
showed repetitive non-reentrant ventriculoatrial synchrony
(RNRVAS), which was associated with hypotension and chest
discomfort (Fig. 1). We suspected that the RNRVAS caused the
hypotension; therefore, we performed electrophysiologic and
hemodynamic studies. A 24-h ambulatory electrocardiograph also
indicated RNRVAS that was initiated by either a premature
ventricular or atrial beat. The EPS indicated that a single ventricular extrastimulus from the right ventricular apex reproducibly
induced and termed the RNRVAS. Under the setting for DDIR, the
heart rate was lowered to 70 bpm and 80 bpm, and RNRVAS was
induced repetitively. The shortened AV delay caused heart failure
due to increasing ventricular pacing. Other setting changes such as
prolonging the lowered rate interval were not effective in preventing RNRVAS. During RNRVAS, the patient's systolic blood
pressure decreased by approximately 20 mmHg (6070 mmHg)
compared to that during the atrial pacing ventricular sensing
rhythm (8090 mmHg, Fig. 2). During the atrial pacing ventricular
pacing rhythm, his blood pressure also decreased compared to that
during the ventricular sensing rhythm.

1880-4276/$ - see front matter & 2013 Japanese Heart Rhythm Society. Published by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.joa.2013.04.009

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Fig. 1. Repetitive non-reentrant ventriculoatrial synchrony (RNRVAS) on the intracardiac electrogram recorded by the implantable cardioverter-debrillator (ICD).
Ventricular extrastimulus from the right ventricular apex lead caused retrograde VA conduction in the postventriculoatrial refractory period (PVARP). Ineffective atrial
pacing noted as AV delay and lower rate interval occurred in the atrial refractory period (ARP). Thereafter, ventricular pacing occurred, leading to retrograde VA conduction;
thus, RNRVAS was maintained. PVARP, postventriculoatrial refractory period; RNRVAS, repetitive non-reentrant ventriculoatrial synchrony.

Fig. 2. Hemodynamics during RNRVAS with the AAI mode. Blood pressure during RNRVAS decreased by 20 mmHg compared to that during atrial pacing ventricular sensing
rhythm. RNRVAS was termed by an atrial premature beat. RNRVAS, repetitive non-reentrant ventriculoatrial synchrony; APB, atrial premature beat.

In addition, the site of earliest retrograde atrial activation

during RNRVAS was recorded on the electrograms of the His
bundle (Fig. 3). Because this atrial activation involved only a single
retrograde pathway with a decremental conduction property, we
considered it to be retrograde VA conduction occurring via the fast
AV nodal pathway. The elective replacement indicator was triggered in the ICD; therefore, we replaced the ICD with another
device (7278 PROTECTAs, Medtronic, Minneapolis, MN, USA), to
manage the ventricular pacing mode and to provide functional
AAI/R pacing that was equipped with a safe dual-chamber ventricular support that would allow automatic switching between
AAI and DDD mode pacing. The parameters after replacement
were as follows: MVP mode (AAI, 80 bpm and DDD, 80120 bpm),
paced AV delay 180 ms, and PVARP 320 ms. Cumulative percentages of pacing and sensing were atrial pacing (AP)ventricular
sensing (VS) 97.3%, AP 99.1%, and ventricular pacing 1.8%.
Thus far, no report of RNRVAS following ICD replacement has
been reported. After this replacement, the patient's hypotension
improved.

2. Discussion
To the best of our knowledge, this is the rst report describing
the hemodynamic state and retrograde conduction in a patient
with an ICD who showed RNRVAS on an intracardiac electrogram.
We found that automatic mode switching between AAI and DDD
could prevent RNRVAS.
RNRVAS is becoming a well-known pacemaker for arrhythmia,
as DDD or DDI modes have often been selected in clinical
situations [14]. This arrhythmia occurs in cases of intact retrograde VA conduction. Furthermore, the pacemaker must be
programmed with a sufciently long PVARP so that retrograde
conduction does not induce endless loop tachycardia. One nal
prerequisite is a sufciently high base rate to ensure a relatively
short atrial escape interval and an even shorter interval from the
retrograde atrial depolarization, thus rendering the atrial tissue
physiologically refractory.
Functional undersensing occurs when the retrograde P wave is
not sensed because it coincides with the PVARP. Because of the

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117

Fig. 3. Intracardiac electrogram recording during RNRVAS. The site of earliest retrograde atrial activation during RNRVAS was recorded on the electrograms of the His bundle
during RNRVAS. Because this atrial activation involved only a single retrograde pathway with a decremental conduction property, we considered it to be retrograde VA
conduction occurring via the fast AV nodal pathway. RNRVAS, repetitive non-reentrant ventriculoatrial synchrony; VPC, ventricular premature complex; PVARP,
postventriculoatrial refractory period; ARP, atrial refractory period; HRA, high right atrium; HBE, His bundle electrogram; CS, coronary sinus; RVA, right ventricular apex;
d, distal; p, proximal.

relatively high rate and the failure to reset the atrial timing cycle,
atrial pacing is delivered while the atrial myocardium is physiologically refractory, resulting in functional atrial non-capture.
Functional undersensing and non-capture play critical roles in
maintaining RNRVAS. After the ineffective atrial pacing, the AV
interval times out, and a ventricular paced event occurs, by which
time, the AV node and atrial myocardium are fully recovered,
facilitating retrograde conduction. Thus, RNRVAS is caused by the
sequence of a combination of an AV paced rhythm with repeated
functional atrial undersensing and non-capture [5].
In the present case, RNRVAS onset was recorded (Fig. 1). The
pattern was consistent with ventricular pacing from the right
ventricular ICD lead, which led to retrograde conduction in PVARP
and produced an atrial refractory period in the atrium. Thus,
programmed atrial pacing during the atrial refractory period
caused a functional atrial non-capture. This repeated AV synchronous rhythm, RNRVAS has been described previously.
Clinical symptoms consist of the pacemaker syndrome, including palpitations and hemodynamic instability, as in our case. The
denitive management of RNRVAS requires sufcient time for the
atrial tissue to recover from the refractory period. Barold et al.
reviewed several general modes that could prevent RNRVAS [1].
First, the atrial escape interval must be prolonged to allow the
atrial myocardium to recover. Second, the lower base rate should
be decreased or the lower rate increased. Third, the sensor-driven
upper rate should also be decreased. Lastly, the AV delay must be
shortened. In addition, a higher base rate is effective for suppressing atrial brillation. However, some of these management
options are not clinically appropriate. Other algorithms to prevent
RNRVAS have also been suggested; however, to our knowledge,
automatic switching between AAI and DDD has not yet been
reported. Furthermore, ablation of a retrograde pathway, which
involves maintaining RNRVAS, may be a therapeutic option,

provided that the retrograde pathway is not the AV nodal fast

pathway, as determined from the EPS.
The mechanism by which RNRVAS is prevented via automatic
mode switching between AAI and DDD involves the termination of
the inappropriate synchronous atrial and ventricular pacing mode
using an AV conduction check. The MVP mode (Medtronic,
Minneapolis, MN, USA) [6,7] is one such switching mode. During
a sequential atrial and ventricular pacing rhythm in the MVP
mode, an AV conduction check is scheduled every 1, 2, 4, and
8 min for up to 16 h following a transition from AAI to DDD. The
AV conduction check is temporary, consists of only 1 beat, and uses
an AAI pacing mode to monitor for conducted ventricular sensing.
In this case, during RNRVAS, the scheduled AV conduction check in
the MVP mode allowed both atrial and ventricular sensing, which
did not initiate retrograde VA conduction because the AV node had
not recovered from the refractory period (Fig. 4). Hence, the
RNRVAS was terminated. In addition, the MVP mode has other
algorithms, including a dynamic atrial refractory period and
postventricular premature beat option, which can prevent RNRVAS
given that the atrial escape interval is prolonged after a nonconducted P wave or ventricular premature beat.
To suppress atrial brillation, a higher rate of atrial pacing with
a dual-chamber pacing mode and a long AV delay, a relatively fast
lower rate, or both has recently been applied in clinical situations.
Overdrive pacing over intrinsic atrial activity may reduce paroxysmal atrial brillation by affecting the pattern of atrial depolarization and suppressing premature atrial beats. However, an
increase in the cumulative proportion of right apex ventricular
pacing is associated with an increased risk of death and heart
failure, most likely through ventricular desynchronization and
hemodynamic deterioration [8]. It is difcult to prevent unnecessary right ventricular pacing in patients with a dual-chamber ICD
with prolonged settings for the AV delay alone.

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T. Kitamura et al. / Journal of Arrhythmia 30 (2014) 115118

Fig. 4. RNRVAS termination through the managed ventricular pacing (MVP) mode. Scheduled AV conduction check in the MVP mode allowed atrial and ventricular sensing,
which did not initiate retrograde VA conduction leading to RNRVAS. RNRVAS, repetitive non-reentrant ventriculoatrial synchrony; AP, atrial pacing; VP, ventricular pacing;
AR, atrial sensing in atrial refractory period; AS, atrial sensing; VS, ventricular sensing; ARP, atrial refractory period; PVARP, postventriculoatrial refractory period.

Thus, there are many possible clinical situations where RNRVAS

might arise. In this case, atrial pacing prevented atrial brillation;
hence, we maintained atrial pacing. However, AV-sequential and
RNRVAS ventricular pacing led to hemodynamic instability and
deterioration. To prevent unnecessary ventricular pacing, including RNRVAS with atrial pacing, the MVP mode was employed to
provide the AAI or AAIR mode for monitoring AV conduction, and
to provide an automatic switching to DDD or DDDR mode when
the AV block persisted beyond a single dropped ventricular
beat [4]. The MVP mode successfully addresses a high rate of
atrial pacing and consequently prevents unnecessary ventricular
pacing, including both RNRVAS and AV sequential pacing.
3. Conclusion
We believe that automatic switching between AAI and DDD can
prevent RNRVAS and hemodynamic instability.
Conict of interest
None.

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