Single lead or Dual leadPacemakers?

NICE has spoken! See:

NICE technology appraisals [TA324] Published date: November 2014

www.Nice.org.uk

This is a fantastic review of outcomes and cost effectiveness.

I would recommend reading the summary, and if you really want to understand PM medical work, the whole appraisal.

Well done the NHS UK.

3 Comments

NICE update

by golden_snitch - 2014-12-01 03:12:55

Hey Selwyn,

isn't that already standard therapy?

In Germany, you hardly have any SSS patients that get a single-chamber pacemaker only, not nowadays, they all get DDD pacemakers. According to our national pacemaker registry, SSS accounts for about 37% of all pacemaker implants. Of these patients less than 0.5% receive an AAI pacemaker and 5.5% a VVI pacemaker. So, more than 90% of SSS patients get a dual-chamber device. What is it like in the UK? I thought, you only see a little more AAI-implants in Scandinavia, but the rest of the Western world is mostly using DDD systems for SSS patients.

I got an AAIR pacemaker back in 1999, after several sinus node ablations. Still believe that, given my young age, this was absolutely perfect. You do not want to place more leads than you really need in someone who's got many, many years with a pacemaker ahead. Also, an AAIR pacemaker solves the problem of unnessary right ventricular pacing. There are quite a lot of SSS patients with DDD pacemaker who are paced in the ventricle, although this is not needed. I mean, let's be honest: Many cardios never ever optimize settings, and with nominal settings in DDD mode you often get some percentage of right ventricular pacing even in patients with a sick sinus node only.

Inga

Single or Dual leads

by Selwyn - 2014-12-02 12:12:29

I agree with you Inga, this should be standard therapy to have Dual leads, though until NICE has actually said so, there is not a 'golden standard'. Any deviation from recommendations must be clearly justified to peers on the basis of evidence. This becomes difficult given the excellent review NICE has produced.

Outcomes are better with dual pacing ( hence the NICE recommendations). The lead number issue you mention I feel is not really relevant, as the box may be changed and the lead life is therefore prolonged. Any single lead may fail at any time, each lead being taken on its own merits. Better to have two in my opinion.

I do agree about having the optimised settings. How may times have we read of members of this club being upset because of this? I list myself as one.

Dual‑chamber pacemakers are recommended as an option for treating symptomatic bradycardia due to sick sinus syndrome without atrioventricular block.(NICE), mimicking the natural cardiac cycle. Dual lead pacing lessens the chance of atrial fibrillation, and helps restore exercise tolerance. Pacemaker syndrome is lessened.

On this basis no one should be getting a single lead pacemaker these days.

Selwyn

by golden_snitch - 2014-12-02 12:12:52

Isn't right ventricular (apical) pacing known to cause heart failure and atrial fibrillation? So, why should a dual-chamber pacemaker in an SSS patient lessen the chance of Afib? On the contrary, I would expect that you see more Afib, because patients are paced in the ventricle. I have never heard anyone with an AAIR pacemaker complaining about a real pacemaker syndrome, those I know were VVI paced patients. I had a pseudo pacemaker syndrome, but that was due to my AV-node being too fast, and nothing changed about this problem when I got my upgrade to a dual-chamber device.

When you are young, you do not only need to have pacemaker units replaced, but leads, too. My first transvenous lead lasted only 7 years. So, I think it's better to start with one lead, if that solves the problem (lazy sinus node only). That way, there is much space for more leads, when the first lead fails. Removing leads is still a risky procedure. I have epicardial leads now due to my reconstructed vena cava superior. But I still have that old atrial lead, it could not be removed. It has caused blockages, so I'm on blood thinners to prevent that those blockages from the subclavian and innominate vein do not worsen and lead to a blockage in the reconstructed vena cava superior, too. Leads are the weak spot of pacemakers, so why put in two, if all you need is one?

I am not convinced that a dual-chamber pacemaker is really what every SSS patient needs. In my opinion it has become standard therapy mostly because doctors want to be on the safe side. Some doctors claim that SSS patients at some point develop a heart block, but I have seen no data supporting this. Bi-nodal disease is really rare, say my cardios and EPs. Last but not least, industry does not make much money with single-chamber devices, the big money is made with CRTs/ICDs.

So, I would not support that no one should be getting a single-lead pacemaker. Depends on the patient, there are certainly still patients for whom an AAI or VVI pacemaker is perfect. Nevertheless, I think it's good that NICE now allows dual-chamber pacing for SSS patients, so that those patients for whom it's considered to be beneficial, have easier access to such a pacemaker.

Inga

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