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consisting of four letters The first letter refers to the chamber that is stimulated (A = atrium, V = ventricle, D = dual, for both) The second letter refers to the chamber in which sensing occurs (also A, V, or D) The third letter refers to the sensory mode (I = inhibition by a sensed impulse, T = triggering by a sensed impulse, D = dual modes of response) The fourth letter refers to the programmability or rate modulation capacity (usually P for programming for two functions, M for programming more than two, and R for rate modulation) A pacemaker that senses and paces in both chambers is the most physiologic approach to pacing patients who remain in sinus rhythm AV synchrony is particularly important in patients in whom atrial contraction produces a substantial increment in stroke volume and in those in whom sensing the atrial rate to provide rate-responsive ventricular pacing is useful Dual-chamber pacing is most useful for individuals with LV systolic or perhaps more importantly diastolic dysfunction and for physically active individuals In patients with single-chamber pacemakers, the lack of an atrial kick may lead to the so-called pacemaker syndrome, in which the patient experiences signs of low cardiac output while upright Pulse generators are also available that can increase their rate in response to motion or respiratory rate when the atrial rate is not an indication of the optimal heart rate These are most useful in active individuals Follow-up after pacemaker implantation, usually by telephonic monitoring, is essential All pulse generators and lead systems have an early failure rate that is now below 5% and an expected battery life varying from 4 years to 10 years

Barold SS Atrioventricular block revisited Compr Ther 2002 Spring;28(1):74 8 [PMID: 11894446] Bourke JP Atrioventricular block and problems with atrioventricular conduction Clin Geriatr Med 2002 May;18(2):229 51 [PMID: 12180245] Toff WD et al; United Kingdom Pacing and Cardiovascular Events Trial Investigators Single-chamber versus dual-chamber pacing for high-grade atrioventricular block N Engl J Med 2005 Jul 14;353(2):145 55 [PMID: 16014884]

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bundle system The classification as Mobitz type I or Mobitz type II is only partially reliable because patients may appear to have both types on the surface ECG, and the site of origin of the 2:1 AV block cannot be predicted from the ECG The width of the QRS complexes assists in determining whether the block is nodal or infranodal When they are narrow, the block is usually nodal; when they are wide, the block is usually infranodal Electrophysiologic studies may be necessary for accurate localization Management of AV block in acute myocardial infarction has already been discussed This section deals with patients in the nonischemic setting First-degree and Mobitz type I block may occur in normal individuals with heightened vagal tone They may also occur as a drug effect (especially digitalis, calcium channel blockers, -blockers, or other sympatholytic agents), often superimposed on organic disease These disturbances also occur transiently or chronically due to ischemia, infarction, inflammatory processes, fibrosis, calcification, or infiltration The prognosis is usually good, since reliable alternative pacemakers arise from the AV junction below the level of block if higher degrees of block occur Mobitz type II block is almost always due to organic disease involving the infranodal conduction system In the event of progression to complete heart block, alternative pacemakers are not reliable Thus, prophylactic ventricular pacing is required Complete (third-degree) heart block is a more advanced form of block often due to a lesion distal to the His bundle and associated with bilateral bundle branch block The QRS is wide and the ventricular rate is slower, usually less than 50 beats/min Transmission of atrial impulses through the AV node is completely blocked, and a ventricular pacemaker maintains a slow, regular ventricular rate, usually less than 45 beats/min Exercise does not increase the rate The first heart sound varies in intensity; wide pulse pressure, a changing systolic blood pressure level, and cannon venous pulsations in the neck are also present Patients may be asymptomatic or may complain of weakness or dyspnea if the rate is less than 35 beats/min; symptoms may occur at higher rates if the left ventricle cannot increase its stroke output During periods of transition from partial to complete heart block, some patients have ventricular asystole that lasts several seconds to minutes Syncope occurs abruptly Patients with episodic or chronic infranodal complete heart block require permanent pacing, and temporary pacing is indicated if implantation of a permanent pacemaker is delayed.

FIGURE 3-27

When a ventricular pacemaker is firing at a rate faster than or close to the sinus rate (accelerated idioventricular rhythm, ventricular premature beats, or ventricular tachycardia), atrial impulses arriving at the AV node when it is refractory may not be conducted This phenomenon is AV dissociation but does not necessarily indicate AV block No treatment is required aside from management of the causative arrhythmia

The indications for permanent pacing have been discussed: symptomatic bradyarrhythmias, asymptomatic Mobitz II AV block, or complete heart block The versatility of pacemaker generator units has increased markedly, and dual-chamber multiple programmable units are being implanted with increasing frequency A standardized nomenclature for pacemaker generators is used, usually

Intraventricular conduction defects, including bundle branch block, are common in individuals with otherwise normal hearts and in many disease processes, including ischemic heart disease, inflammatory disease, infiltrative disease, cardiomyopathy, and postcardiotomy Below the AV node and bundle of His, the conduction system trifurcates into a right

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