Validation of a Method for Choice of Pacing Mode in Carotid Sinus Syndrome With or Without Sinus Bradycardia MICHELE BRIGNOLE,* CARLO MENOZZI.** GINO LOLLI,** DANIELE ODDONE,* LORELLA GIANFRANGHI,* and ANTONIO BERTULLA* From the "Laboratory of Etectrophysiology and Pacing, Service of Cardiology, Hospital of Lavagna (GE); and the **Division of Cardiology, Hospital of Reggio Emilia, Italy

BRIGNOLE, M., ET AL.: Validation of a Method for Choice of Pacing Mode in Carotid Sinus Syndrome With or Without Sinus Bradycardia. A new method for selection of the pacing mode in 60 consecutive patients with severe cardioinhibitory or mixed carotid sinus syndrome was prospectively validated. DDD pacing was preferred for 26 patients with: (1) the cardioinhibitory form and who had symptomatic pacemaker effect; (2) mixed type I form, (cardioinhibitory and vasodepressorj with symptomatic pacemaker effect, ventriculoatrial conduction or orfhostatic hypolension; (3) mixed type U; or (4) severe bradycardia. W I pacing was selected in the remaining 34 patients without these symptoms. During a 32 ± 10 month foJiow-up period syncope and severe dizziness persisted in five patients in the VVI group (15%) and in three patients in the DDD group (12%). Symptomatic relief occurred in 87% {52/60} of patients. Minor symptoms persisted in 47% of the VVI group and 42% of the DDD group. No patient developed cardiac insufficiency or intolerance to pacing. During a 2-month duration a single-blind, randomized, cross-over study compared VVI and DDD pacing, 69% of the patients programmed from DDD to VVI suffered more frequent, severe, and intolerable symptoms. (IJ Thirty four of 60 patients {57% of the entire group) in whom VVI pacing was satisfactory were identified prior to pacemaker impiant. In the remainder, VVI pacing was contraindicated as it produced frequent side effects. (2) The preimpiant predictive vaiue (hat VVI pacing would be successful was 85% for those eventually receiving W I pacemakers and the preimpiant predictive value that VVI pacing would fail was 69% for those who underwent DDD impJant. (PACE, VoJ. 14, February, Part I 1991) carotid sinus syndrome, cardiac pacing, syncope, sinus node dysfunction, cardioinhibition, vosodepressor

Introduction Cardiac pacing effectively relieves the cardioinhibitory and the mixed forms of carotid sinus syndrome.^"^ Ventricular inhibited (VVl) pacing generally relieves symptoms in patients with the cardioinhibitory form,'^ but lesser symptoms may

Address for reprints: Michele Brignole, Via A. Grilli 164.16041 Borzonasca (GE). Italy. Fax 38185306506. Received September 12. 1989: revision fanuary 4. 1990; revision September 17, 1990; accepted September 17, 1990.

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persist in some, especially those with a vasodepressor component. In some patients with the mixed cardioinhibitory and vasodepressor form, VVI pacing is poorly tolerated and therefore is contraindicated.^"^ Dual chamber pacing is superior to single chamber ventricular (VVI) pacing in the mixed form, but the latter alone may be adequate in some patients.^~^ Preimplant diagnostic issues persist concerning whicb patients will require dual chamber and for whom VVI pacing will suffice. Controversy derives from the absence of a widely accepted method of carotid sinus massage

February 1991, Part I

PACE, Vol. 14

VALIDATION OF A NEW METHOD

and equally accepted classification of the carotid sinus syndrome, making published results difficult to compare. Moreover, the association of carotid sinus syndrome with sinus node dysfunction is common and can limit the effectiveness of the pacing mode selected.^"'^ In an earlier study of 39 patients^^ with the carotid sinus syndrome, predictors of ventricular inhibited (VVI) pacing failure were identified by a classification of our design. We then began a prospective validation of sixty consecutive new patients with carotid sinus syndrome. They constitute the population of the present study.

Methods Inclusion Criteria (1) Severe and frequently recurrent syncope with lesser symptoms that were not well tolerated and interfered with daily activity; (2) Reproduction of spontaneous symptoms by carotid sinus massage that caused abnormal cardioinhibitory or mixed response; (3) Reproducibility of tbe response to carotid sinus massage on different days; (4) Absence of other causes of syncope except for an associated sinus bradycardia. As association with sinus node disease is frequent; in most cases, when features of sinus node disease are minor, tbe diagnosis may be clinically obvious. In other instances selection of the dominant diagnosis may be difficult.""" Preimplant Assessment of Predictors of VVI Failure These predictors have been described previously in detail,^^ and consisted of: (1) Classification

of

carotid

sinus

The classification is based on the reproduction of spontaneous symptoms by carotid sinus massage during electrocardiographic monitoring and manual measurement of systolic arterial pressure (Table I). The right and left carotid sinuses were massaged for 10 seconds with the patient erect and supine [interrupted in the event of syncope). We elected a lO-second massage instead of

PACE, Vol. 14

Table I Classification of the Carotid Sinus Syndrome Resulting from Basal and After-Atropine Supine and Standing Carotid Sinus Massage (CSM).* Dominant Cardioinhibitory Type Basal CSM: ventricular asystole {>3 sec) with reproduction of spontaneous symptoms CSM atropine: absence of symptoms Therefore in this type vasodepressor component is absent or. if present, it is insufficient to cause symptoms. Mixed Types Basal CSM: ventricular asystole {>3 sec) with reproduction of spontaneous symptoms. CSM + atropine: persistence of symptoms, generally slight, caused by fall of systolic blood pressure. Type I: the onset of symptoms begins during ventricular asystole (basal CSM). Type II: the onset of symptoms begins after the resumption of ventricular systole (basal CSM}. Dominant Vasodepressor Type ** Basal CSM: symptoms due to fall of systolic blood pressure while ventricular asystole is absent or, if present,

Validation of a method for choice of pacing mode in carotid sinus syndrome with or without sinus bradycardia.

A new method for selection of the pacing mode in 60 consecutive patients with severe cardioinhibitory or mixed carotid sinus syndrome was prospectivel...
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