By Charles J. Love

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Should the pacemaker pace at the end of the programmed AVI when the atrial rate is faster than the URL, the ventricular rate would exceed the URL. Because the ventricular output is delayed, the AVI appears prolonged giving a Wenckebach appearance. Each successive AVI will lengthen until a P-wave falls into the atrial refractory period. Since this last P-wave cannot be tracked, the following ventricular output is “dropped” and the cycle starts over again. If the atrial rate continues to rise and exceeds the atrial tracking limit imposed by the TARP, then 2:1 block will occur.

Pacing in this fashion may waste considerable battery power if the patient has a good intrinsic heart rate most of the time. It may also result in the induction of arrhythmias by pacing during the vulnerable period of the T-wave. This would be similar to the “R on T” phenomenon that results in ventricular tachycardia for some patients. VOO is rarely programmed as a continuous mode of operation. It may be used for a patient that is pacemaker dependent (has no significant intrinsic rate of their own above 40 beats per minute) when oversensing or inappropriate inhibition of the device is suspected.

It varies with adrenergic tone and the heart rate. The PR interval shortens as the heart rate increases to continue providing optimal preload. Most newer dual chamber pacemakers now offer a feature known as adaptive AVI. As the name suggests, the AVI adapts based on the heart rate. Faster heart rates cause a shortening of the AVI (Fig. 3). This results in two benefits. The first is more optimal hemodynamics for the patient by preserving the natural change in timing between atria and ventricles.

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