The contribution of rate adaptive pacing with single or dual sensors to health-related quality of life

AIMS

The characteristics of sensors to perform rate adaptive pacing are well established but whether their contribution improves health-related quality of life (QoL) remains disputable. To compare the effects on QoL with an integrated dual sensor [minute ventilation (MV) and acceleration, TT sensor] with a single MV sensor, and with no rate adaptive pacing.

METHODS AND RESULTS

This Dutch multi centre, prospective, single- (patient) blind study was performed in patients after first pacemaker (PM) implant for sick sinus syndrome or AV block. After a 3-month 'sensor off'-period following DDD PM implantation, where the latter 2 months permitted the MV sensor to learn the intrinsic rhythm, a 2-month period of DDDR with TT sensor or 2 months of DDDR with MV sensor, subsequently the two modes were crossed over. Quality of life was determined with Aquarel, the disease-specific instrument for PM patients. Heart rate, percentages of sensor driven and intrinsic rhythm were retrieved from PM memories. Sixty-four patients completed the 7-month study. In sick sinus patients, percentages of sensor-driven pacing occurred significantly more frequently than in AV block patients After implant QoL improved significantly: before 71.3 and after 83.5% (P < 0.001) measured with Aquarel and in 3 of 9 SF-36 scales, but no significant additive QoL benefit with dual or MV sensor pacing was observed. Pacing diagnosis, percentages of rate adaptive pacing, and heart rate influencing medication did not influence this result.

CONCLUSION

Pacemaker implantation strongly improves QoL, but neither single- nor dual- sensor-driven pacing offered additional improvement in QoL during the initial 8 months after the first PM implant.

Health-related quality of life relative to clinical outcomes in patients with atrial fibrillation treated with ventricular rate stabilisation pacing

AIMS

It is uncertain whether patient perception of atrial fibrillation (AF) is based on the fast ventricular rate as such or the irregularity of the ventricular responses. This trial was designed to confirm the effectiveness of a ventricular rate stabilisation (VRS) algorithm in reducing ventricular irregularity during permanent pacing in patients with AF and to assess the patient preference and effect on quality of life (QoL).

METHODS

In this multicentre single-blind randomised crossover trial, 184 patients with drug-refractory permanent (n=91) or paroxysmal (n=93) AF received a VVI(R) or DDD(R) pacemaker respectively and were paced in a randomised sequence with VRS on or off for two months. Clinical assessments (QoL, New York Heart Association (NYHA) classification, echocardiography, six-minute walk test and Holter recording) were carried out at baseline, at randomisation and after each crossover period. QoL assessment was performed using Aquarel, a new disease-specific QoL questionnaire for pacemaker patients, the Short Form 36 survey (SF-36), the Duke Activity Status Index (DASI) and the Symptom Checklist frequency and severity scores. At the end of the study patients preferences for VRS-on or VRS-off were recorded.

RESULTS

VRS pacing reduced ventricular irregularity without increasing the mean ventricular rate. VRS-on was preferred by 65.8% of patients with paroxysmal AF; patients with permanent AF had no preference. QoL did not show improvement during VRS pacing on any of the instruments.

CONCLUSION

VRS pacing is effective in reducing ventricular rhythm irregularity. QoL does not improve during VRS pacing but preference for VRS pacing appears particularly outspoken for patients with paroxysmal AF.

The relevance of health related quality of life in paced patients

With the tremendous advances in cardiac pacing during the past four decades, cardiac pacemaker implantation is now a common clinical procedure. In recent years, the indications for permanent pacemakers have expanded. This increase in reasons for pacing and shift in mode of pacing have been caused by the evolution of pacemaker therapy from a life-saving measure (mortality), to one aimed at improving health-related quality of life (HRQoL). Until now the efficacy of pacing therapy has predominantly been measured using "objective" criteria. However, in recent years the importance of HRQoL as an outcome measure has increasingly been recognized as patients prefer quality over quantity of life. In this review we describe the development and testing of Aquarel, a new developed HRQoL questionnaire for pacemaker patients, composed of a generic core module with disease specific add-ons. Current and future research to improve the Aquarel questionnaire is also described.

A randomized study of combining maze surgery for atrial fibrillation with mitral valve surgery

AIM

Mitral valve surgery seldom suppresses atrial fibrillation (AF), present prior to surgery. Maze III surgery eliminates AF in >80% of cases, the reason why combining this procedure with mitral valve surgery in patients with AF seems worthwhile. We prospectively studied the outcome of combining the Maze III procedure with mitral valve surgery.

METHODS

Thirty-five patients with AF and a mean age of 64 years undergoing mitral valve surgery were prospectively randomized according to a 2.5:1 ratio to surgery with (n=25), or without (n=10) maze III and followed for at least 1 year.

RESULTS

At discharge and after 12 months freedom from AF was 56% and 92%, respectively, in the maze group, and 0% and 20%, respectively, in patients without maze (group differences at discharge p=0.002, after 12 months p=0.0007). Sinus node incompetence was seen in 1 of 25 maze patients requiring pacing. No in-hospital or late death occurred; stroke was observed in 1 patient (without maze). Quality of life markedly improved after surgery, but did not differ between patients with or without maze surgery.

CONCLUSIONS

This first prospective randomized study shows that combining maze III with mitral valve surgery resulted in a significantly better elimination of preoperative AF than mitral valve surgery alone. As the quality of life did not differ between patients with, or without maze surgery, additional maze surgery is primarily recommended in patients in whom anticoagulation therapy can be avoided after surgery, specifically in patients with scheduled mitral valve plasty.