1126 Letters to the Editor

Guiqing Yao resolved immediately by reprogramming to 2. Benjamin EJ, Wolf PA, D’Agostino RB,
University of Birmingham DDD mode.3 It is likely that the lower inci- Silbershatz H, Kannel WB, Levy D. Impact of
UK dence of PMS reported in CTOPP is because atrial fibrillation on the risk of death. The
Framingham heart study. Circulation 1998;98:
reoperation rather than reprogramming was
Melanie J. Calvert 946–952.
required biasing their results. If 30% of
3. Ellenbogen KA, Stambler BS, Orav EJ,
University of Birmingham patients require an upgrade to the DDD Sgarbossa EB, Tullo NG, Love CA, Wood MA,
UK mode early after implantation of a VVI Goldman L, Lamas GA. Clinical characteristics
system, the effects on patients’ quality of of patients intolerant to VVIR pacing. Am J
John G.F. Cleland life and healthcare costs will be marked. A Cardiol 2000;86:59–63.
Department of Cardiology recent meta-analysis showed that the cost 4. Castelnuovo E, Stein K, Pitt M, Garside R, Payne E.
University of Hull difference between single and dual-chamber The effectiveness and cost-effectiveness of
Castle Hill Hospital dual-chamber pacemakers compared with
systems over 5 years is small—£700 more for
Kingston upon Hull dual-chamber devices.4 single-chamber pacemakers for bradycardia
UK The authors suggest AAI systems, by
due to atrioventricular block or sick sinus
syndrome: systematic review and economic
Lucinda Billingham reducing ventricular pacing, should be used evaluation. Health Technol Assess 2005;9:1–262
University of Birmingham instead of DDD systems in patients with 5. Glotzer TV, Hellkamp AS, Zimmermann J,
SND because of ‘low’ requirement of Sweeney MO, Yee R, Marinchak R, Cook J,
UK
upgrade to DDD (0.6–8.4%). This is not insig- Paraschos A, Love J, Radoslovich G, Lee KL,
nificant, and therefore, AAIR implantation Lamas GA. Atrial high rate episodes detected

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Jean-Claude Daubert
for SND is only 1–3% in the US and central by pacemaker diagnostics predict death and
Department of Cardiology
Europe. Manufacturers have addressed this stroke: report of the atrial diagnostics ancillary
Hôpital Pontchaillou
study of the MOde Selection Trial (MOST).
Rennes by developing algorithms that reduce
Circulation 2003;107:1614–1619.
France ventricular pacing to a minimum with a
6. Padeletti L, Santini M, Boriani G, Botto G,
‘pseudo-AAI’ mode with backup ventricular Gulizia M, Molon G, Luzzi G, Senatore G,
Stirling Bryan pacing, if required. It is likely that the Giraldi F, Zolezzi F, Pieragnoli P, Pro F, Desanto
University of Birmingham benefits observed by Nielsen et al. with AAI T, Grammatico A. Long-term reduction of
UK pacing can be extrapolated to these new atrial tachyarrhythmia recurrences in patients
DDD devices. This is further supported by paced for bradycardia–tachycardia syndrome.
the linear relationship of ventricular pacing Hearth Rhythm 2005;2:1047–1057.

doi:10.1093/eurheartj/ehi803 percentage and heart failure hospitalization

and risk of AF in MOST. Large studies with
Online publish-ahead-of-print 23 February 2006 these newer DDD systems may show superior-
ity over VVI pacing and should be awaited
before prematurily abandoning DDD pacing.
Pacemaker selection: time for a DDD devices also improve patient diagnos- John Silberbauer
rethinking of complex pacing systems tics allowing accurate arrhythmia detection Department of Cardiology
and enhanced pacemaker programming and Eastbourne General Hospital
can inform or monitor drug treatment and Kings Drive
The article by Musilli and Padeletti is a need for anti-coagulation. AF episodes Eastbourne BN21 2UD
thought-provoking challenge to the wide- recorded in this way have been shown to UK
spread use of DDD pacing. They suggest predict stroke5 and improve treatment by Tel: þ44 1323 417400
that single-chamber devices, AAI and VVI, reducing AF-related hospitalizations.6 With Fax: þ44 1323 435821
are a more rational choice in most cases of home telemetry of Holter data, these moni- E-mail address: [email protected]
sinus node disease (SND) and AV block, toring features are going to become a crucial
respectively. aspect of modern devices. Neil Sulke
The authors advocate VVI systems instead Technological advances in device therapy Eastbourne General Hospital
of DDD systems because of non-inferiority will continue. With clearer identification of Eastbourne
with regard to stroke and mortality, as treatment goals, for example, less arrhyth- UK
shown by MOST, CTOPP, PASE, and UKPACE. mia symptoms, reduced arrhythmia burden,
However, in patients paced for a slower beneficial remodelling effects, improved
Carsten W. Israel
intrinsic rate, a significantly higher mortality quality of life, or better exercise capacity,
J.W. Goethe University
has been reported using VVI vs. DDD we will understand whether increasing com-
Frankfurt
systems.1 These studies also show that VVI plexity of device hardware is beneficial and
Germany
pacing increases the risk of developing cost-effective. It is our opinion that these
chronic atrial fibrillation (AF) by 20%. AF is objectives will not be met by the use of
the leading arrhythmia cause of hospitaliz- simple systems. Nils Edvardsson
ation, increases the risk of stroke by five- Sahlgrenska University Hospital
fold, and doubles mortality,2 but the Goethenborg
number needed to treat with a DDD system Reference Sweden
(CTOPP) to prevent AF is nine. MOST
1. Tang AS, Roberts RS, Kerr C, Gillis AM, Green MS, Lluis Mont
showed heart failure hospitalization
Talajic M, Yusuf S, Abdollah H, Gent M,
reduction of 27% with DDD pacing. Hospital Clinico y Provincial
Connolly SJ. Relationship between pacemaker
MOST and PASE show the incidence of Unidad de Arritmias y Electrofisiologia
dependency and the effect of pacing mode
pacemaker syndrome (PMS) to be about on cardiovascular outcomes. Circulation 2001; Barcelona
25–33%, which occurred early and was 103:3081–3085. Spain
Letters to the Editor 1127

Josef Kautzner difference in part or entirely is to be ascribed Mangione CM, Goldman L. Quality of life and
Department of Cardiology to intolerance of dual chamber stimulation.2 clinical outcomes in elderly patients treated
Institute for Clinical and Thus, we greatly appreciate what was with ventricular pacing as compared with dual-
chamber pacing. N Engl J Med 1998;338:
Experimental Medicine written by Toff et al.1: ‘Our results, supported
1097–1104.
Prague by the PASE and CTOPP trials, suggest that the
Czech Republic clinical benefits associated with dual-
chamber pacing for atrioventricular block
have been overestimated.’ Luigi Padeletti
Phillippe Ritter
This reply gives us the opportunity to Internal Medicine and Cardiology Institute
Cabinet de Cardiologie
introduce an important point that we did University of Florence
Saint-Cloud
not consider in our article: the incidence of V.le Morgagni 85
France
perioperative complications in dual-chamber 50134 Florence
pacing resulted significantly higher in both Italy
A. John Camm Tel: þ39 0557497634
Department of Cardiology UKPACE1 and CTOPP3 trials. The conse-
quence of this is a further increase of differ- E-mail address: [email protected]
St George’s Hospital
London ence in costs between dual-chamber and
UK single-chamber devices.
Concerning the new DDD pacemakers Nicola Musilli
equipped with algorithms for minimizing Internal Medicine and Cardiology Institute

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the ventricular pacing in patients with sinus University of Florence
doi:10.1093/eurheartj/ehi804 node disease (SND), we believe that: (i) in V.le Morgagni 85
the absence of data from large trials, it is 50134 Florence
Online publish-ahead-of-print 23 February 2006 Italy
not scientifically correct to extrapolate the
benefits observed by Nielsen et al.4 with
Pacemaker selection: time for a atrial pacing to these new devices; (ii) the
rethinking of complex pacing systems: percentage of patients with SND who doi:10.1093/eurheartj/ehi805
reply develop AV block is low even if not insignifi-
cant in some reports, as mentioned by Online publish-ahead-of-print 16 February 2006
We appreciate the interest in our article Silberbauer et al.; a strategy of routine
expressed by Silberbauer and colleagues. implantation of such a pacemaker whose Gatekeeper for coronary angiography
We are surprised to read that we ‘advocate cost is higher by at least ]2000 to one SSIR
VVI systems instead of DDD systems is totally unjustified; (iii) these new DDD We would like to compliment Hoilund-Carlsen
because of non-inferiority with regard to devices in the presence of advanced AV and colleagues on their well-designed study
stroke and mortality as shown by MOST, block work just as the traditional ones; the on myocardial perfusion scintigraphy (MPS)
CTOPP, PASE, and UKPACE.’ Indeed, we reasons why they may show superiority as gatekeeper for coronary angiography.1
never mentioned UKPACE trial,1 published over VVI pacing and furnish different However, we have some doubts with regard
in July 2005, until the submission of our results from UKPACE1 and PASE5 trials to the use of MPS in a not-low-risk popu-
article. remain yet to be explained. lation. In this selection of patients scheduled
UKPACE trial (in which John Camm is one for coronary angiography, obstructive coro-
of the top investigators) compared the clini- nary artery disease (CAD) was present in
cal effects of VVI(R) pacing and DDD(R) Reference half of the population. This is more than
pacing in elderly patients with high-grade twice the prevalence found in populations
1. Toff WD, Camm AJ, Skehan JD. Single-chamber
AV block. No significant differences were screened for acute chest pain.2 In such
versus dual-chamber pacing for high-grade
observed between the two pacing modes in atrioventricular block. N Engl J Med 2005; not-low-risk populations, it has been
the rates of deaths from all causes, atrial 353:145–155. advised to use a test with high sensitivity
fibrillation, heart failure, or a composite of 2. Gilligan DM, Morillo CA, Wood MA, Ellenbogen to identify all patients with the most
stroke, transient ischaemic attack, or other KA. Hemodynamics of pacing: new aspects and severe forms of disease in order to improve
thromboembolisms.1 This confirms exactly unresolved issues. In: Barold SS, Mugica J, eds. event-free survival and cost-effectiveness
what we wrote about the treatment of Recent Advances in Cardiac Pacing. Goals
at a long term.3 In our opinion, a sensitivity
patients with AV block. for the 21st Century. Armonk, NY: Futura
of 81% for obstructive CAD and 94% for three-
Publishing Company, Inc.; 1998. p3–34.
Regarding the pacemaker syndrome, data vessel disease, as was found by Hoilund-
3. Connolly SJ, Kerr CR, Gent M, Roberts RS, Yusuf
from CTOPP trial are totally confirmed by Carlsen and colleagues, is too low to
S, Gillis AM, Sami MH, Talajic M, Tang AS, Klein
UKPACE trial. The clinical significance of GJ, Lau C, Newman DM. Effects of physiologic incorporate MPS as effective gatekeeper in
this has been underlined by Toff et al. 1: pacing versus ventricular pacing on the risk of a pre-coronary angiography strategy.
‘The low crossover rate (3.1%) from single- stroke and death due to cardiovascular causes. Furthermore, we share their concern that
chamber to dual-chamber pacing in our N Engl J Med 2000;342:1385–1391. too many coronary angiographies are per-
study was similar to that in the CTOPP trial 4. Nielsen JC, Kristensen L, Andersen HR, formed in patients with normal coronary
(2.7%) suggesting that single-chamber Mortensen PT, Pedersen OL, Pedersen AK. A
arteries. A diagnostic test with a high-
pacing is well tolerated.’ randomized comparison of atrial and dual-
negative predictive value could therefore
chamber pacing in 177 consecutive patients
Moreover, in CTOPP, the percentage of best serve as a filter for coronary angio-
with sick sinus syndrome: echocardiographic
patients who crossed from DDD to VVI mode graphy, but the estimated negative predic-
and clinical outcome. J Am Coll Cardiol
at 5 years was 17.1%. If we consider that in 2003;42:614–623. tive value of MPS for obstructive CAD was
this group the annual rate of patients devel- 5. Lamas GA, Orav EJ, Stambler BS, Ellenbogen only 82%. We suggest that other imaging
oping atrial fibrillation and consequently KA, Sgarbossa EB, Huang SK, Marinchak RA, modalities, such as electron beam computed
crossed to ventricular pacing was 5.3%, the Estes NA III, Mitchell GF, Lieberman EH, tomography (EBCT), may better serve as an