Pouillot C, Mabo P, Lelong B, Cazeau S, Paillard F, de Place C, Daubert J C
Service de cardiologie A, Hôtel-Dieu, CHR, Rennes.
Arch Mal Coeur Vaiss. 1990 Nov;83(12):1833-42.
Twelve patients with isolated symptomatic sinus node dysfunction or bradycardia-tachycardia syndrome with atrial chronotropic incompetence during exercise testing were managed by single chamber rate responsive atrial pacing (AAIR) when AV conduction was normal, or by a dual chamber DDDR pacemaker programmed in the AAIR mode when AV conduction was abnormal, and followed up for 12.5 +/- 9.8 months. The patients were assessed clinically, by 3 monthly ECG and Holter recordings and comparative exercise tests in AAI and AAIR modes at the 6th month. One patient with an AAIR system was excluded at M21 because of symptomatic AV block requiring reimplantation of a DDD pacemaker. Ten of the 11 remaining patients are asymptomatic and have an excellent quality of life; one patient had invalidating symptoms on exercise attributed to the "AAIR pacemaker syndrome" which were corrected by reprogramming the pacemaker and modifying the medical therapy. The comparative exercise stress tests showed a significantly higher heart rate in the AAIR mode compared to AAI pacing at the initial and intermediate exercise levels (30 to 70 W); on the other hand, the heart rates were not significantly different at the highest exercise levels although in the AAI mode, the terminal acceleration sometimes occurred in junctional rhythm whereas it was usually an atrial paced rhythm in the AAIR mode. The total duration of exercise was longer in the AAIR mode (+22%; p less than 0.01) when the 8/11 patients with chronotropic incompetence during the baseline study were considered. The spike-R interval adapted normally to exercise in only one case: in the other patients, the interval remained constant or, in the worst of cases (N = 4), it increased paradoxically, to result in the "AAIR pacemaker syndrome": this phenomenon is observed mainly in patients treated by antiarrhythmics and/or betablockers. The AAIR mode would therefore seem to be a simple, effective and reliable method of treating patients with sinus node dysfunction and chronotropic incompetence; however, the failure of adaptation of the PR interval is a real limitation to its use and may constitute an argument in favour of the choice of a DDR pacemaker in these patients.
12例孤立性症状性窦房结功能障碍或心动过缓-心动过速综合征且运动试验时存在心房变时性功能不全的患者，若房室传导正常，则采用单腔频率应答式心房起搏（AAIR）治疗；若房室传导异常，则采用双腔DDDR起搏器并程控为AAIR模式进行治疗，随访12.5±9.8个月。通过临床评估、每3个月进行一次心电图和动态心电图记录以及在第6个月时对AAI和AAIR模式进行对比运动试验来评估患者。1例采用AAIR系统的患者在第21个月时因出现症状性房室传导阻滞而被排除，需要重新植入DDD起搏器。其余11例患者中有10例无症状，生活质量良好；1例患者运动时出现无效症状，归因于“AAIR起搏器综合征”，通过重新程控起搏器和调整药物治疗得以纠正。对比运动应激试验显示，在初始和中等运动水平（30至70瓦）时，AAIR模式下的心率明显高于AAI起搏；另一方面，在最高运动水平时，心率无显著差异，不过在AAI模式下，终末加速有时出现在交界性心律，而在AAIR模式下通常为心房起搏心律。当考虑基线研究时存在变时性功能不全的8/11例患者时，AAIR模式下的总运动时长更长（+22%；p<0.01）。仅1例患者的起搏信号-R间期能正常适应运动；在其他患者中，该间期保持不变，或者在最糟糕的情况下（n = 4）反而反常增加，导致“AAIR起搏器综合征”：这种现象主要在接受抗心律失常药物和/或β受体阻滞剂治疗的患者中观察到。因此，AAIR模式似乎是治疗窦房结功能障碍和变时性功能不全患者的一种简单、有效且可靠的方法；然而，PR间期不能适应是其使用的一个实际限制，可能成为这些患者选择DDR起搏器的一个依据。
