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Modes of cardiac pacing: Nomenclature and

selection
Author: Mark S Link, MD
Section Editor: N A Mark Estes, III, MD
Deputy Editor: Susan B Yeon, MD, JD, FACC

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Oct 2020. | This topic last updated: Jan 24, 2019.

INTRODUCTION

Once it has been established that bradycardia or a conduction disorder warrants

permanent pacing, the most appropriate pacing mode for the patient must be
selected. The choice depends upon the specific abnormality that is present, since a
wide range of pacemaker functions have been developed to accommodate specific
clinical needs ( table 1). (See "Permanent cardiac pacing: Overview of devices and
indications".)

To facilitate the use and understanding of pacemakers, a standardized classification

code has been developed. Most patients can be managed with one of two or three
common modes (AAI, VVI, or DDD), with or without rate responsiveness.

Contemporary pacemakers are versatile and capable of the most commonly used
pacing modes and basic functions (ie, mode switching and rate responsiveness). Some
advanced features are available in selected devices.

Pacemaker nomenclature and the clinical application of common pacing modes and
functions will be reviewed here.
NOMENCLATURE

Five position code — A three-letter code describing the basic function of the various
pacing systems was first proposed in 1974 by a combined task force from the
American Heart Association and the American College of Cardiology and subsequently
updated by a committee from the North American Society of Pacing and
Electrophysiology (NASPE) and the British Pacing and Electrophysiology Group (BPEG).
The code, which has five positions, is designated the NBG code for pacing
nomenclature ( table 2) [1].

The code is generic and does not describe specific or unique functional characteristics
for each device. When a code includes only three or four characters, it can be assumed
that the positions not mentioned are "O" or absent.

Position I — The first position reflects the chamber(s) paced. "A" indicates the
atrium, "V" indicates the ventricle, and "D" means dual chamber (ie, both the atrium
and the ventricle).

Position II — The second position refers to the chamber(s) sensed. The letters are
the same as those for the first position: "A" for atrium, "V" for ventricle, "D" for dual. An
additional option "O" indicates an absence of sensing. Programmed in this mode, a
device will pace automatically at a specified rate, ignoring any intrinsic rhythm. (See
'Asynchronous pacing' below.)

Manufacturers sometimes use "S" in the first and second positions to indicate that the
device is capable of pacing only a single cardiac chamber. Once the device is implanted
and connected to a lead in either the atrium or the ventricle, "S" should be changed to
"A" or "V" in the clinical record to reflect the chamber in which pacing and sensing are
occurring.

Position III — The third position refers to how the pacemaker responds to a sensed
event.

● "I" indicates that a sensed event inhibits the output pulse and causes the
pacemaker to recycle for one or more timing cycles.

● "T" indicates that an output pulse is triggered in response to a sensed event.

 ● "D" indicates that there are dual modes of response. This designation is restricted
to dual-chamber systems. An event sensed in the atrium inhibits the atrial output
but triggers a ventricular output. There is a programmable delay between the
sensed atrial event and the triggered ventricular output to mimic the normal PR
interval. If the ventricular lead senses a native ventricular signal during the
programmed delay, it will inhibit the ventricular output.

● "O" indicates no response to sensed input; it is most commonly used in

conjunction with an "O" in the second position.

Position IV — The fourth position reflects rate modulation, also referred to as rate
responsive or rate adaptive pacing. (See 'Rate responsiveness' below.)

● "R" in the fourth position indicates that the pacemaker has rate modulation and
incorporates a sensor to adjust its programmed paced heart rate in response to
patient activity. From a practical standpoint, "R" is the only indicator commonly
used in the fourth position.

● "O" indicates that rate modulation is either unavailable or disabled. "O" is often
omitted from the fourth position (ie, DDD is the same as DDDO).

Position V — The fifth position is rarely ever utilized but specifies the location or
absence of multisite pacing, defined as stimulation sites in both atria, both ventricles,
more than one stimulation site in any single chamber, or a combination of these.

The fifth position of the code is rarely used.

● "O" means no multisite pacing

● "A" indicates multisite pacing in the atrium or atria
● "V" indicates multisite pacing in the ventricle or ventricles
● "D" indicates dual multisite pacing in both atrium and ventricle

The most common application of multisite pacing is biventricular pacing for the
management of heart failure. This issue is discussed in detail separately. (See "Cardiac
resynchronization therapy in heart failure: Indications".)

Features — In addition to the above basic pacing modes, modern pacemakers have
additional features to improve performance in a variety of specific clinical settings.
Mode switching and rate responsiveness are available in all contemporary
pacemakers. Some features are available in select devices and can be utilized as
specific clinical situations demand.

Mode switching — In dual-chamber pacing systems (DDD/DDDR or less commonly,

VDD/VDDR), the ventricle will be paced following every sensed atrial event, up to a
programmed maximum ventricular rate. If the patient develops a paroxysmal atrial
tachyarrhythmia (eg, atrial fibrillation), the ventricle would then be paced at this
maximum programmed rate for the duration of the arrhythmia, which is obviously
undesirable.

Mode switching refers to automatic reprogramming of a pacemaker to a mode that no

longer tracks the intrinsic atrial rate, usually VVI, DDI, or DVI with or without rate
responsiveness. When the sensed atrial rate again falls below the mode switching
cutoff and the device assumes that a physiologic rhythm has been restored (ie, with
termination of the arrhythmia), the pacing mode automatically reverts to the original
programming.

All contemporary dual-chamber pacemakers have mode switching capabilities. This

feature can be activated or disabled, depending upon the clinical situation.

Rate responsiveness — As described above, rate responsiveness, also referred to

as rate modulation or rate adaptation, refers to the ability of a pacemaker to adjust its
programmed paced rate based upon patient activity. A variety of sensors have been
designed to determine when a patient is physically active (eg, vibration, minute
ventilation, change in right ventricular impedance). The range of heart rates, the pace
of acceleration and deceleration, and the degree of activity required to initiate this
response are all programmable in rate-adaptive pacing modes.

Modes to minimize ventricular pacing — Right ventricular (RV) pacing causes the

right ventricle to contract before the left ventricle (LV), and causes the septum to
contract before the lateral wall of the LV, simulating the effects of left bundle branch
block. This phenomenon is referred to as ventricular dyssynchrony or asynchrony.
Whether due to RV pacing or intrinsic conduction abnormalities, dyssynchrony can
cause or exacerbate heart failure in some patients and increase the frequency of atrial
fibrillation. (See "Overview of cardiac pacing in heart failure" and "The role of
pacemakers in the prevention of atrial fibrillation".)
Native atrioventricular (AV) conduction is hemodynamically preferable to RV pacing.
With an increased understanding of the detrimental effects of RV pacing, efforts have
been made to develop pacing modes that minimize ventricular pacing [2-7]. Examples
of novel pacing strategies for this purpose include the following:

● Ventricular avoidance pacing algorithms – A dual-chamber device can be

programmed to pace AAI (allowing native conduction), but if specific criteria are
met that signify a loss of AV conduction, the pacemaker will automatically switch
to DDD pacing for some period of time until the algorithm once again determines
the presence of intrinsic AV conduction. This approach has been associated with a
markedly lower rate of frequency of ventricular pacing compared with
conventional dual-chamber pacing (9 versus 99 percent and 4 versus 74 percent in
two studies) [3,4,7].

● AV search hysteresis – Algorithms exist that will prolong the programmed AV delay
in a dual-chamber device to allow native conduction when present. The
mechanism and frequency with which the algorithm allows AV prolongation to
determine the presence of intrinsic AV conduction and the degree to which the AV
delay can be extended are variable depending on manufacturer and model [5]. If
native conduction with a long PR or AR is present, the device will allow this to
continue until the allowed interval is exceeded and there is no intrinsic QRS. This
will generally reset the algorithm to the original programmed AV interval.

Biventricular pacing — In some patients, ventricular dyssynchrony is unavoidable

due to intrinsic conduction disease or inevitable ventricular pacing. If such a patient
also has heart failure and LV dysfunction, synchrony may be restored with
biventricular pacing, or cardiac resynchronization therapy (CRT), which improves
outcomes in selected patients. Cardiac resynchronization therapy is discussed in detail
elsewhere. (See "Cardiac resynchronization therapy in heart failure: Indications".)

Patients with LV dysfunction and a mildly reduced ejection fraction (EF; eg, 36 to 49
percent) who have an indication for permanent pacing have traditionally received a
standard dual-chamber pacemaker. However, given the potential for ventricular
pacing (especially RV apical pacing) to cause or exacerbate LV dysfunction, it is
believed that patients might have better outcomes if cardiac resynchronization
therapy (ie, biventricular pacing) was the initially implanted device. One trial, BLOCK-
HF, demonstrated that in patients with AV block and LV systolic dysfunction (LVEF <50
percent) with NYHA class I, II, or III heart failure, biventricular pacing was superior to
conventional RV pacing for the primary outcome of time to death from any cause,
urgent IV therapy for heart failure, or 15 percent or greater increase in LV end-systolic
volume index [8]. In a post hoc analysis of the BLOCK-HF trial, patients in the
biventricular pacing arm were more likely to have improvement in NYHA functional
status and in a clinical composite score incorporating various clinical outcomes [9].

Additional randomized clinical trials are needed to assess conventional pacing versus
biventricular stimulation in patients with mildly reduced LV function.

PACING MODES

In selecting the ideal pacing mode, the patient's overall physical condition, associated
medical problems, exercise capacity, left ventricular function, and chronotropic
response to exercise must be considered along with the underlying rhythm
disturbance. Some of the various ventricular and atrial pacing systems available and
their NBG codes are shown in the table ( table 3).

Single-chamber pacing — Early pacemakers were designed to sense and pace in a

single chamber. Ventricular pacing can prevent ventricular bradyarrhythmias or
asystole of any etiology. Atrial pacing can be used in patients with isolated sinus node
dysfunction (SND) and intact AV conduction.

VVI or VVIR pacing — Ventricular demand pacing (ventricle paced, ventricle

sensed, and pacemaker inhibited in response to a sensed beat) remains the most
commonly used pacing mode. Advantages of ventricular demand pacing include the
requirement for only a single lead and the ability to protect the patient from
dangerous bradycardias of any etiology. However, ventricular demand pacing cannot
maintain AV synchrony, and lack of AV synchrony can result in pacemaker syndrome.
(See 'Pacemaker syndrome' below.)

Virtually all devices currently in use are capable of VVIR pacing. VVIR pacing is primarily
indicated in patients with chronic atrial fibrillation with a slow ventricular response.
By contrast, in a patient with normal sinus rhythm, VVIR pacing should not be used as
an excuse to forego attempts at placing an atrial lead. If sinus node function is intact,
dual-chamber (DDD) pacing preserves AV synchrony and maintains the patient's
natural heart rate response to activity. This approach is optimal and should be used
whenever possible. (See 'Physiologic pacing' below.)

AAI or AAIR pacing — Atrial demand pacing (atrium paced, atrium sensed, and
pacemaker inhibited in response to sensed atrial beat) is appropriate for patients with
SND who have intact AV nodal function. Patients with symptomatic sinus bradycardia
or sinus pauses, but with an intact ability to accelerate their heart rate with exertion,
can be programmed in an AAI mode. Those who cannot adequately accelerate their
heart rate should have rate responsive capability available (ie, AAIR).

As with ventricular demand pacemakers, these devices have the benefit of requiring
only a single lead. However, unlike ventricular single-chamber pacemakers, they will
not protect patients from ventricular bradyarrhythmias due to AV conduction block.
Due to this limitation, atrial demand pacemakers are infrequently used. Many
clinicians are concerned that a patient who already has sinus node disease will later
develop AV conduction disease. Although it would be uncommon for AV block to
develop precipitously and result in a catastrophic event, gradual development of AV
conduction system disease may require upgrade of the pacemaker to a dual-chamber
device. Pacemaker upgrade can be technically more difficult than original placement
of a dual-chamber pacemaker, and the second procedure obviously entails additional
cost and patient risk.

However, if the patient with SND is assessed carefully and does not have AV node
disease at the time of pacemaker implant, the occurrence of clinically significant AV
nodal disease is very low (less than 2 percent per year) [10]. Assessment prior to use of
an AAI system should include incremental atrial pacing at the time of pacemaker
implant. Although criteria vary among institutions and implanting clinicians, the adult
patient should be capable of 1:1 AV nodal conduction to rates of 120 to 140
beats/minute.

Dual-chamber pacing
 DDD or DDDR pacing — The dual-chamber (DDD) pacing system provides
physiologic pacing (see 'Physiologic pacing' below), with sensing and pacing
capabilities in both the atrium and the ventricle.

● The pacemaker will be totally inhibited in the presence of sinus rhythm with
normal AV conduction if the sinus rate is faster than the programmed lower rate
of the pacemaker and the intrinsic AV conduction is faster than the programmed
AV interval.

● If there is sinus bradycardia but normal AV conduction with the intrinsic QRS
occurring before the end of the programmed AV interval, there will be atrial
pacing with a native QRS complex following each paced atrial beat.

● Both the atrium and ventricle will be paced if there is sinus bradycardia and
delayed or absent AV conduction.

● The ventricle will be paced synchronously with the atrium if there is normal sinus
rhythm with delayed or absent AV conduction.

As a result, there are four different rhythms that can be seen with normal pacemaker
function ( waveform 1):

● Normal sinus rhythm

● Atrial pacing, normally conducted to the ventricle with a native QRS
● AV sequential pacing
● Atrial sensing and ventricular pacing

The DDD pacing mode is appropriate for patients with AV block who have normal sinus
node function. DDD pacing is also considered by some to be the mode of choice in
carotid sinus hypersensitivity with symptomatic cardioinhibition. However, most
patients should receive a pacemaker capable of DDDR pacing, even if rate response is
not initially programmed "on."

The ideal patient for DDDR pacing is one with combined sinus nodal and AV nodal
dysfunction in whom DDDR pacing would restore rate responsiveness and AV
synchrony. DDDR pacing is also appropriate for patients with SND and normal AV
conduction. As noted above, many practitioners are not comfortable with AAIR pacing.
Use of DDDR pacing mode with an algorithm that will minimize ventricular pacing is
often preferred.

DDI or DDIR pacing — In the DDI pacing mode, there is atrial sensing and pacing,
and ventricular sensing and pacing; however, the pacemaker will not track intrinsic
atrial activity. When there is a sensed native atrial rate, the pacemaker will inhibit both
atrial and ventricular output, thereby allowing native conduction to the ventricle. If AV
block develops, ventricular pacing will occur at a programmed rate, but will not be
synchronized with the atrium.

As an example, if a device is programmed DDI at 50 beats per minute, and the patient
has sinus rhythm at 60 with 1:1 AV conduction, the device will be fully inhibited. If AV
block develops, the pacemaker will pace the ventricle at 50 beats per minute. If sinus
bradycardia develops, the pacemaker will pace the atrium and ventricle synchronously
at 50 beats per minute.

In the DDI mode, if the sinus rate is below the programmed rate, the pacemaker will
pace the atrium and ventricle sequentially.

There are few, if any, advantages of DDI or DDIR pacing at this time. At one time, this
mode was helpful for the patient with atrial tachyarrhythmias. Since DDI does not
"track," this mode would alleviate the concern of fast ventricular rates in response to
the atrial tachyarrhythmia. However, this has become much less important since
essentially all dual-chamber devices now have mode switching capability. (See 'Mode
switching' above.)

Less common modes — VDD and DVI mode remain programmable options in most
pacemakers but are rarely used.

VDD pacing — VDD pacing (ventricle paced, atrium and ventricle sensed, and
either inhibition or tracking of the pacemaker in response to a sensed beat) may be
appropriate for the patient with normal sinus node function and conduction disease of
the AV node. Dual-chamber (two lead) VDD pacing systems have largely been
supplanted by DDD pacemakers.

However, a single-lead VDD pacing system, now available for many years, has
increased interest in the use of VDD as the initial pacing mode in patients with AV
block but normal sinus node function [11-13]. In these systems, atrial sensing is
accomplished from "floating" sensing electrodes on the atrial portion of the
ventricular pacing lead.

One limitation to the use of a single-lead VDD pacemaker is that patients with initially
normal SA node function may develop SND. This would then require a second
procedure to place an atrial lead capable of pacing in order to maintain AV synchrony
and chronotropic competence. However, this is an infrequent occurrence [14,15].

DVI pacing — DVI pacemakers (atrium and ventricle paced, ventricular sensing

only, and inhibition of pacemaker in response to sensed ventricular beat) are now of
historical interest only. DVI pacing is, by definition, limited by the absence of atrial
sensing, which prevents the restoration of rate responsiveness in the chronotropically
competent patient. In addition, lack of atrial sensing may lead to competitive atrial
pacing and initiation of atrial rhythm disturbances.

Asynchronous pacing — Pacemakers may be programmed to pace at a fixed rate,

without attempting to sense or react to native cardiac activity. These modes are
referred to as asynchronous pacing.

AOO, VOO, or DOO mode — In these modes, the atrium, ventricle, or both are
paced, but the pacemaker has no sensing capability and hence there is no sensing
response of the pacemaker.

Asynchronous pacing modes are rarely used long-term. These modes, however, may
be temporarily necessary for patients who are undergoing a surgical procedure,
especially if the patient is pacemaker-dependent. Electrocautery could be sensed by
the pacemaker and misinterpreted as native cardiac activity, thereby inhibiting pacing
output. This could produce significant bradycardia or asystole in a pacemaker-
dependent patient.

Thus, prior to surgery, the pacemaker could be reprogrammed to an asynchronous

mode that turns off its sensing capability. After surgery, the pacemaker should be
reprogrammed to its prior mode. Alternatively, a magnet placed over the pacemaker
will deactivate its ability to sense and, while left in place, will result in asynchronous
pacing. Although this approach has been used for many years there are some
concerns that are likely more theoretical than real.
Pacing in an asynchronous mode can be associated with competition between the
native and the paced rhythms, with the possibility that a paced impulse will occur
during a native T wave (or the vulnerable period). To reduce this risk, asynchronous
pacing could be programmed to a relatively higher rate (≥80 beats/minute).

PHYSIOLOGIC PACING

Physiologic pacing is a term that has been used to describe pacing systems that most
closely approximate normal cardiac behavior. It most commonly refers to systems that
maintain AV synchrony (eg, AAI or DDD systems, in contrast to VVI systems), but has
also been applied to rate responsive pacemakers. (See 'Rate responsiveness' above.)

Potential advantages — Physiologic pacing has several potential hemodynamic and

clinical advantages compared with VVI pacing [16]. These include:

● Reduced incidence of atrial fibrillation (AF) – The incidence of atrial

tachyarrhythmias, particularly AF, is reduced by physiologic compared with VVI
pacing. (See "The role of pacemakers in the prevention of atrial fibrillation".)

● Reduced incidence of thromboembolic events – A lower rate of thromboembolic

events is suggested in the meta-analysis of physiologic pacing discussed below,
and may be secondary to the lower incidence of AF [17].

● Improved hemodynamics – The maintenance of AV synchrony and "atrial kick" is

hemodynamically favorable and physiologic pacing improves cardiac output,
arterial pressure, and coronary blood flow [18-21]. The magnitude of these
improvements is small, and their clinical significance is not clear but, in some
studies, physiologic pacing has resulted in a lower incidence of heart failure [22].
(See "Hemodynamic consequences of atrial fibrillation and cardioversion to sinus
rhythm", section on 'Atrial systole'.)

● Avoidance of pacemaker syndrome – VVI pacing is associated with the

development of "pacemaker syndrome." This syndrome is due to AV dyssynchrony
or retrograde ventricular-to-atrial conduction. It is prevented by physiologic
pacing [23,24]. (See 'Pacemaker syndrome' below.)
 Effect on morbidity and mortality — Several trials and a meta-analysis have
compared physiologic and VVI pacing [17,24-29]. In the aggregate, these reports
demonstrate that across the spectrum of patients with bradycardic indications for
pacemakers, physiologic pacing does not improve survival or the incidence of heart
failure, but does reduce the incidence of atrial fibrillation (AF) and may reduce the
incidence of stroke.

The meta-analysis included data from five randomized trials [17]:

● A Danish trial of 225 patients with sinus node dysfunction (SND) and normal AV
conduction [22,25,30].

● The MOST trial of 2010 patients with SND, 20 percent of whom also had AV
conduction disease [26,31].

● The CTOPP trial of 2568 patients with both SND and AV conduction disease (42
percent with SND) [27,29,32,33].

● The PASE trial of 407 patients, 43 percent with SND [24,34].

● The UKPACE trial of 2021 elderly patients, all of whom had AV conduction disease
[28].

The meta-analysis included 7231 patients and over 35,000 patient-years of follow-up.
The average patient age was 76. Most patients randomly assigned to physiologic
pacing received a dual-chamber (DDD) pacemaker, while all of those in the Danish trial
and some in CTOPP received an AAI pacemaker. The following findings were noted:

● There was no difference in the incidence of heart failure or in all-cause mortality

between physiologic and VVI pacing (31 versus 33 percent all-cause mortality).

● Physiologic pacing significantly reduced the incidence of AF (17 versus 22 percent).

● Physiologic pacing appeared to reduce the incidence of stroke (5.2 versus 6.3
percent). However, the authors suggested cautious interpretation of this finding,
due to borderline statistical significance (95% CI 0.67-0.99, p = 0.035) and the lack
of adjustment for multiple hypothesis testing.
 ● Subgroup analysis suggested that physiologic pacing may be more beneficial in
patients with SND than those with AV block. Among patients with SND, physiologic
pacing appeared to reduce the combined endpoint of stroke or cardiovascular
death. However, the authors suggested caution in the interpretation of this
subgroup analysis, because of heterogeneity in the populations of the included
trials (ie, different percentages of patients with SND). Issues specifically related to
physiologic pacing and SND are discussed separately.

● There was no additional advantage in several other subgroups that are often
considered to derive a greater benefit from physiologic pacing (eg, those with left
ventricular dysfunction or heart failure).

● Patients appear to prefer physiologic pacing, suggested by relatively high

crossover rates from VVI to dual-chamber pacing in the two trials in which this was
easy to do. (See 'Patient preference' below.)

The results of the meta-analysis are broadly consistent with those of the individual
trials. However, due to the some differences in the patient populations (eg, SND versus
AV block, elderly patients), and the pacemakers used (eg, AAI versus DDD), some
points from individual studies are worth consideration:

● As in the subgroup analysis, results from the Danish trial suggested a greater
benefit of physiologic pacing in patients with SND than in those with AV block,
which we now understand to be a function of maintaining intrinsic AV conduction
in the SND group [30].

● In the very elderly, the rates of AF and stroke are high regardless of pacing mode.
The value of physiologic pacing may be less significant in this group, particularly
those with AV block [28,35]. This was best illustrated in the UKPACE trial of 2021
elderly patients (average age 80), all of whom had AV block [28]. In this population,
physiologic pacing did not reduce the rates of mortality, AF, or thromboembolism.

Pacemaker syndrome — Pacemaker syndrome is a phenomenon associated with the

loss of AV synchrony and is seen most commonly with single-chamber VVI pacing. It is
defined as the adverse hemodynamics associated with a normally functioning pacing
system, resulting in overt symptoms or limitation of the patient's ability to achieve
optimal functional status [23]. The development of the pacemaker syndrome with VVI
pacing may require upgrade from a VVI pacemaker to a dual-chamber system in some
patients.

Symptoms most commonly include general malaise, easy fatigability, dyspnea,

orthopnea, cough, dizziness, atypical chest discomfort, and a sensation of throat
fullness and, less commonly, may result in pre-syncope or syncope. Physical
examination may reveal hypotension, rales, increased jugular venous pressure with
cannon A waves, peripheral edema, and murmurs of tricuspid and/or mitral
regurgitation [23,36].

Patient preference — Although no consistent mortality benefit has been identified in

randomized clinical trials with physiologic pacing, patients seem to prefer physiologic
pacing as illustrated by the following observations:

● In a double-blind crossover study of different pacing modes, 86 percent of

patients preferred physiologic pacing [37].

● In PASE and MOST, quality of life scores were higher in patients with SND
randomly assigned to physiologic pacing [24,26].

● In the clinical trials comparing physiologic and VVI pacing, when crossing over
from VVI to physiologic pacing was easy, up to 38 percent of patients chose to
cross over. In PASE and MOST, all patients received dual-chamber pacemakers,
and randomization to physiologic or VVI pacing occurred after implantation
[24,26]. Thus, crossover required only device reprogramming (as opposed to a
second procedure). The crossover rates in these two trials were 26 and 38 percent
(compared with less than 5 percent in the other trials).

The high crossover rate in MOST led to questions about the validity of the results.
However, in a later study, the results of intention-to-treat and on-treatment analyses
were similar [31]. As in the original report from MOST [26], the on-treatment analysis
showed no difference in the primary endpoint between the two pacing modes, but
there was a significant reduction in the incidence of atrial fibrillation with physiologic
pacing.

Based upon the reduced incidence of atrial fibrillation and patient preference, we
suggest that physiologic pacing should be used in most patients who require a
pacemaker.
MODE SELECTION ALGORITHMS

A number of guidelines and algorithms are available for determining the appropriate
pacing mode for patients with sinus node disease and AV node disease [38].

The indications and contraindications for the various types of pacing modes are listed
in the accompanying tables ( table 4) [38]. In this listing, chronotropically competent
refers to the ability of a patient to achieve an appropriate heart rate for a given
physiologic activity.

Several algorithms are also available:

● General algorithms for all bradycardic indications ( algorithm 1 and figure 1)

● An algorithm for sick sinus syndrome ( algorithm 2)
● An algorithm for AV block ( figure 2)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and

regions around the world are provided separately. (See "Society guideline links:
Cardiac implantable electronic devices".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond
the Basics." The Basics patient education pieces are written in plain language, at the
5th to 6th grade reading level, and they answer the four or five key questions a patient
might have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. Beyond the Basics
patient education pieces are longer, more sophisticated, and more detailed. These
articles are written at the 10th to 12th grade reading level and are best for patients who
want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage
you to print or e-mail these topics to your patients. (You can also locate patient
education articles on a variety of subjects by searching on "patient info" and the
keyword(s) of interest.)

● Basics topic (see "Patient education: Pacemakers (The Basics)")

● Beyond the Basics topic (see "Patient education: Pacemakers (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

The following summary and recommendations apply to the selection of pacemakers

for implantation in patients with a standard bradycardic indication for pacing. (See
"Permanent cardiac pacing: Overview of devices and indications".)

Most patients can be managed with one of three common pacing modes (with or
without rate responsive pacing): AAI(R), VVI(R), or DDD(R). At the time of implantation,
one should consider how many leads will be necessary and which additional features,
if any, will be of potential value.

Single- or dual-chamber pacemakers — The most important choice in most patients

is whether to place a single- or dual-chamber pacemaker. The choice varies with the
clinical setting:

● In patients with chronic atrial fibrillation (AF) who require a pacemaker due to slow
ventricular response, we recommend a single-chamber ventricular pacemaker
(VVI or VVIR) (Grade 1B).

● In patients with conditions that could be managed with either a single- or a dual-
chamber pacemaker (eg, AV block, sinus node dysfunction [SND]), we suggest a
dual-chamber pacemaker (Grade 2B). (See 'Physiologic pacing' above.)

A single-chamber pacemaker is a reasonable alternative in patients who are very

elderly or whose anatomy and physical condition make the implantation of two leads
more difficult than usual. In such cases, the additional costs and risks of a dual-
chamber physiologic pacemaker may outweigh the potential benefits of the reduced
risk of AF and patient preference. VVI(R) pacing will be effective in all such patients.

An AAI(R) pacemaker is a reasonable alternative to VVI(R) pacing in the subset of

patients with SND in whom AV conduction is intact and meets intraimplant testing
criteria (see "Sinus node dysfunction: Treatment"). However, effective AAIR pacing is
more commonly accomplished with a dual-chamber pacemaker with a ventricular
pacing avoidance option.

Additional features — The following additional features are appropriate for selected

patients:

● Rate responsiveness can be programmed for patients who are active, but not
chronotropically competent. (See 'Rate responsiveness' above.)

● Mode switching can be programmed for patients with paroxysmal atrial

arrhythmias. (See 'Mode switching' above.)

● Ventricular avoidance pacing algorithms are appropriate for most patients with PR
prolongation or type II AV block. Some parameter to minimize ventricular pacing
is available in most contemporary devices. (See 'Modes to minimize ventricular
pacing' above.)

ACKNOWLEDGMENT

The UpToDate editorial staff would like to thank Dr. David L. Hayes for his past
contributions as an author to prior versions of this topic review.

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES
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2. Sweeney MO, Prinzen FW. A new paradigm for physiologic ventricular pacing. J
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5. Olshansky B, Day JD, Moore S, et al. Is dual-chamber programming inferior to

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6. Ricci RP, Botto GL, Bénézet JM, et al. Association between ventricular pacing and
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9. Curtis AB, Worley SJ, Chung ES, et al. Improvement in Clinical Outcomes
With Biventricular Versus Right Ventricular Pacing: The BLOCK HF Study. J Am Coll
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10. Hayes DL, Furman S. Stability of AV conduction in sick sinus node syndrome
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12. Rey JL, Tribouilloy C, Elghelbazouri F, Otmani A. Single-lead VDD pacing: long-
term experience with four different systems. Am Heart J 1998; 135:1036.
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comparison of VDD and DDD pacing. Pacing Clin Electrophysiol 2004; 27:19.

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patients with AV block: implications for single lead VDD pacing. Heart 1999;
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dysfunction in pacemaker patients with isolated atrioventricular block. Pacing
Clin Electrophysiol 1998; 21:1430.

16. Lamas GA, Ellenbogen KA. Evidence base for pacemaker mode selection: from
physiology to randomized trials. Circulation 2004; 109:443.

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pacing compared with ventricular pacing: meta-analysis of randomized trials,
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18. Stewart WJ, Dicola VC, Harthorne JW, et al. Doppler ultrasound measurement of
cardiac output in patients with physiologic pacemakers. Effects of left ventricular
function and retrograde ventriculoatrial conduction. Am J Cardiol 1984; 54:308.

19. Rediker DE, Eagle KA, Homma S, et al. Clinical and hemodynamic comparison of
VVI versus DDD pacing in patients with DDD pacemakers. Am J Cardiol 1988;
61:323.

20. Boon NA, Frew AJ, Johnston JA, Cobbe SM. A comparison of symptoms and intra-
arterial ambulatory blood pressure during long term dual chamber
atrioventricular synchronous (DDD) and ventricular demand (VVI) pacing. Br
Heart J 1987; 58:34.

21. Takeuchi M, Nohtomi Y, Kuroiwa A. Effect of ventricular pacing on coronary blood

flow in patients with normal coronary arteries. Pacing Clin Electrophysiol 1997;
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22. Nielsen JC, Andersen HR, Thomsen PE, et al. Heart failure and echocardiographic
changes during long-term follow-up of patients with sick sinus syndrome
 randomized to single-chamber atrial or ventricular pacing. Circulation 1998;
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23. Ausubel K, Furman S. The pacemaker syndrome. Ann Intern Med 1985; 103:420.

24. Lamas GA, Orav EJ, Stambler BS, et al. Quality of life and clinical outcomes in
elderly patients treated with ventricular pacing as compared with dual-chamber
pacing. Pacemaker Selection in the Elderly Investigators. N Engl J Med 1998;
338:1097.

25. Andersen HR, Thuesen L, Bagger JP, et al. Prospective randomised trial of atrial
versus ventricular pacing in sick-sinus syndrome. Lancet 1994; 344:1523.

26. Lamas GA, Lee KL, Sweeney MO, et al. Ventricular pacing or dual-chamber pacing
for sinus-node dysfunction. N Engl J Med 2002; 346:1854.

27. Connolly SJ, Kerr CR, Gent M, et al. Effects of physiologic pacing versus ventricular
pacing on the risk of stroke and death due to cardiovascular causes. Canadian
Trial of Physiologic Pacing Investigators. N Engl J Med 2000; 342:1385.

28. Toff WD, Camm AJ, Skehan JD, United Kingdom Pacing and Cardiovascular Events
Trial Investigators. Single-chamber versus dual-chamber pacing for high-grade
atrioventricular block. N Engl J Med 2005; 353:145.

29. Kerr CR, Connolly SJ, Abdollah H, et al. Canadian Trial of Physiological Pacing:
Effects of physiological pacing during long-term follow-up. Circulation 2004;
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30. Andersen HR, Nielsen JC, Thomsen PE, et al. Long-term follow-up of patients from
a randomised trial of atrial versus ventricular pacing for sick-sinus syndrome.
Lancet 1997; 350:1210.

31. Hellkamp AS, Lee KL, Sweeney MO, et al. Treatment crossovers did not affect
randomized treatment comparisons in the Mode Selection Trial (MOST). J Am Coll
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32. Skanes AC, Krahn AD, Yee R, et al. Progression to chronic atrial fibrillation after
pacing: the Canadian Trial of Physiologic Pacing. CTOPP Investigators. J Am Coll
Cardiol 2001; 38:167.

33. Tang AS, Roberts RS, Kerr C, et al. Relationship between pacemaker dependency
and the effect of pacing mode on cardiovascular outcomes. Circulation 2001;
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34. Ellenbogen KA, Stambler BS, Orav EJ, et al. Clinical characteristics of patients
intolerant to VVIR pacing. Am J Cardiol 2000; 86:59.

35. Jahangir A, Shen WK, Neubauer SA, et al. Relation between mode of pacing and
long-term survival in the very elderly. J Am Coll Cardiol 1999; 33:1208.

36. Link MS, Hellkamp AS, Estes NA 3rd, et al. High incidence of pacemaker syndrome
in patients with sinus node dysfunction treated with ventricular-based pacing in
the Mode Selection Trial (MOST). J Am Coll Cardiol 2004; 43:2066.

37. Sulke N, Chambers J, Dritsas A, Sowton E. A randomized double-blind crossover

comparison of four rate-responsive pacing modes. J Am Coll Cardiol 1991; 17:696.

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the Evaluation and Management of Patients With Bradycardia and
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Cardiology/American Heart Association Task Force on Clinical Practice Guidelines
and the Heart Rhythm Society. J Am Coll Cardiol 2019; 74:e51.

Topic 950 Version 27.0

GRAPHICS

Guidelines for choice of pacemaker generator in selected indications for pacing

Neurally-mediated
Type of Sinus node
AV block syncope or carotid
pacemaker dysfunction
sinus hypersensitivity

Single-chamber No suspected abnormality Not appropriate Not appropriate (unless AV

atrial of AV conduction and not block systematically excluded)
at increased risk for future
AV block

Maintenance of AV
synchrony during pacing
desired

Rate response available if

desired

Single-chamber Maintenance of AV Chronic atrial fibrillation or Chronic atrial fibrillation or

ventricular synchrony during pacing other atrial tachyarrhythmia or other atrial tachyarrhythmia
not necessary maintenance of AV synchrony
during pacing not necessary Rate response available if
Rate response available if desired
desired Rate response available if
desired

Dual-chamber AV synchrony during AV synchrony during pacing Sinus mechanism present

pacing desired desired
Rate response available if
Suspected abnormality of Atrial pacing desired desired
AV conduction or increased
risk for future AV block Rate response available if
desired
Rate response available if
desired

Single-lead, atrial- Not appropriate Normal sinus node function and Not appropriate
sensing no need for atrial pacing
ventricular
Desire to limit number of
pacemaker leads

AV: atrioventricular.

Data from Gregoratos G, Cheitlin MD, Conill A, et al. Circulation 1998; 97:1325.

Graphic 51504 Version 3.0

Revised NBG code for pacing nomenclature

Position I II III IV V

Category Chamber(s) Chamber(s) Response to Rate Multisite

paced sensed sensing modulation pacing

O = None O = None O = None O = None O = None
A = Atrium A = Atrium T = Triggered R = Rate A = Atrium
V = Ventricle V = Ventricle I = Inhibited modulation V=
D = Dual (A+V) D = Dual (A+V) D = Dual (T+I) Ventricle
D = Dual
(A+V)

Manufacturer's S = Single (A S = Single (A or

designation only: or V) V)

Note: Positions I through III are used exclusively for antibradyarrythmia function.

Adapted from Bernstein AD, Daubert JC, Fletcher RD, et al. Pacing Clin Electrophysiol 2002; 25:260.

Graphic 68327 Version 3.0

Types of cardiac pacemakers and NBG codes

Code Meaning

VOO Asynchronous ventricular pacemaker; no adaptive rate control or antitachyarrhythmia functions

VVI Ventricular "demand" pacemaker with electrogram-waveform telemetry; no adaptive rate control or
antitachyarrhythmia functions

DVI Multiprogrammable atrioventricular-sequential pacemaker; no adaptive rate control

DDD Multiprogrammable "physiologic" dual-chamber pacemaker; no adaptive rate control or

antitachyarrhythmia functions

DDI Multiprogrammable DDI pacemaker (with dual-chamber pacing and sensing but without atrial-
synchronous ventricular pacing); no adaptive rate control or antitachycardia functions

VVIR Adaptive-rate VVI pacemaker with escape interval controlled adaptively by one or more unspecified
variables

DDDR Programmable DDD pacemaker with escape interval controlled adaptively by one or more unspecified
variables

Graphic 79459 Version 1.0

Rhythms seen with a normal DDD pacemaker

The rhythms that occur in a patient with a DDD pacemaker depend upon the
underlying heart rate and atrioventricular (AV) nodal conduction. The pacemaker spike
is represented in blue. First panel: The pacemaker may be completely inhibited when
the sinus rate is greater than the lower rate limit of the pacemaker. Second panel: P-
wave synchronous pacing occurs when there is intrinsic AV nodal delay which is
greater than the AV delay in the pacemaker. Third panel: Atrial pacing occurs when the
sinus rate falls below the lower limit of the pacemaker and AV nodal conduction is
intact. Fourth panel: If there is sinus bradycardia and AV nodal conduction delay, the
pacemaker paces both atrium and ventricle, known as AV sequential pacing.

Graphic 52858 Version 3.0

Pacing modes indications and contraindications

Generally agreed upon Controversial

Mode Contraindications
indications indications

VVI/VVIR ◾ Fixed atrial arrhythmias ◾ Symptomatic bradycardia in ◾ Patients with known

(atrial fibrillation or flutter)
with symptomatic
bradycardia in the CC
patient (VVI) or CI patient
(VVIR)
the patient with associated
terminal illness or other
medical conditions from
which recovery is not
anticipated and pacing is
life-sustaining only
pacemaker syndrome or
hemodynamic deterioration
with ventricular pacing at
the time of implant
◾ CI patient who will benefit
from rate response
◾ Patients with hemodynamic
need for dual-chamber
pacing

AAI/AAIR ◾ Symptomatic bradycardia as ◾ Sinus node dysfunction with

a result of sinus node associated AV block either
dysfunction; used when AV demonstrated
conduction can be proven spontaneously or during
normal in the otherwise CC pre-implant testing
patient (AAI) or CI patient ◾ When adequate atrial
(AAIR) sensing cannot be attained

DVI*

VDD ¶/VDDR Δ ◾ Congenital AV block ◾ Sinus node dysfunction

◾ AV block when sinus node ◾ AV block when
function can be proven accompanied by sinus node
normal in the CC patient dysfunction
(VDD) or CI patient (VDDR) ◾ When adequate atrial
sensing cannot be attained
◾ AV block when
accompanied by PSVT

DDI/DDIR ◊ ◾ Need for dual-chamber ◾ Sinus node dysfunction in ◾ CI patient with a

pacing in the presence of the absence of AV block in demonstrated need or
significant PSVT in the CC the presence of significant improvement with rate
patient (DDI) or CI patient PSVT in the CC patient (DDI) responsiveness
(DDIR) or CI patient (DDIR)

DDD/DDDR ◾ AV block and sinus node
dysfunction in the CC
patient (DDD) or CI patient
(DDDR)
◾ Need for AV synchrony to
maximize cardiac output in
CC active patients (DDD)
◾ Previous pacemaker
syndrome
◾ For any rhythm disturbance
when atrial sensing and
capture is possible for the
potential purpose of
minimizing future atrial
fibrillation and improved
morbidity and survival
◾ Presence of chronic atrial
fibrillation, atrial flutter,
giant inexcitable atrium or
other frequent PSVTs
◾ When adequate atrial
sensing cannot be attained

CC: chronotropically competent (ie, the ability to achieve an appropriate heart rate for a given physiologic activity); CI:
chronotropically incompetent (ie, the inability to achieve an appropriate heart rate for a given physiologic activity); AV:
atrioventricular; PSVT: paroxysmal supraventricular tachycardia.
* DVI as a stand-alone pacing mode (ie, a pacemaker capable of DVI as the only dual-chamber mode of operation) is
obsolete. All primary uses of this mode should be considered individually.
¶ VDD as a stand-alone pacing mode (ie, a pacemaker capable of VDD as the only dual-chamber mode of operation) is
currently used primarily as a single-lead VDD system. If a dual-lead system is implanted, then the capability of DDD pacing
is desirable.
Δ In current single-lead VDDR pacemakers, P-wave tracking occurs as long as the sinus rate is appropriate. However, in the
presence of sinus bradycardia or chronotropic incompetence, the pacemaker operates in the VVIR mode.
◊ DDIR has been supplanted by DDD or DDDR pacemakers with the capability of mode-switching (ie, the pacemaker
automatically reprograms to a mode incapable of tracking the atrial rhythm in the presence of an atrial rhythm that the
pacemaker classifies as a pathological rhythm). When the pacemaker recognizes the atrial rhythm as being physiological,
the pacemaker reprograms to the previously programmed mode.

Graphic 120148 Version 1.0

Pacemaker algorithm

Algorithm for the use of the different types of pacemakers depending upon the need for
atrioventricular (AV) sequential pacing, the presence of sinoatrial (SA) node chronotropic
competence, the AV conduction rate, and the need for rate-responsiveness.

Courtesy of MD McGoon, MD.

Graphic 64626 Version 2.0

Simplified pacemaker algorithm for use with rate adaptive
pacemakers

Simplified algorithm for the choice of pacemaker mode assuming that a rate-
responsive pacemaker (DDDR or VVIR) will be used.

Courtesy of MD McGoon, MD.

Graphic 76446 Version 2.0

Selection of pacemaker systems for patients with sinus node dysfunction

Decisions are illustrated by diamonds. Shaded boxes indicate type of pacemaker.

AV: atrioventricular.

Reproduced with permission from: Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-
Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. J Am Coll Cardiol 2008; 51(21):e1-e62. Illustration used with permission of
Elsevier Inc. All rights reserved. Copyright © 2008 Elsevier Inc.

Graphic 77929 Version 4.0

 Selection of pacemaker systems for patients with atrioventricular block

Decisions are illustrated by diamonds. Shaded boxes indicate type of pacemaker.

AV: atrioventricular.

Reproduced with permission from: Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for
Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2008; 51(21):e1-e62. Illustration used with
permission of Elsevier Inc. All rights reserved. Copyright © 2008 Elsevier Inc.

Graphic 71370 Version 3.0

Contributor Disclosures
Mark S Link, MD Patent Holder: Tufts Medical Center [Chest wall protector]. N A Mark Estes,
III, MD Consultant/Advisory Boards: Medtronic [Arrhythmias (Pacemakers and ICDs)]; St Jude
Medical [Arrhythmias (Pacemakers and ICDs)]; Abbott [Arrhythmias (Pacemakers and ICDs)];
Boston Scientific [Arrhythmias (Pacemakers and ICDs)]. Susan B Yeon, MD, JD, FACC Nothing to
disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found,
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