Pacing Modes

Dr. Toheed Ashraf

Trainee Registrar
Dept. of Cardiology
Pacing Nomenclature
Nomenclature of Cardiac Pacing

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

classification code has been developed.

• 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.

• This code was 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.
NBG Coding System
The NBG Coding System

• The code is generic and does not describe specific or unique

functional characteristics for each and every device.

• When a code includes only three or four characters, it can be assumed

that the positions not mentioned are "O" or absent.

• Most patients can be managed with one of two or three common

modes (AAI, VVI, or DDD), with or without rate responsiveness.
The NBG Coding System
The NBG Coding System
The NBG Coding System
1st Letter

• The first letter reflects the chamber(s) paced.

 "A" indicates the atrium
 "V" indicates the ventricle
 "D" means dual chamber
The NBG Coding System
The NBG Coding System
2nd Letter
• The second letter reflects the chamber(s) sensed.
 "A" indicates the atrium
 "V" indicates the ventricle

 "D" means dual chamber

• 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.
The NBG Coding System
The NBG Coding System
3rd Letter
• 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.

The NBG Coding System
The NBG Coding System
3rd Letter
• The third position refers to how the pacemaker responds 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.
The NBG Coding System
The NBG Coding System
4th Letter
• The fourth position reflects rate modulation, also referred to as rate responsive
or rate adaptive pacing.
 "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 (i.e. DDD is the same as DDDO).
The NBG Coding System
The NBG Coding System
4th Letter
• The fourth position reflects rate modulation, also referred to as rate responsive
or rate adaptive pacing.
 "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 (i.e. DDD is the same as DDDO).
The NBG Coding System
The NBG Coding System
5th Letter
• 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.
 "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.
The NBG Coding System
Special Features of
Pacemakers
Special Features of Pacemakers
Rate Responsiveness/ Rate Modulation

• 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’s activity.

• A variety of sensors have been designed to determine when a patient is

physically active (e.g. vibration, minute ventilation, etc).

• 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.
Special Features of Pacemakers
Mode Switching
• In dual-chamber pacing systems (DDD/DDDR), the ventricle will be paced
following every sensed atrial event, up to a programmed maximum ventricular
rate (max tracking rate).

• Mode switching refers to automatic reprogramming of a pacemaker to a mode

that no longer tracks the intrinsic atrial rate, usually VVI or DDI with or without
rate responsiveness.

• When the sensed atrial rate again falls below the mode switching cut-off and the
device assumes that a physiologic rhythm has been restored (i.e., with
termination of the arrhythmia), the pacing mode automatically reverts to the
original programming.
Special Features of Pacemakers
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.

• 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.
Common Pacing
Modes
Common Pacing Modes
VVI/ VVIR

• 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.
Common Pacing Modes
VVI/ VVIR

• 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.

Common Pacing Modes
VVI/ VVIR
Common Pacing Modes
AAI/ AAIR

• 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 (i.e., AAIR).
Common Pacing Modes
AAI/ 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 bradyarrhythmia 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.
Common Pacing Modes
AAI/ AAIR
• 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).

• 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.
Common Pacing Modes
AAI/ AAIR
Common Pacing Modes
DDD/ DDDR

• The dual-chamber pacing system provides physiologic pacing

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
Common Pacing Modes
DDD/ DDDR

• 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.
Common Pacing Modes
DDD/ DDDR
• As a result, there are four different rhythms that can be seen
with normal pacemaker function.

 Normal sinus rhythm

 Atrial pacing, normally conducted to the ventricle with a native QRS

 AV sequential pacing
 Atrial sensing and ventricular pacing
Common Pacing Modes
DDD/ DDDR
Common Pacing Modes
DDD/ DDDR
Common Pacing Modes
DDD/ DDDR
Common Pacing Modes
DDD/ DDDR
Common Pacing Modes
DDD/ DDDR
Common Pacing Modes
Aysnchronous Pacing (AOO, VOO, DOO)

• 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.

• 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.
Common Pacing Modes
Aysnchronous Pacing (AOO, VOO, DOO)

• 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.
Thank You