Is Dual Defibrillator Better than Conventional DDD Pacing in Brady-Tachy Syndrome? Results of the ICARUS Trial (Internal Cardioversion Antitachypacing and Prevention: Resource Utilization Study)

  • Massimo Santini
  • Renato Ricci
  • Carlo Pignalberi
  • Maurizio Russo
  • Barbara Magris
  • Nicoletta Grovale
  • Tiziana De Santo


Aim of the study: To compare the impact of dual defibrillator versus conventional DDD pacing on quality of life and hospitalizations in patients with sinus node disease and recurrent symptomatic atrial fibrillation.

Study design: Prospective, parallel, controlled trial.

Methods: Sixty-three patients (41 M, mean age 71 ± 8 years) with sinus node disease and at least three symptomatic episodes of atrial fibrillation during the last year were enrolled. Thirty-one consecutive patients received a dual defibrillator (group A) and 32 standard DDD pacing (group B). In group A, 12 patients received an external remote-control device in order to shock themselves in case of atrial fibrillation, while 19 were scheduled for early in-hospital manual shock. Seventy-five percent had been hospitalized during the last year and 57% had required electrical cardioversion. Atrial fibrillation was persistent in 63.5% and paroxysmal in 37.5%. The follow-up lasted 1 year.

Results: Atrial fibrillation recurred in 83.3% in group A and 79.3% in group B (p = ns). Electrical cardioversion was applied in 54.8% in group A and in 21.9% in group B (p < 0.05). On the whole, 89.5% of electrical cardioversions were delivered in the defibrillator group (p < 0.0001). In the whole population 27.0% patients had cardiac-related hospitalization (31.2% in the pacemaker group and 22.6% in the defibrillator group, p = n.s.). In patients with persistent atrial fibrillation, cardiac-related hospitalization rate was significantly lower in the group A (0% vs. 30%, p < 0.05). Considering Symptom Check List, symptoms significantly improved in the whole population, but symptom number and frequency improved significantly only in the group A. Similarly, SF-36 questionnaire scores showed a little higher quality of life improvement in the group A.

Conclusions: Dual defibrillator showed consistent trends toward a higher effectiveness when compared with standard DDD pacing. Dual defibrillator was associated to reduced in-patient cardioversions and to better quality of life. All-cause hospitalizations were reduced only in patients with persistent atrial fibrillation


brady-tachy syndrome atrial fibrillation dual chamber pacing dual defibrillator 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Sutton R, Kenny RA. The natural history of sick sinus syndrome. PACE 1986;9:1110–1114.PubMedGoogle Scholar
  2. 2.
    Camm AJ, Katritsis D. Ventricular pacing for sick sinus syndrome: A risky business? PACE 1990;13:695–699.PubMedGoogle Scholar
  3. 3.
    Santini M, Alexidou G, Ansalone G, Cacciatore G, Cini R, Turitto G. Relation of prognosis in sick sinus syndrome to age, conduction defects and modes of permanent cardiac pacing. Am J Cardiol 1990;65:729–735.CrossRefPubMedGoogle Scholar
  4. 4.
    Stangl K, Seitz K, Wirtzfeld A, Alt E, Blommer H. Differences between atrial single chamber pacing (AAI) and ventricular single chamber pacing (VVI) with respect to prognosis and antiarrhythmic effect in patients with sick sinus syndrome. PACE 1990;13:2080–2085.PubMedGoogle Scholar
  5. 5.
    Feuer JM, Shandling AH, Messenger JC. Influence of cardiac pacing mode on the long-term development of atrial fibrillation. Am J Cardiol 1989;64:1376–1379.CrossRefPubMedGoogle Scholar
  6. 6.
    Rosenqvist M, Brandt J, Schuller H. Long-term pacing in sinus node disease: Effects of stimulation mode on cardiovascular morbidity and mortality. Am Heart J 1988;116:16–22.CrossRefPubMedGoogle Scholar
  7. 7.
    Hesselson AB, Parsonnet V, Bernstein AD, Bonavita GJ. Deleterious effects of long-term single-chamber ventricular pacing in patients with sick sinus syndrome: The hidden benefits of dual-chamber pacing. J Am Coll Cardiol 1992;19:1542–1549.PubMedGoogle Scholar
  8. 8.
    Sgarbossa EB, Pinski SL, Maloney JD, Simmons TW, Wilkoff BL, Castle LW, Trohman RG. Chronic atrial fibrillation and stroke in paced patients with sick sinus syndrome. Relevance of clinical characteristics and pacing modalities. Circulation 1993;88:1045–1053.PubMedGoogle Scholar
  9. 9.
    Santini M, Ricci R, Puglisi A, Mangiameli S, Proclemer A, Menozzi C, De Fabrizio G, Leoni G, Lisi F, de Seta F. Long-term haemodynamic and antiarrhythmic benefits of DDIR versus DDI pacing mode in sick sinus syndrome and chronotropic incompetence. G Ital Cardiol 1997;27:892–900.PubMedGoogle Scholar
  10. 10.
    Andersen HR, Nielsen JC, Thomsen PEB, Thuesen L, Mortensen PT, Vesterlund T, Pedersen AK. Long-term follow up of patients from a randomised trial of atrial versus ventricular pacing for sick-sinus syndrome. Lancet 1997;350:1210–1216.CrossRefPubMedGoogle Scholar
  11. 11.
    Mattioli AV, Vivoli D, Mattioli G. Influence of pacing modalities on the incidence of atrial fibrillation in patients without prior atrial fibrillation: A prospective study. Eur Heart J 1998;19:282–286.CrossRefPubMedGoogle Scholar
  12. 12.
    Skanes AC, Krahn AD, Yee R, Klein GJ, Connolly SJ, Kerr CR, Gent M, Thorpe KE, Roberts RS for the CTOPP Investigators: Progression to chronic atrial fibrillation after pacing: The Canadian Trial of Physiologic Pacing. J Am Coll Cardiol 2001;38:167–172.CrossRefPubMedGoogle Scholar
  13. 13.
    Lamas GA, Lee KL, Sweeney MO, Silverman R, Leon A, Yee R, Marinchak RA, Flaker G, Schron E, Orav EJ, Hellkamp AS, Goldman L, for the Mode Selection Trial in Sinus Node Dysfunction. Ventricular pacing or dual chamber pacing for sinus node dysfunction. N Engl J Med 2002;346:1854–1862.CrossRefPubMedGoogle Scholar
  14. 14.
    Ricci R, Santini M, Puglisi A, Azzolini P, Capucci A, Pignalberi C, Boriani G, Botto GL, Spampinato A, Bellocci F, Proclemer A, Grammatico A, de Seta F. Impact of consistent atrial pacing algorithm on premature atrial complexe number and paroxysmal atrial fibrillation recurrences in brady-tachy syndrome: A randomized prospective cross over study. J Interv Card Electrophysiol 2001;5:33–44.CrossRefPubMedGoogle Scholar
  15. 15.
    Friedman PA, Dijkman B, Warman EN, Xia HA, Mehra R, Stanton MS, Hamill SC, for the Worldwide Jewel AF Investigators. Atrial therapies reduce atrial arrhythmia burden in defibrillator patients. Circulation 2001;104:1023–1028.PubMedGoogle Scholar
  16. 16.
    Ricci R, Pignalberi C, Disertori M, Capucci A, Padeletti L, Botto G, Boriani G, Miraglia F, de Santo T, Santini M. Antitachycardia pacing therapy to treat spontaneous atrial tachyarrhythmias: The 7250 Dual Defibrillator Italian Registry. Eur Heart J 2001;3(Suppl. P):P25–P32.Google Scholar
  17. 17.
    Wellens HJJ, Lau CP, Luderitz B, Akhtar M, Waldo AL, Camm AJ, Timmermans C, Tse HF, Jung W, Jordaens L, Ayers G. Atrioverter: an implantable device for the treatment of atrial fibrillation. Circulation 1998;98:1651–1656.PubMedGoogle Scholar
  18. 18.
    Gold MR, Sulke N, Schwartzman DS, Mehra R, Euler DE, for the Worldwide Jewel AF-Only Investigators: Clinical experience with a dual chamber implantable cardioverter defibrillator to treat atrial tachyarrhythmias. J Cardiovasc Electrophysiol 2001;12:1247–1253.CrossRefPubMedGoogle Scholar
  19. 19.
    Ricci R, Pignalberi C, Disertori M, Capucci A, Padeletti L, Botto G, Toscano S, Miraglia F, Grammatico A, Santini M. Efficacy of a dual chamber defibrillator with atrial antitachycardia functions in treating spontaneous atrial tachyarrhythmias in patients with life-threatening ventricular tachyarrhythmias. Eur Heart J 2002;23:1471–1479.CrossRefPubMedGoogle Scholar
  20. 20.
    Adler SW, Wolpert C, Warman EN, Musley SK, Koehler JL, Euler DE for the Worldwide Jewel AF Investigators. Efficacy of pacing therapies for treating atrial tachyarrhythmias in patients with ventricular arrhythmias receiving a dual-chamber implantable cardioverter defibrillator. Circulation 2001;104:887–892.PubMedGoogle Scholar
  21. 21.
    Wijffels MCEF, Kirchhof CJHJ, Dorland RD, Allessie MA. Atrial fibrillation begets atrial fibrillation. A study in awake chronically instrumented goats. Circulation 1995;92:1954–1968.PubMedGoogle Scholar
  22. 22.
    Savelieva I, Camm J. The results of pacing trials for the prevention and termination of atrial tachyarrhythmias: Is there any evidence of therapeutic breakthrough? J Interv Cardiac Electrophysiol 2003;8:103–115.Google Scholar
  23. 23.
    Jenkins LS, Bubien RS. Quality of life in patients with atrial fibrillation. Cardiol. Clin. 1996;14:597–606.PubMedGoogle Scholar
  24. 24.
    Ware JE. The SF-36 health survey manual and interpretation guide. Boston, MA, The Health Institute, New England Medical Center; 1993.Google Scholar
  25. 25.
    Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med. Care 1992;30:473–483.PubMedGoogle Scholar
  26. 26.
    McHorney CA, Ware JE, Raczek AE. The MOS 36-item short-form health (SF-36). II. Psychometric and clinical tests of validity in measuring physical and mental health conditions. Med. Care 1993;81:247–263.Google Scholar
  27. 27.
    McHorney CA, Ware JE, Lu JFR, Sherbourne CD. The MOS 36-item short-form health (SF-36), III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med. Care 1994;82:40–66.Google Scholar
  28. 28.
    Bubien RS, Kay GN, Jenkins LS. Test specifications for symptom checklist. Frequency and severity. 1993. Milwaukee, University of Wisconsin-Milwaukee.Google Scholar
  29. 29.
    Tanigawa M, Fukatani M, Konoe A, Isomoto S, Kadena M, Hashiba K. Prolonged and fractionated atrial electrograms during sinus rhythm in patients with paroxismal atrial fibrillation and sick sinus node syndrome. J Am Coll Cardiol 1991;17:403–408.PubMedGoogle Scholar
  30. 30.
    Centurion OA, Fukatani M, Konoe A, Tanigawa M, Shimizu A, Isomoto S, Kaibara M, Hashiba K. Different distribution of abnormal endocardial electrograms within the right atrium in patients with sick sinus syndrome. Br Heart J 1992;68:596–600.PubMedGoogle Scholar
  31. 31.
    De Sisti A, Leclercq JF, Fiorello P, Manot S, Halimi F, Attuel P. Electrophysiologic characteristics of the atrium in sinus node dysfunction: Atrial refractoriness and conduction. J Cardiovasc Electrophysiol 2000;11:30–33.Google Scholar
  32. 32.
    De Sisti A, Attuel P, Manot S, Fiorello P, Halimi F, Leclercq JF. Electrophysiological determinants of atrial fibrillation in sinus node dysfunction despite atrial pacing. Europace 2000;2:304–311.Google Scholar
  33. 33.
    Stabile G, Senatore G, De Simone A, Turco P, Coltorti F, Nocerino P, Vitale DF, Chiariello M. Determinants of efficacy of atrial pacing in preventing atrial fibrillation recurrences. J Cardiovasc Electrophysiol 1999;10:2–9.PubMedGoogle Scholar
  34. 34.
    Timmermans C, Levy S, Ayers GM, for the Metrix Investigators. Spontaneous episodes of atrial fibrillation after implantation of the Metrix atrioverter: Observations on treated and nontreated episodes. J Am Coll Cardiol 2000;35:1428–1433.CrossRefPubMedGoogle Scholar
  35. 35.
    Tse HF, Lau CP, Yu CM, Lee KL, Michaud GF, Knight GP, Morady F, Strickberger SA. Effect of the implantable atrial defibrillator on the natural history of atrial fibrillation. J Cardiovasc Electrophysiol 1999;10:1200–1209.PubMedGoogle Scholar
  36. 36.
    Ricci R, Quesada A, Pignalberi C, Roda J, Disertori M, Capucci A, Raviele A, Santini M. Dual defibrillator improves quality of life and decreases hospitalizations in patients with drug refractory atrial fibrillation. J Interv Card Electrophysiol 2004;10:85–92.CrossRefPubMedGoogle Scholar
  37. 37.
    Jung W, Luderitz B. Quality of life in patients with atrial fibrillation. J Cardiovasc Electrophysiol 1998;9(Suppl.8):S177–S186.PubMedGoogle Scholar
  38. 38.
    Herrmann C, vonzurMuhen F, Schaumann A, Buss U, Kemper S, Wantzen C, Gonska BD. Standardized assessment of psychological well-being and quality-of-life in patients with implanted defibrillators. Pacing Clin Electrophysiol 1997;20:95–103.PubMedGoogle Scholar
  39. 39.
    Padeletti L, Santini M, Boriani G, Botto GL, Capucci A, Gulizia M, Ricci R, Spampinato A, Pieragnoli P, Warman E, Vimercati M, Grammatico A. Temporal variability of atrial tachyarrhythmia burden in bradycardia-tachycardia syndrome patients. Eur Heart J 2005;26:165–172.PubMedGoogle Scholar
  40. 40.
    Padeletti L, Pieragnoli P, Ciapetti C, Colella A, Musilli N, Porciani MC, Ricci R, Pignalberi C, Santini M, Puglisi A, Azzolini P, Spampinato A, Martelli M, Capucci A, Boriani G, Botto G, Proclemer A. Randomized crossover comparison of right atrial appendage pacing versus interatrial septum pacing for prevention of paroxysmal atrial fibrillation in patients with sinus bradycardia. Am Heart J 2001;142:1047–1055.CrossRefPubMedGoogle Scholar
  41. 41.
    Sweeney MO, Hellkamp AS, Ellenbogen KA, Greenspon AJ, Freedman RA, Lee KL, Lamas GA. for the Mode Selection Trial (MOST) Investigators: Adverse effect of ventricular pacing on heart failure and atrial fibrillation among patients with normal baseline QRS duration in a clinical trial of pacemaker therapy for sinus node dysfunction. Circulation 2003;107:2932–2937.CrossRefPubMedGoogle Scholar
  42. 42.
    Boodhoo L, Mitchell A, Ujhelyi M, Sulke N. Improving the acceptability of the atrial defibrillator: Patient-activated cardioversion versus automatic night cardioversion with and without sedation (ADSAS 2). Pacing Clin Electrophysiol 2004;27:910–917.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science + Business Media, Inc. 2006

Authors and Affiliations

  • Massimo Santini
    • 1
  • Renato Ricci
    • 1
  • Carlo Pignalberi
    • 1
  • Maurizio Russo
    • 1
  • Barbara Magris
    • 1
  • Nicoletta Grovale
    • 1
  • Tiziana De Santo
    • 1
  1. 1.Department of CardiologyS. Filippo Neri HospitalRomeItaly

Personalised recommendations