Pacemaker Holter ECG: Value and Limitations in Follow-up of Pacemaker Patients
Conventional Holter ECG devices have no separate track for the pacemaker spike recording. Thus, an exact differentiation of the underlying rhythm, pacemaker rhythm, background and pacemaker-related arrhythmias or pacemaker dysfunctions (failure to sense; failure to output; failure to capture) is not possible. This seems however to be important since several investigators found that up to 30% of pacemaker patients were symptomatic. The aim of the study was to investigate the clinical reliability of three different pacemaker Holter ECG devices (Del Mar Avionics: Trendsetter, Pa-cerecorder; Reynolds: Pathfinder; Ela Medical: Anatec). Therefore we performed 24-hour pacemaker Holter ECG recordings in 157 consecutive pacemaker patients (47 female; 83 male, age: 63 ± 12 years). The patients had 119 VVI, 5 AAI, 13 DDD, 5 DVI, 1 VAT and 14 rate adaptive pacemakers. In each patient a careful exploration of the anamnesis and symptoms was performed. A good signal quality can be achieved by careful electrode position and cable fixation, avoidance of high amplitude artefacts and electrostatic interference. An automatic analysis of the tapes is technically possible in VVI and AAI pacemakers. An additional visual control of the tapes should nevertheless be performed in each case. We found a high sensitivity combined with a high number of false-positive events. A differentiation of the rhythm, arrhythmias and pacemaker reactions was easily possible. Pacemaker dysfunctions could be separated according to type and incidence (I°: no dysfunctions; IP: 1 dysfunction per hour; III°: 1 to 30 dysfunctions per hour; IV°: 30 dysfunctions per hour). In some pacemaker Holter ECG devices, the differentiation of fusion beats from failure to sense is not always performed correctly. Failure to sense detected mainly in patients with premature ventricular beats, tachyarrhythmia and bundle branch blocks. Failure to output is often the consequence of false inhibition by noise. According to our data pacemaker patients at high risk are the following: patients with AV-block IIP and increased ventricular vulnerability (VES Lown III°, IV°) or ≥ 1 pacemaker dysfunctions per hour.
In conclusion, the pacemaker Holter ECG is a time consuming technique, but a powerful diagnostic tool in pacemaker patient follow-up.
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