Bipolar ventricular far-field signals in the atrium.

In an attempt to evaluate the prevalence and predisposing factors of bipolar ventricular far-field oversensing, 57 patients were studied who had a Medtronic dual chamber pacemaker implanted (models 7940: n = 6; 7960i: n = 41; 401: n = 3; 8968i: n = 7) and bipolar atrial leads with a dipole spacing from 8.6 to 60 mm attached to various parts of the atrial wall (lateral/anterior: n = 30; appendage: n = 10; atrial septum: n = 10; floating: n = 7). Median bipolar sensing threshold for P waves was 4.0 mV (2.8-4.0 mV, lower and upper quartile) with standard leads and 0.35 (0.25-1.4) mV with single pass (VDD) devices. At the highest sensitivity available, 43 of 50 DDD pacemakers but only two of seven VDD systems detected intrinsic R waves in the atrium (P < 0.01). Ventricular far-field oversensing occurred at 0.5 mV in 28 (56%) and at 1.0 mV in 16 of 50 DDD units (32%), respectively, and there was one observation in a septal implant at a sensitivity of even 2.8 mV. With ventricular pacing, VDD systems were as susceptible to far-field signals as DDD pacemakers. Outside the postventricular blanking period (100 ms), evoked R waves were detected by 27 of 57 systems (47%) at maximum atrial sensitivity, by 10 (18%) at 0.5 mV, and by 2 (4%) at a setting of 1.0 up to 1.4 mV, respectively. There was no definite superiority of any lead position, there was a trend in favor of the atrial free wall for better intrinsic R wave rejection, but just the opposite was the case for paced ventricular beats. Bipolar signal discrimination tended to be higher with short tip-to-ring spacing (1 7.8 mm) but the difference to larger dipole lengths (30-60 mm) was not significant in terms of the R to P wave ratio and the overall far-field susceptibility. In summary, bipolar ventricular far-field oversensing in the atrium is common with short postventricular blanking times and high atrial sensitivity settings that may be warranted for tachyarrhythmia detection and mode switching. A potentially more discriminant effect of shorter dipole lengths (< or = 10 mm) remains to be tested.