Bradycardia-dependent rise in the atrial capture threshold early after cardiac pacemaker implantation in patients with sick sinus syndrome Akira Kimata,

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Bradycardia-dependent rise in the atrial capture threshold early after cardiac pacemaker implantation in patients with sick sinus syndrome Akira Kimata, MD, Kentaro Yoshida, MD, Noriyuki Takeyasu, MD, Rieko Nakagami, MD, Jun Osada, MD, Takeshi Mitsuhashi, MD, Kazutaka Aonuma, MD, Akihiko Nogami, MD HeartRhythm Case Reports Volume 2, Issue 1, Pages 27-31 (January 2016) DOI: 10.1016/j.hrcr.2015.08.012 Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 1 Programmed atrial stimulation was performed on the fifth day after implantation. The basic stimuli (S1) cycle length was 600 milliseconds, and one atrial extrastimulus (S2) was delivered 1714 milliseconds to 250 milliseconds after S1. When the S1-S2 interval was 1714 milliseconds (35 bpm), S2 was captured with reproducibility. When the S1-S2 interval ranged from 1500 milliseconds (40 bpm) to 750 milliseconds (80 bpm), S2 did not capture the atrium. When the S1-S2 interval ranged from 706 milliseconds (85 bpm) to 260 milliseconds, S2 captured the atrium. When the S1-S2 interval was ≤ 250 milliseconds, S2 did not capture the atrium (atrial effective refractory period = 260 milliseconds). The “noncapture range” lay between 1500 milliseconds and 750 milliseconds. HeartRhythm Case Reports 2016 2, 27-31DOI: (10.1016/j.hrcr.2015.08.012) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 2 Programmed atrial stimulation was performed 1 month after implantation. The S2 stimulus failed to capture the atrium only when the S1-S2 interval was 1000 milliseconds. The “noncapture range” was clearly reduced. HeartRhythm Case Reports 2016 2, 27-31DOI: (10.1016/j.hrcr.2015.08.012) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 3 Our assumption as to the membrane potentials of atrial myocardium around the pacing lead according to the results from the electrophysiological study of Case 1. A: The greater diastolic (phase 4) depolarization caused by acute histologic changes creates a wide noncapture range on the fifth day after implantation. B: As diastolic depolarization gradually improves, the noncapture range is reduced at 1 month after implantation. C: Three months after implantation, the noncapture range has disappeared. HeartRhythm Case Reports 2016 2, 27-31DOI: (10.1016/j.hrcr.2015.08.012) Copyright © 2016 Heart Rhythm Society Terms and Conditions