Editorial

A simple new code for multisite cardiac pacing and implantable cardioverter defibrillator

Rogelio Robledo Nolasco,* José Constancio Ruiz Soto*

* Servicio de Hemodinamia y Electrofisiología. Centro Médico Nacional 20 de Noviembre ISSSTE.

Correspondence:
Dr. Rogelio Robledo Nolasco.
Félix Cuevas Núm. 340,
Col. Del Valle. 03100.
México D.F.
Telephone–Fax:(+52–55) 5200 3483.
E–mail: rogelio_robledo@hotmail.com

Recibido: 15 de junio de 2005
Aceptado: 13 de enero de 2006

Key words: Pacemaker code. Multisite cardiac pacing. Implantable cardioverter defibrillator.

Palabras clave: Código de marcapasos. Marcapasos multisitio. Desfibrilador cardioverter implantable.

Most pacemakers of the 1960's presented no problem for the description of their functions because they were all essentially the same: they paced a single cardiac chamber, had no sensing capability and had no adjustable characteristics. For the first time, in 1974 the Inter–Society Commission for Heart Disease (ICHD) proposed a three–position "generic" or "conventional" pacemaker code: the first letter corresponded to chamber paced, the second letter to chamber sensed and the third letter to mode of response.¹ In 1981 a revised code was published by the same designers, this code was augmented by two additional positions: programmability at position IV and special antitachyarrhythmia function at position V.² One year later, the Pacemaker Study Group includes the letter C of Communicating in the IV position.³ The pacemaker code used until three years ago was introduced in 1987 by the Mode Code Committee of the North American Society of Pacing and Electrophysiology (NASPE) together with the British Pacing and Electrophysiology Group (BPEG).⁴This code retains all the characteristics of the 1974 ICHD Code and some of those of the later five–position codes.

With the development of the implantable cardioverter defibrillator therapy, in 1993, Bernstein et al.⁵ published the NASPE/BPEG code, which consisted of four letters, the first for the shock chamber, the second for the antitachycardia pacing chamber, the third for the form of tachycardia detection and the last one for the antibradycardia– pacing chamber. This code did not surpass the one described in 1974 and its use was limited among the cardiologists.

By the middle of the 90's, cardiac resynchronization therapy and biatrial pacing for the treatment of dilated cardiomiophaty and paroxysmal atrial fibrillation arise.^6–12 With the aforementioned, it was possible to stimulate three or four cardiac chambers simultaneously, but the 1987 code was not enough to be able to describe its mode of stimulation; therefore, it was necessary to modify this code. Barold^13,14 proposed that the split format may be useful in the development of the new code for multisite pacing, while other authors proposed different modifications to the code.^15,16 In 2002, Bernstein et al¹⁷ published the NASPE/BPEG code for adaptive–rate, and multisite pacing. The first three positions remain essentially the same as those of the 1987 Code. "R" in the fourth position to rate modulation (adaptive–rate pacing) and "0" when it does not have this mode. In the fifth letter, "0", when there is no resynchronization, "A" when there is biatrial pacing, "V" when it is biventricular, and "D" when the four cavities are being paced.

These modifications to the code solved the problem of denomination when there is multisite function, but they did not solve the tachycardias treatment function description. The NASPE/BPEG defibrillator code of 1993 is obsolete, since, at the present time, the therapies are multiple, there are diverse algorithms of detection for arrhythmias and there are devices with the association of multisite pacing and implantable cardioverter defibrillator. Probably, the solution to this problem, without changing the simplicity of the NASPE/BPEG code, is to add a sixth letter: a) "0" when there is not this function, b) "A" when it exists in the atrium, c) "V" when, in the ventricle, the different arrhythmias can be treated and d) "D" when the therapies can be applied in both atrial and ventricular chambers (Table I). For example, the combination of cardiac resynchronization and implantable cardioverter defibrillator with rate modulation would be denominated DDDRVV. In the same way, the device to treat atrial tachycardias would be denominated DDDROA.

References

1. Parsonnet V, Furman S, Smyth NPD: Implantable cardiac pacemakers; Status report and resource guideline. Pacemaker Study Group, Inter–Society Commission for Heart Disease Resources (ICHD). Circulation 1974; 50: A21–A35.        [ Links ]

2. Parsonnet V, Furman S, Smyth NPD: A revised code for pacemaker identifícation. PACE 1981; 4: 400–403.        [ Links ]

3. Parsonnet V, Furman S, Smyth NPD, Bilitch M: Implantable cardiac pacemakers: Status report and resource guidelines, 1982. Pacemaker Study Group, Inter–Society Commission for Heart Disease Resources (ICHD). Circulation 1983; 68: 226A–244A.        [ Links ]

4. Bernstein AD, Camm AJ, Fletcher R, Gold RD, Rickards AF, Smyth NPD, Spielman SR, Sutton R: The NASPE/BPEG Pacemaker Code for antibradyarrhythmia and adaptive–rate pacing and antitachyarrhythmia devices. PACE 1987; 10: 794–799.        [ Links ]

5. Bernstein AD, Camm AJ, Fisher JD, Fletcher RD, Mead RH, Nathan AW, et al: The NASPE/BPEG Defibrillator Code. PACE 1993; 16: 1776–1780.        [ Links ]

6. Cazeau S, Ritter P, Bakdach S, Lazarus A, Limousin M, Henao L, et al: Four chamber pacing in dilatedcardiomyopathy PACE 1994; 17(Pt. II): 1974–1979.        [ Links ]

7. Gras D, Mabo P, Tang T, Luttikuis O, Chatoor R, Pedersen A, et al: Multisite pacing as a supplemental treatment of congestive heart failure. PACE 1998; 21: 2249–55.        [ Links ]

8. Cazeau S, Leclercq C, Lavergne T: Multisite stimulation in cardiomyopathies (MUSTIC) study investigators. Effects of multisite biventricular pacing in patients with heart failure and intraventricular delay. N Engl J Med 2001; 344: 873–880.        [ Links ]

9. Kuhlkamp V, The InSync 7272 ICD Word wide investigators: Initial experience implantable cardioverter–defibrillator incorporating cardiac resynchronization therapy. J Am Coll Cardiol 2002; 39: 790–797.        [ Links ]

10. Friedman PA, Hill MR, Hammll SC, Hayes DL, St anton MS: Randomized prospective pilot study of long–term dual–site atrial pacing for prevention of atrial fibrillation. Mayo Clin Proc 1998; 73: 848–854.        [ Links ]

11. Prakash A, Delfaut P, Krol RB, Saksena S: Regional right and left atrial activation patterns during single– and dual–site atrial pacing in patients with atrial fibrillation. Am J Cardiol 1996; 82:1197–1204.        [ Links ]

12. Lau CP, Tse HF, Yu CM, TeoWS, Kam R, Ng KS, et al: New indication for preventive pacing in atrial fibrillation (NIPP–AF) Investigators. Dual–site atrial pacing for atrial fibrillation in patients without bradycardia. Am J Cardiol 2001; 88(4): 371–375.        [ Links ]

13. Barold SS, Barold HS, Cazeau S: Should the split format in the third position of the pacemaker code be resurrected? Am J Cardiol 2000; 86: 545–546.        [ Links ]

14. Barold SS: Multisite cardiac pacing. A proposal for a simple code. Acta Cardiol 2001; 56: 253–254.        [ Links ]

15. Nagele H, DoringV, KalmarP, Schmidek G, Stubbe HH, Rodiger W: Long–term hemodynamic benefít ofatrial synchronization with A2A2D or A2A2T paccing in sinus node syndrome after orthotopic heart transplantation. J Heart Lung Transplant 1998; 17: 906–912        [ Links ]

16. Robledo NR, Buenfil MJC, Soto SJ, Zaragoza RG, Flores FJ, Sánchez PJL, et al: Estimulación trícameral en la miocardiopatía dilatada. Modo de estimulación TTDR? Arch Inst Cardiol Mex 2000; 70:391–398.        [ Links ]

17. Bernstein AD, Daubert JC, Fletcher RD, Hayes DL, Luderitz B, Reynolds DW, et al: The Revised NASPE/BPEG Generic Code for antibradycardia, adaptive–rate, and multisite pacing. PACE 2002; 25: 260–264.        [ Links ]