Emergency pacemaker implantation in nonagenarians with CHB: single-versus dual-chamber pacing

In ambulatory patients with complete heart block (CHB), dual-chamber (DDD) pacing confers physiological benefits versus single-chamber (VVI) pacing, however, the impact on mortality is disputed. Nonagenarians constitute an expanding proportion of pacemaker recipients, yet data on device selection and outcomes are limited, especially in emergency situations. In nonagenarians with emergent CHB, we compared the clinical characteristics and outcomes of patients receiving VVI versus DDD pacemakers. Cox proportional-hazards analysis examined all-cause mortality and death from congestive cardiac failure (CCF). There were 168 consecutive patients followed-up for 30.6 ± 15.5 months. Of these, 22 patients (13.1%) received VVI pacemakers; when compared with DDD recipients, these patients had similar median age (93 vs. 91 years, p=0.15) and left ventricular (LV) systolic function (LV ejection fraction [EF] 49.2% ± 9.7 vs. 50.7% ± 10.1, p=0.71), but were more frail (Rockwood scale 5.2 ± 1.8 vs. 4.3 ± 1.1, p=0.004) and more likely to have dementia (27.3% vs. 8.9%, p=0.011). Post-implant, device interrogation demonstrated that VVI recipients had higher respiratory rates (21.3 ± 2.4 vs. 17.5 ± 2.6 breaths per minute, p=0.002), lower mean heart rates (65.5 ± 10.1 vs. 71.9 ± 8.6 bpm, p=0.002), and lower daily activity levels (0.57 ± 0.3 vs. 1.5 ± 1.1 hours of activity, p=0.016) than DDD recipients. Adjusting for age, frailty and dementia, VVI pacing was associated with an increased risk of all-cause mortality (adjusted hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.08 to 4.1, p=0.03) and death from CCF (adjusted HR 7.1, 95%CI 2.5 to 20.6, p