Identifying atrial arrhythmias versus pacing-induced rhythm disorders with state-of-the-art cardiac implanted devices

Repetitive non-reentrant ventriculo-atrial synchrony (RNRVAS) is a pacemaker-induced arrhythmia that must be distinguished from atrial fibrillation (AF). Pacemaker-induced arrhythmias are commonly detected as atrial high rate episodes (AHRE) by implanted cardiac devices. Two main types of atrial oversensing are recognized: far-field R-wave (FFRW) oversensing and pacemaker-induced arrhythmias, which include pacemaker-mediated tachycardia and RNRVAS. The presence of ventriculo-atrial conduction is required for both types of pacemaker-induced arrhythmias. The incidence of RNRVAS can increase with the use of various device settings and functions, such as long atrioventricular (AV) interval programming, the rate-adaptive mode, and the atrial overdrive pacing algorithm. The negative aspects of pacemaker-induced arrhythmias, especially RNRVAS, include (1) loss of optimal AV delay, (2) inappropriate increase in ventricular pacing, (3) induction of atrial arrhythmias, and (4) inaccurate diagnosis of AHRE. We review the incidence of arrhythmias, electrophysiological mechanisms, and the clinical diagnosis of RNRVAS identified by using dual-chamber implantable cardiac devices.