CASE STUDY

AF Suppression™—Instead of an Ablation
Michael G. Isaac, MD, F.A.C.C.
Sherman Cardiovascular Care Associates
Sherman, Texas

Introduction:
With the advent of the AF Suppression™ pacing feature
available in St. Jude Medical pacemakers, practitioners have
discovered a new tool in their arsenal for atrial arrhythmia
management. Rather than resorting to ablation as a near-end
effort in upper chamber arrhythmia management, device-based
therapy is being utilized to supplant ablation in some instances.
This case describes a patient with a competitive, dual-
chamber, mode-switch capable device who was initially
considered for ablation but received an Integrity® DR model
5346 pacemaker instead.
The patient’s physician, Dr. Michael Isaac, was considering an
AV nodal radiofrequency ablation. Before subjecting the patient
to complete heart block, however, the decision was made to
forego the ablation on this patient and to prophylactically
change the Thera® DR device to an Integrity ® DR model 5346
pacemaker and try the AF Suppression™ algorithm. The
changeout was technically unremarkable, and Dr. Isaac was
particularly pleased to see the AF Suppression™ algorithm
engage even before the patient was taken from the procedure
table.

Patient History: Follow-up:

The patient is a 53-year-old male with a complicated medical
history. He has had three separate coronary bypass operations,
the most recent one in 2000. He also has Type II diabetes,
hypertension, and ischemic cardiomyopathy. He had a
Medtronic Thera® DR pacemaker implanted in 1998 for sick
sinus syndrome. He developed atrial arrhythmias after his
second bypass surgery.
At his most recent follow-up (three months post implantation)
this patient has had only two mode switch events, each of less
than one minute in duration (Figure 2) and has had no
recurrence of chest pain, dizziness or palpitations. He has also
been tapered off his amiodarone therapy.

The patient’s major complaint was frequent bouts of

simultaneous chest pain, dizziness, and palpitations. These
episodes were attributed to paroxysmal atrial fibrillation/flutter
(AF/AFl), leading to the initiation of amiodarone therapy.
However, the highly symptomatic episodes continued, despite
the mode-switch function of his pacemaker. At the last
follow-up prior to implant, the Medtronic device registered
greater than 255 mode-switch events (Figure 1). While this may
not seem like a great number, it is the maximum number that
the Thera® DR mode-switch diagnostic can record. The
patient’s symptomatology suggested that the actual number
was far greater.

Figure 2. Printout of most recent follow-up, showing only two mode switch
occurrences.

Figure 1. Printout from Thera ® DR device showing 255 mode switch episodes.
 CASE STUDY

Conclusion:
This case points out the benefit of the AF Suppression™
algorithm, available only from St. Jude Medical, for patients with
atrial fibrillation (AF) and atrial tachycardias. By avoiding an
ablation (and its subsequent pacemaker dependency),
decreasing symptomatic episodes, and allowing the removal of
an antiarrhythmic medication with many side effects, AF
Suppression™ pacing has greatly improved this patient’s quality
of life.
About AF Suppression™:
This unique algorithm is designed to provide a high percentage of
atrial overdrive to usurp control of the atrial rate, while at the same
time providing dynamic circadian rate variation throughout normal
daily activities. AF Suppression™ is backed by sound clinical
performance, evidenced by the ADOPT-A (Atrial Dynamic Overdrive
Pacing Trial-A) clinical trial, which showed a:
• 25.03% reduction in AF burden compared to DDDR pacing alone
(p<0.05)*
• 36.33% reduction in AF burden compared to DDDR pacing alone
(p=0.0163)* when patients with no AF ≥ 30 days after implant
were excluded
• 6.3% reduction in hospitalization days compared to DDDR
pacing alone (p=ns)*
• 62.7% reduction of cardioversion compared to DDDR pacing
alone (p=0.0925)*

Further analysis of the ADOPT-A study showed a:

• 65.3% reduction in organized atrial tachyarrhythmia (OAT)
burden (i.e., atrial flutter and other atrial tachyarrhythmias)
compared to DDDR pacing alone (p < 0.0005)**

* Summary of Safety and Effectiveness, P880086/S83 and P830045/S76;

St. Jude Medical, CRMD.
** Carlson MD, et al. Dynamic atrial overdrive pacing decreases symptomatic atrial
arrhythmia burden in patients with sinus node dysfunction. (abstract) Circulation
2001; 104 (supplement): II-383.

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