You could also record left atrial activity with a bipolar catheter in the esophagus.

Thank you Dr. Pinski.

You are right, but still I need an EP workstation which is not available in our pacemaker lab. We have it only in the EP lab.

You can pace the RV using a temporary pacing lead placed earlier through femoral vein and see the activity on PSA with the permanent pacing lead floating in the atrium (before implantation in RV)

Excellent idea.

I could use even the same subclavian vein.

I 'll let you know if it works. Definetely it must work.

Although not that sensitive, as you said, you can use the surface ECG but running at a higher speed (50 mm/sec) or increasing sensitivity and checking DII, V1 and aVR for retrograde P waves. Perhaps you can do a little work comparing measurement with the electrode in the atrium (Dr Bhargava's suggestion) and surface EKG!

Thank you for your answer.

Sometimes yes, this is possbile to confirm it on the surface ECG.

Today I had 2 cases with evident ventriculo-atrial conduction on 12-lead ECG and the third one needed a catheter in the right atrium.

What does it mean to increase sensitivity for surface ECG?

I was talking about setting the 1 mV mark to 20 mm instead of 10 mm. Of course you have more risk of detecting interference, but it might be useful too.

I go back to Cismaru´s answer to Sergio Pinski´s correct suggestion.

You dont need an elaborated EP equipment. Just a simple ECG machine with RA and LA electrodes connected to both pins of a bipolar esophageal catheter. And if you do not have such a catheter, you may improvise one of them with a used implantable pacemaker bipolar electrode, the one left after explanted from a patient (please dont forget to clean and sterilize it!)

Saul Drajer

It's so easy then.

Thank you. I will folow your advice Dr. Drajer.

Another possibility is using Echo Doppler to see atrial contraction flow

As Saul told, you can connect the pins of an EP catheter or even an PM lead placed wherever you prefer (right atrium, esophagous...) to a "normal" ECG machine. I'd rather connect to a monopolar lead (any precordial) and set signal gain to maximum.

It may be easier looking at Doppler mitral or tricuspid flow, or even M mode to see atrial wall contraction...

I would not recommend implanting a VVIR pacemaker if there is good AV node conduction and sinus rhythm to avoid retrograde activation of the atria. Patients with a normal PR interval have normally a good AV node conduction. So it depends on the indication for pacing. Sick sinus is different from AV node disease. I occasionally implant AAIR pacemakers for sick sinus syndrome. To check whether they need a ventricular lead, I assess the Wenckebach point on atrial stimuation, if >140bpm, they normally don't need a ventricular lead. Elderly patients with complete heart block often feel fine with a VVIR rather than a DDDR, especially if their mobility is poor or they are limited by lung disease. The UK-PACE trial would support this.

To Reto Gamma.

I agree with your opinion concerning VVIR in eldery patients. But...

What about complete heart block in eldery, with good VA retrograde conduction after adrenaline infusion ?

It is not common practice here to infuse adrenaline in patients with complete heart block, I don't think one would get a relevant information from such a test. Of course you will also speed up the patient's sinus rate and get even more confused about what you see.... There may be some benefit from giving Atropine if one suspects vagally mediated AV block. I had cases of younger patients with asymptomatic complete heart block that were just caused by their high fitness level and vagotonus. In those cases, an exercise treadmill test is very helpful. My patients were all able to increase their ventricular rate to target and did not need a pacemaker.

The only argument for adrenaline is for unvailing ventriculo-atrial conduction when absent in basal state. This could argue in favor of DDDR.