In a patient with chronic permanent atrial fibrillation who currently has a VVI leadless pacemaker and is experiencing dizziness, is it appropriate to upgrade to a dual‑chamber pacemaker?

You Are Correct—Upgrading to Dual-Chamber Pacing is Inappropriate in Permanent Atrial Fibrillation

Dual-chamber pacing or single-chamber atrial pacing should not be used in patients with permanent or longstanding persistent atrial fibrillation in whom efforts to restore or maintain sinus rhythm are not planned 1. This is a Class III recommendation (meaning it should not be done) with Level of Evidence C.

Why This is Contraindicated

The guideline evidence is unequivocal across multiple consensus statements:

• For AV block with permanent AF: "Dual-chamber pacing should not be used in patients with AV block in permanent or longstanding persistent AF in whom efforts to restore or maintain sinus rhythm are not planned" 1

• For any indication with permanent AF: The 2019 ACC/AHA/HRS guidelines explicitly state that "in patients with permanent or persistent AF in whom a rhythm control strategy is not planned, implantation of an atrial lead should not be performed" 2

The Clinical Reasoning

In permanent atrial fibrillation:

1. No atrial mechanical function exists to provide AV synchrony—the primary benefit of dual-chamber pacing is lost
2. The atrial lead provides no useful information for rate control or arrhythmia discrimination
3. Increased procedural risks without benefit: Dual-chamber systems have a 3.09-fold higher complication rate compared to single-chamber devices within 2 months of implant 3
4. Long-term complications increase with additional leads, including higher rates of lead dislodgement, infection risk, and need for future extractions 4

What to Do Instead

For this patient with chronic permanent AF, dizziness, and a VVI leadless pacemaker:

• Keep the single-chamber ventricular pacing system (VVI or VVIR mode)
• Investigate the dizziness through other means:
  • Check pacing percentage and adequacy of rate response
  • Evaluate for pacemaker syndrome (though less common with VVI in permanent AF)
  • Consider rate-adaptive programming (VVIR) if chronotropic incompetence is contributing
  • Rule out non-pacing causes of dizziness

Important Caveat

The only exception mentioned in guidelines: If the patient already has an existing dual-chamber system and subsequently develops persistent AF, it may be reasonable to use another dual-chamber device at generator change (rather than capping the atrial lead) to allow future rhythm control attempts and because of sparse safety data on MRI with abandoned leads 3. However, this does not apply to upgrading from single-chamber to dual-chamber.

Recent Leadless Technology Context

While recent studies show technical feasibility of upgrading leadless pacemakers from single to dual-chamber 5, 6, these were performed in patients with sinus node dysfunction or evolving conduction disease—not permanent AF. The technical capability to upgrade does not change the fundamental contraindication in permanent AF.