Dual-site atrial pacing for atrial fibrillation in patients without bradycardia

doi:10.1016/S0002-9149(01)01681-2

The American Journal of Cardiology

Volume 88, Issue 4, 15 August 2001, Pages 371-375

https://doi.org/10.1016/S0002-9149(01)01681-2 Get rights and content

Abstract

Atrial pacing has been shown to delay the onset of atrial fibrillation (AF) when compared with ventricular pacing in patients with sick sinus syndrome. The role for pacing in the control of AF in patients without bradycardia is uncertain. We performed a randomized, crossover, single-blinded study in 22 patients (14 women, aged 63 ± 10 years) with paroxysmal AF refractory to treatment with oral sotalol (202 ± 68 mg/day) and no bradycardic indication for pacing. All patients received a dual-chamber pacemaker with 2 atrial pacing leads positioned at the high right atrium and coronary sinus ostium, respectively. Patients were randomized in a crossover fashion to be paced for 12 weeks, either with high right atrial (RA) pacing at 30 beats/min (“Off”) or dual-site RA pacing with an overdrive algorithm that maintained atrial pacing at a rate slightly above the sinus rate (“On”). Treatment on resulted in a significantly higher percentage of atrial pacing and a reduction in atrial ectopic frequency than the treatment off period. The time to the first clinical AF recurrence was prolonged (15 ± 17 to 50 ± 35 days, p = 0.006), and total AF burden was reduced (45 ± 34% vs 22 ± 29%, p = 0.04) in the on-treatment phase. However, there was no difference in AF checklist symptom scores or overall quality-of-life measures. Dual-site RA pacing with continued sinus overdrive prolonged the time to AF recurrence and decreased AF burden in patients with paroxysmal AF. The absence of a major impact on symptom control suggests that pacing should be used as an adjunctive therapy with other treatment modalities for AF.

Section snippets

Patient population

Consecutive patients of either sex, between age 18 and 85 years old, with symptomatic paroxysmal AF who were refractory or intolerant to AV nodal blocking agents and class I agents were recruited from 4 clinical centers. Informed consent was obtained from all patients according to a protocol that was approved by the ethics committee of each individual institution. The inclusion criteria specified patients with ≥2 documented symptomatic AF episodes of at least 5 minutes in duration over the 3

Results

Twenty-two patients experienced AF recurrences on sotalol (mean dosage: 202 ± 68 mg/day) during phase 1 and consented to pacemaker implantation. This group included 8 men and 14 women (average age 63 ± 10 years). Eighteen patients had no cardiovascular disease, 1 patient had hypertension, 1 patient had ischemic heart disease, 1 patient had hypertrophic cardiomyopathy, and 1 patient had congenital heart disease.

Dual-site atrial pacing was successfully accomplished in all patients. The mean

Discussion

In this randomized crossover study, dual-site atrial overdrive pacing prolonged the time to the first recurrence of symptomatic AF and reduced the total AF burden compared with no pacing in a patient population without a conventional indication for pacing. The use of consistent overdrive pacing provided 80% atrial pacing without significantly raising the average heart rate, and allowed 33% suppression of atrial premature beats. However, there was no measurable difference in QOL scores between

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Cited by (73)

Sinus Node Dysfunction
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Sinus Node Dysfunction
2021, Cardiac Electrophysiology Clinics
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Several specialized pacing methods have been proposed that may have utility in SND patients but additional study is needed. These include dual-site atrial pacing,97,98 pacing the region of Bachman’s bundle pacing as a means to diminish intra-atrial conduction delays,99,100 cardiac resynchronization pacing, and more recently His bundle, and left-bundle branch pacing that offer more physiologic pacing techniques that may reduce valvular regurgitation and intra-atrial pressures. Potentially, these could be assistance in SND patients, but adequate studies have not yet been undertaken.
Effect of conventional cardiac pacing. Alternative pacing sites
2007, Revista Espanola de Cardiologia Suplementos
Desde la primera publicación del abordaje transvenoso para la implantación de marcapasos en 1959, el ápex del ventrículo derecho ha sido el sitio tradicional de estimulación por ser de fácil acceso y proporcionar estabilidad a largo plazo y umbrales crónicos de estimulación óptimos. La estimulación en orejuela derecha y ápex de ventrículo derecho ha permitido establecer una frecuencia cardiaca estable y lograr la sincronía auriculoventricular, dos de los objetivos principales de la estimulación eléctrica extrínseca; sin embargo, con ello no se ha conseguido lograr un patrón de activación y sincronía fisiológicos.
Múltiples estudios publicados en los últimos años han puesto de manifiesto los efectos perjudiciales de la estimulación convencional, tanto funcionales como estructurales, con las consiguientes morbilidad y mortalidad. De ahí el interés surgido en la búsqueda de sitios alternatives de estimulación que permitan obtener despolarización y contracción miocárdica fisiológicas.
En este capítulo se plantea la posibilidad de estimulación auricular en sitios alternativos, con el objetivo fundamental de prevenir las arritmias auriculares. Se revisan, asimismo de forma pormenorizada, las evidencias demostradas hasta el momento acerca de los efectos hemodinámicos y funcionales de la estimulación en tracto de salida de ventrículo derecho, así como su influencia en la duración del QRS y su correlación con la función ventricular. Finalmente, se desarrolla la estimulación permanente del haz de His, con las ventajas que supone la activación ventricular vía sistema específico de conducción.
Since the appearance of the first publication on the transvenous approach to pacemaker implantation in 1959, the apex of the right ventricle has been the conventional site for pacing because it is readily accessible, it provides long-term stability, and the chronic pacing threshold is optimal. Pacing in the right atrial appendage and the ventricular apex enables the heart rate to be stabilized and atrioventricular synchrony to be established, two of the main objectives of extrinsic electrical pacing. However, it does not lead to the establishment of physiologic activation and synchrony patterns.
Numerous studies published over the past few years have demonstrated the deleterious effects, both functional and structural, of conventional pacing, and its associated morbidity and mortality. These findings have triggered a search for alternative pacing sites that would enable more physiologic myocardial depolarization and contraction to be achieved.
This article discusses the possibility of using alternative atrial pacing sites, with the fundamental aim of preventing atrial arrhythmia. In addition, it also contains a detailed review of the evidence published to date on the hemodynamic and functional effects of right ventricular outflow tract pacing, its influence on the QRS duration, and its correlation with ventricular function. Finally, there is a discussion of permanent His bundle pacing, and the possible advantages associated with ventricular activation via this particular conduction system.
Management of atrial fibrillation
2007, Lancet
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Recent modification of the surgical procedure with the use of thoracoscopic techniques and different energy ablation probes to a less invasive and simplified approach, including a shortened procedure time and improved safety, are more acceptable alternatives for a wider population of patients with atrial fibrillation. The use of permanent atrial pacing to treat paroxysmal atrial fibrillation in patients without conventional indications for pacing has not been proven.58 In patients with conventional indications for pacemaker implantations—such as sinus node disease, symptomatic bradycardia, and chronotropic incompetence—the use of a physiological pacemaker (dual-chamber or atrial) rather than a single-chamber ventricular pacemaker has been shown to prevent atrial fibrillation.59
Atrial fibrillation is the most common sustained cardiac rhythm disorder, and confers a substantial mortality and morbidity from stroke, thromboembolism, heart failure, and impaired quality of life. With the increasingly elderly population in the developed world, as well as improvements in the management of myocardial infarction and heart failure, the prevalence of atrial fibrillation is increasing, resulting in a major public-health problem. This Review aims to provide an overview on the modern management of atrial fibrillation, with particular emphasis on pharmacological and non-pharmacological approaches. Irrespective of a rate-control or rhythm-control strategy, stroke prevention with appropriate thromboprophylaxis still remains central to the management of this common arrhythmia. Electrophysiological approaches could hold some promise for a curative approach in atrial fibrillation.
Improved atrial mechanical efficiency during alternate- and multiple-site atrial pacing compared with conventional right atrial appendage pacing: Implications for selective site pacing to prevent atrial fibrillation [3]
2006, Journal of the American College of Cardiology
Antiarrhythmic properties of atrial pacing
2017, Advances in Clinical and Experimental Medicine

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View full text

Dual-site atrial pacing for atrial fibrillation in patients without bradycardia

Abstract

Section snippets

Patient population

Results

Discussion

Long-term pacing in sinus node diseaseeffects of stimulation mode on cardiovascular morbidity and mortality

Am Heart J

Dual-chamber versus ventricular pacing. Critical appraisal of current data

Circulation

Long-term follow-up of patients from a randomised trial of atrial versus ventricular pacing for sick-sinus syndrome

Lancet

Quality of life and clinical outcomes in elderly patients treated with ventricular pacing as compared with dual-chamber pacing. Pacemaker Selection in the Elderly Investigators

N Engl J Med

Effects of physiologic pacing versus ventricular pacing on the risk of stroke and death due to cardiovascular causes. Canadian Trial of Physiologic Pacing Investigators

N Engl J Med

Atrial pacing periablation for prevention of paroxysmal atrial fibrillation

Circulation

Prevention of recurrent atrial fibrillation with chronic dual-site right atrial pacing

J Am Coll Cardiol

Permanent atrial resynchronization by synchronous bi-atrial pacing in the preventive treatment of atrial flutter associated with high degree interatrial block

Arch Mal Coeur Vaiss