PACING TO PREVENT ATRIAL FIBRILLATION

doi:10.1016/S0733-8651(05)70125-9

Cardiology Clinics

Volume 18, Issue 1, 1 February 2000, Pages 25-36

https://doi.org/10.1016/S0733-8651(05)70125-9 Get rights and content

Atrial fibrillation(AF) is the most common sustained arrhythmia and is associated with substantial morbidity and mortality.²⁶ Present pharmacologic treatment strategies are directed at heart rate control or prescription of class I/III antiarrhythmic drugs to prevent AF recurrence.⁴⁵ Both strategies are frequently ineffective, or the drugs prescribed are not tolerated because of adverse effects, including ventricular proarrhythmia.9, 14, 45 Consequently, interest in the development of nonpharmacologic therapies for the prevention of AF has arisen.

Section snippets

MECHANISMS OF ATRIAL FIBRILLATION

The initiation of AF requires a trigger as well as an abnormal electrophysiologic substrate for maintenance of the arrhythmia. Most episodes of AF are believed to be due to a reentrant mechanism.1, 16, 25 A supraventricular premature beat (SVPB) usually initiates the arrhythmia, which is maintained if a region of slow conduction or heterogeneity of repolarization exists. Typically, multiple wavelets of reentry develop for AF to persist. Some episodes of AF may develop as a result of focal

FACTORS CONTRIBUTING TO INITIATION OF ATRIAL FIBRILLATION

Some clinical reports suggest that significant bradycardia may precede the initiation of AF. The concept of nocturnal vagally mediated AF was promoted by Coumel et al,¹⁰ who reported a series of patients with nocturnal bradycardia associated with AF onset, which was prevented by atrial pacing.³ It has been hypothesized that bradycardia exaggerates the dispersion of atrial repolarization, which might provide the substrate for AF.18, 20 Subsequent studies investigating the electrocardiographic

MECHANISMS OF PACING TO PREVENT ATRIAL FIBRILLATION

There are several mechanisms by which atrial pacing might prevent AF:

1
Atrial pacing may reduce bradycardia-induced dispersion of atrial repolarization, which contributes to the electrophysiologic substrate for AF.20, 43
2
Atrial overdrive suppression of SVPBs and runs of SVPBs would eliminate the trigger for AF.15, 18, 55
3
Some forms of atrial pacing may change atrial activation patterns, preventing the development of intra-atrial reentry should an SVPB occur.5, 28, 34 This concept is

SINGLE-SITE RIGHT ATRIAL PACING

A number of retrospective studies have reported that atrial-based pacing (AAI/R) or atrioventricular (AV) sequential pacing reduces the incidence of AF over time compared with ventricular pacing in patients with sinus node disease or complete heart block.8, 21, 38, 42, 44 Connolly et al⁸ reviewed 10 of these retrospective trials and calculated that the annual incidence of AF was 2.6% per year in patients receiving physiologic pacing compared with 6.8% per year in patients receiving a

PREVENTION OF ATRIAL FIBRILLATION WITH SINGLE-SITE PACING

Some clinical data suggest that single-site right atrial pacing is less effective in preventing AF in patients with right atrial conduction delays and in patients with increased dispersion of right atrial refractoriness.⁴⁸ Some patients may benefit from site-specific pacing (e.g., atrial septum or Bachmann's bundle).4, 5, 31, 47 Preliminary data suggest that pacing from the septum or Bachmann's bundle may shorten overall atrial activation time and that this may play a role in preventing AF.

APPROPRIATE PACING MODALITY AFTER ATRIOVENTRICULAR NODE ABLATION

The PA³ Investigators compared the effects of DDDR versus VDD pacing after total AV node ablation for prevention of persistent AF in 67 patients with antiarrhythmic drug–refractory AF.7, 17 The time to first recurrence of AF after AV node ablation was similar in the DDDR group compared with the VDD group. As well, the AF burden increased over time in both groups. A substantial number of patients (28%) developed persistent AF 6 months postablation, and 48% of patients were in persistent AF 12

MULTISITE ATRIAL PACING

Multisite atrial pacing has been evaluated for prevention of atrial flutter and AF. Daubert et al¹¹ described biatrial pacing using the high right atrium and distal coronary sinus. Saksena et al12, 40, 41 have described dual-site right atrial pacing using the high right atrium and the coronary sinus os. Preliminary studies suggest that these approaches may have an incremental benefit for prevention of AF compared with high right atrial pacing if used in conjunction with antiarrhythmic drug

PACING THERAPIES TO TERMINATE ATRIAL FIBRILLATION

Newer pulse generators will include antitachycardia pacing therapies for termination of atrial tachycardias, atrial flutter, and AF. Studies in patients receiving a dual-chamber implantable cardioverter defibrillator with atrial tachycardia detection features have revealed that atrial tachycardias, atrial flutter, and AF occur frequently in this patient population, particularly in patients with a prior history of AF.⁴⁹ Sixty-seven percent of episodes of atrial tachycardias were terminated by

PREVENTIVE THERAPIES AFTER TERMINATION OF ATRIAL FIBRILLATION

AF frequently recurs after termination of an episode of AF. Some DDDR devices now have rate smoothing features designed to eliminate cyclical variation of the heart rate that might predispose to recurrent AF. Likewise, overdrive pacing at higher rates for periods after termination of AF might prevent recurrence if overdrive pacing suppresses SVPBs. Studies are presently underway evaluating such features for prevention of AF.

IDEAL STUDY OUTCOME EVENT IN ATRIAL FIBRILLATION PACING STUDIES

Some investigators have used the time to first recurrence of any episode of AF¹⁸ and others have used the time to first recurrence of symptomatic AF as the primary study outcome event.13, 27 The time to first recurrence of AF assumes that AF is a random event. It has been shown that the time course of PAF recurrence is not random and that other mathematical models (e.g., a Weibull distribution or a biexponential distribution) may better describe the temporal patterns of AF.³⁷ This type of

VENTRICULAR PACING MAY BE PROARRHYTHMIC

It is possible that atrial pacing per se does not prevent AF, but rather ventricular pacing alters the electrophysiologic substrate in the atria because of the loss of AV synchrony and resulting retrograde conduction, causing left atrial stretch because of atrial contraction against a closed AV valve or increased valvular regurgitation associated with the asynchronous activation pattern, which predisposes to AF (Fig. 8).29, 39, 43, 50 AF may contribute to contractile dysfunction because of an

CONCLUSIONS

Atrial and dual-chamber pacing prevents the development of AF in some pacemaker patients. There is no evidence the single-site right atrial pacing prevents PAF or chronic AF in patients without symptomatic bradycardia. In conjunction with antiarrhythmic drugs, site-specific or dual-site and biatrial pacing may prevent AF recurrences in selected patients. Promising new pacing therapies for early termination of atrial tachyarrhythmias or overdrive suppression of SVPBs may prove to be beneficial

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Atrial pacing peri-ablation for prevention of paroxysmal atrial fibrillation

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Cited by (35)

Pacing for Sinus Node Disease
2011, Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy
Pacing for Sinus Node Disease: Indications, Techniques, and Clinical Trials
2007, Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy
Pacing for sinus node disease: Indications, techniques, and clinical trials
2006, Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy
Cardiac pacing: The state of the art
2004, Lancet
Citation Excerpt :
Whether these episodes indicate true pace termination will need further investigation. Although we are skeptical that atrial fibrillation can be reliably pace-terminated, arrhythmias that trigger atrial fibriallation (such as atrial flutter or tachycardia) can be readily pace-terminated.90,97 Two small studies98,99 have suggested that DDD pacing with a short atrioventricular delay might benefit patients with dilated cardiomyopathy and a prolonged baseline PR interval.
Permanent cardiac pacing remains the only effective treatment for chronic, symptomatic bradycardia. In recent years, the role of implantable pacing devices has expanded substantially. At the beginning of the 21st century, exciting developments in technology seem to happen at an exponential rate. Major advances have extended the use of pacing beyond the arrhythmia horizon. Such developments include dual-chamber pacers, rate-response algorithms, improved functionality of implantable cardioverter defibrillators, combinations of sensors for optimum physiological response, and advances in lead placement and extraction. Cardiac pacing is poised to help millions of patients worldwide to live better electrically. We review pacing studies of sick-sinus syndrome, neurocardiogenic syncope, hypertrophic obstructive cardiomyopathy, and cardiac resynchronisation therapy, which are common or controversial indications for cardiac pacing. We also look at the benefits and complications of implantation in specific arrhythmias, suitability of different pacing modes, and the role of permanent pacing in the management of patients with heart failure.
Ventricular high-rate episodes in pacemaker diagnostics identify a high-risk subgroup of patients with tachy-brady syndrome
2004, Heart Rhythm
The purpose of this study was to evaluate the frequency and clinical significance of ventricular high-rate (VHR) episodes (ventricular rate >162 bpm) in patients with symptomatic bradycardia and paroxysmal atrial fibrillation (AF).
Newer pacemakers have enhanced diagnostic features that permit detection and storage of detailed information about the frequency, duration, and time of onset of multiple episodes of AF, atrial tachycardia (AT), and ventricular tachycardia (VT). However, the prevalence and prognostic value of AF associated with rapid ventricular rates in the pacemaker population are unknown.
We prospectively followed 125 patients who received a Medtronic AT 500/501 pacemaker for symptomatic bradycardia and paroxysmal AF.
AF recurred in 112 patients (90%) during 22 ± 8 months of follow-up. A total of 1,324 VHR episodes occurred in 38 patients (30%). Episodes with available electrograms (n = 560) were reviewed and classified as AF (n = 279; 50%), AT (n = 266; 47%) or VT (n = 15; 3%). AF burden was higher in patients with VHR episodes (median 1.9 vs 0.2 hours/day; P < .001). After controlling for AT/AF burden and heart disease, VHR episodes were a significant independent predictor of hospitalization for cardiovascular symptoms (odds ratio 2.92, 95% confidence interval 1.33–6.38; P = .007). Heart rate control improved over time in the cohort, and the frequency of VHR episodes decreased during follow-up (P < .001).
VHR episodes documented in the pacemaker diagnostics identify a high-risk subgroup of patients with AF. Monitoring VHR episodes may be useful for identifying pacemaker patients with AF who require more vigilant monitoring, additional investigations, and/or additional interventions.
Clinical safety and efficacy of single-chamber atrial pacing in sick sinus syndrome: Long-term follow-up
2002, Revista Espanola de Cardiologia
Aunque el modo de estimulación auricular es el más fisiológico en la disfunción del nodo sinusal, la estimulación en modo DDD y VVI son las empleadas mayoritariamente. El objetivo de nuestro estudio es demostrar que una estimulación en modo AAI/AAIR es eficaz y segura; para ello hemos analizado las complicaciones y la mortalidad de este modo de estimulación en una evolución a largo plazo.
Entre 1982 y 2000 se implantó un marcapasos definitivo por DNS sintomática en modo AAI a 160 pacientes. Se ha realizado un análisis de las características clínicas, de la evolución y complicaciones del modo de estimulación AAI durante un seguimiento medio de 5,4 ± 4,5 años.
La muestra estudiada está compuesta de 104 mujeres y 56 varones, con una edad media de 72 ± 12 años. En el seguimiento fue preciso cambiar el modo de estimulación por bradicardia sintomática en 11 pacientes (1,2% anual), bloqueo auriculoventricular de segundo a tercer grado en 7 pacientes (0,8% anual) y fibrilación auricular crónica con frecuencias lentas en 4 enfermos (0,4% anual). Se presentaron arritmias auriculares en 32 pacientes (3,7% anual), accidentes cerebrovasculares (ACV) en 4 pacientes (0,4% anual) y 27 enfermos (3,1% anual) fallecieron durante el seguimiento.
El modo de estimulación AAI en la disfunción del nodo sinusal es seguro y eficaz, con un bajo porcentaje de cambios de estimulación por progresión a bloqueo auriculoventricular, baja incidencia de arritmias auriculares, ACV y una baja mortalidad durante el seguimiento a largo plazo.
Although atrial pacing is a more physiological mode of stimulation in sinus node dysfunction, the pacing modes most often are used DDD and VVI. The aim of our study was to demonstrate that AAI/AAIR pacing is effective and safe by analyzing the complications and mortality of this pacing mode in a long-term follow-up study.
Between 1982 and 2000 definitive AAI-mode pacemakers were implanted for sinus node dysfunction in mode AAI in 160 patients. We analyzed the clinical characteristics, evolution, and complications of the AAI pacing mode during a follow-up of 5.4 ± 4.5 years.
The sample was made up of 104 women and 56 men with an average age of 72 ± 12 years. During follow-up, it was necessary to change the pacing mode for symptomatic bradycardia in 11 patients (annual incidence 1.2%), which was caused by second or third-degree atrioventricular block in 7 patients (annual incidence 0.8%), and chronic atrial fibrillation with bradycardia in 4 patients (annual incidence 0.4%). During follow-up, atrial arrhythmias occurred in 32 patients (annual incidence 3.7%), stroke in 4 patients (annual incidence 0.4%), and 27 patients (annual incidence 3.1%) died.
The AAI/AAIR pacing mode was safe and effective in sinus node dysfunction, with a low percentage of pacing changes required for progression to atrioventricular block, low incidence of atrial arrhythmias, stroke and low mortality during long term follow-up.

View all citing articles on Scopus

Address reprint requests to Anne M. Gillis, MD, FRCPC, Division of Cardiology, Faculty of Medicine, The University of Calgary, 3330 Hospital Drive NW, Room 1634, HSC, Calgary, Alberta T2N 4N1, CANADA, email:[email protected]

Supported by the Heart and Stroke Foundation of Alberta and the Medical Research Foundation of Canada (PG 11188). Dr. Gillis is a Senior Scholar of the Alberta Heritage Foundation for Medical Research

^*: Department of Pacing and Electrophysiology, Division of Cardiology, Foothills Hospital and the Cardiovascular Research Group, The University of Calgary, Calgary, Alberta, Canada

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PACING TO PREVENT ATRIAL FIBRILLATION

Section snippets

MECHANISMS OF ATRIAL FIBRILLATION

FACTORS CONTRIBUTING TO INITIATION OF ATRIAL FIBRILLATION

MECHANISMS OF PACING TO PREVENT ATRIAL FIBRILLATION

SINGLE-SITE RIGHT ATRIAL PACING

PREVENTION OF ATRIAL FIBRILLATION WITH SINGLE-SITE PACING

APPROPRIATE PACING MODALITY AFTER ATRIOVENTRICULAR NODE ABLATION

MULTISITE ATRIAL PACING

PACING THERAPIES TO TERMINATE ATRIAL FIBRILLATION

PREVENTIVE THERAPIES AFTER TERMINATION OF ATRIAL FIBRILLATION

IDEAL STUDY OUTCOME EVENT IN ATRIAL FIBRILLATION PACING STUDIES

VENTRICULAR PACING MAY BE PROARRHYTHMIC

CONCLUSIONS

Lancet

Int J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

Am J Cardiol

Am J Cardiol

Am Heart J

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Electrophysiologic mechanisms of perpetuation of atrial fibrillation

Am J Cardiol

DDD pacing: An effective treatment modality for recurrent atrial arrhythmias

Pacing Clin Electrophysiol

A prospective randomized trial of Bachmann's bundle pacing for prevention of atrial fibrillation [abstr]

J Am Coll Cardiol

Permanent pacing for Bachmann's bundle: Impact on P-wave duration

Pacing Clin Electrophysiol

Systematic trial of pacing to prevent atrial fibrillation

Heart

Dual-chamber pacing versus ventricular pacing: Critical appraisal of the literature

Circulation

Efficacy and safety of quinidine therapy for maintenance of sinus rhythm after cardioversion

Circulation

Long-term prevention of vagal atrial arrhythmias by atrial pacing at 90/minute: Experience with 6 cases

Pacing Clin Electrophysiol

Atrial tachyarrhythmias associated with a high degree of interatrial block: Prevention by permanent atrial resynchronization

J Cardiovasc Pacing Electrophysiol

Design and implementation of the Dual Site Atrial Pacing to Prevent Atrial Fibrillation (DAPPAF) clinical trial

J Interventional Cardiac Electrophysiol

Antiarrhythmic drug therapy and cardiac mortality in atrial fibrillation

J Am Coll Cardiol

Prevention of atrial arrhythmias during DDD pacing by atrial overdrive

Pacing Clin Electrophysiol

Functional mechanisms underlying tachycardia-induced sustained atrial fibrillation in a chronic dog model

Circulation

for the PA3 Investigators: Comparison of DDDR versus VDD pacing post total AV node ablation for prevention of atrial fibrillation [abstr]

Pacing Clin Electrophysiol

Atrial pacing peri-ablation for prevention of paroxysmal atrial fibrillation

Circulation

Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins

N Engl J Med

for the PA³ Investigators: Comparison of DDDR versus VDD pacing post total AV node ablation for prevention of atrial fibrillation [abstr]