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Atrial resynchronization therapy: An emerging potential to advance physiologic pacing?

  • N.A. Mark Estes III
    Correspondence
    Address reprint requests and correspondence: Dr N.A. Mark Estes III, The Heart and Vascular Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, South Tower 3rd Floor, Room E352.2, 200 Lothrop St, Pittsburgh, PA 15213.
    Affiliations
    The Heart and Vascular Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
    Search for articles by this author
  • Samir Saba
    Affiliations
    The Heart and Vascular Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
    Search for articles by this author
Published:November 25, 2021DOI:https://doi.org/10.1016/j.hrthm.2021.11.029
      Sick sinus syndrome (SSS) represents the most common indication for permanent pacemaker implantation.
      • Dobrzynski H.
      • Boyett M.R.
      • Anderson R.H.
      New insights into pacemaker activity: promoting understanding of sick sinus syndrome.
      SSS is characterized by atrial arrhythmias and sinus node dysfunction manifesting as sinus pauses, bradycardia, and chronotropic incompetence.
      • Dobrzynski H.
      • Boyett M.R.
      • Anderson R.H.
      New insights into pacemaker activity: promoting understanding of sick sinus syndrome.
      The prevalence of atrial fibrillation (AF), the most common atrial arrhythmia in patients with SSS, increases exponentially with age.
      • Dobrzynski H.
      • Boyett M.R.
      • Anderson R.H.
      New insights into pacemaker activity: promoting understanding of sick sinus syndrome.
      Both sinus node dysfunction and atrial arrhythmias result from age-related structural and electrophysiological changes.
      • Dobrzynski H.
      • Boyett M.R.
      • Anderson R.H.
      New insights into pacemaker activity: promoting understanding of sick sinus syndrome.
      AF is associated with an increased stroke risk, vascular embolism, heart failure, and mortality.
      • Dobrzynski H.
      • Boyett M.R.
      • Anderson R.H.
      New insights into pacemaker activity: promoting understanding of sick sinus syndrome.
      Evidence-based medicine with appropriately designed randomized controlled trials has demonstrated that atrial based pacing reduces the incidence of AF as compared with single-chamber right ventricular pacing.
      • Connelly S.J.
      • Kerr C.R.
      • Gent M.
      • et al.
      Effects of physiologic pacing versus ventricular pacing on the risk of stroke and death due to cardiovascular causes.
      It is also established that minimizing the percentage of ventricular pacing in patients with SSS who receive a dual-chamber DDD pacemaker results in a lower risk of developing persistent AF.
      • Connelly S.J.
      • Kerr C.R.
      • Gent M.
      • et al.
      Effects of physiologic pacing versus ventricular pacing on the risk of stroke and death due to cardiovascular causes.
      Prospective randomized trials have not demonstrated the efficacy of atrial overdrive pacing algorithms for the prevention of AF.
      • Hohnloser S.H.
      • Healey J.S.
      • Gold M.R.
      • et al.
      ASSERT Investigators. Atrial overdrive pacing to prevent atrial fibrillation: insights from ASSERT.
      ,
      • Lau C.P.
      • Tachapong N.
      • Wang C.C.
      • et al.
      Prospective randomized study to assess the efficacy of site and rate of atrial pacing on long-term progression of atrial fibrillation in sick sinus syndrome: Septal Pacing for Atrial Fibrillation Suppression Evaluation (SAFE) study.
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      Linked Article

      • Bachmann bundle potential during atrial lead placement: A case series
        Heart Rhythm
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          In 1914 Sir Thomas Lewis1 observed that differences in the speed of atrial impulse propagation are influenced by myofiber orientation. Two years later Jean George Bachmann2 reported that left atrial (LA) activation occurs primarily over a muscular band of longitudinally arranged fibers immediately adjacent to the crista terminalis (CT), which became known as Bachmann bundle (BB). Damage to BB results in interatrial conduction delay (IACD) manifesting as prolonged P-wave duration (PWD) > 120 ms on the surface electrocardiogram.
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