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Atrial Resynchronization Therapy: An Emerging Potential to Advance Physiologic Pacing?

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 MR, Anderson RH. New insights into pacemaker activity: promoting understanding of sick sinus syndrome. Circulation. 2007;115(14):1921–1932-1931

      SSS is characterized by atrial arrhythmias and sinus node dysfunction manifesting as sinus pauses, bradycardia, and chronotropic incompetence.

      Dobrzynski H, Boyett MR, Anderson RH. New insights into pacemaker activity: promoting understanding of sick sinus syndrome. Circulation. 2007;115(14):1921–1932-1931

      The prevalence of atrial fibrillation (AF), the most common atrial arrhythmia in patients with SSS, increases exponentially with age.

      Dobrzynski H, Boyett MR, Anderson RH. New insights into pacemaker activity: promoting understanding of sick sinus syndrome. Circulation. 2007;115(14):1921–1932-1931

      Both the sinus node dysfunction and atrial arrhythmias results from age related structural and electrophysiological changes.

      Dobrzynski H, Boyett MR, Anderson RH. New insights into pacemaker activity: promoting understanding of sick sinus syndrome. Circulation. 2007;115(14):1921–1932-1931

      AF is associated with an increased stroke risk, vascular embolism, heart failure and mortality.

      Dobrzynski H, Boyett MR, Anderson RH. New insights into pacemaker activity: promoting understanding of sick sinus syndrome. Circulation. 2007;115(14):1921–1932-1931

      Evidence-based medicine with appropriately designed randomized controlled trials has demonstrated that atrial based pacing reduces the incidence of AF compared to 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 efficacy of atrial overdrive pacing algorithms for 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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      References:

      1. Dobrzynski H, Boyett MR, Anderson RH. New insights into pacemaker activity: promoting understanding of sick sinus syndrome. Circulation. 2007;115(14):1921–1932-1931

        • 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.
        N Engl J Med. 2000; 342: 1385-1391
        • Hohnloser S.H.
        • Healey J.S.
        • Gold M.R.
        • et al.
        ASSERT Investigators. Atrial overdrive pacing to prevent atrial fibrillation: insights from ASSERT.
        Heart Rhythm. 2012; 9: 1667-1673
        • 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.
        Circulation. 2013; 128: 687-693
        • Shali S.
        • Su Y.
        • Ge J.
        Interatrial septal pacing to suppress atrial fibrillation in patients with dual chamber pacemakers: A meta-analysis of randomized, controlled trials.
        Int J Cardiol. 2016; 219: 421-427
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        The interauricular time interval.
        Am J Physiol. 1916; 41: 309-320
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        Prevention of the initiation of atrial fibrillation: Mechanism and efficacy of different atrial pacing modes.
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        Prevention of chronic atrial fibrillation by pacing in the region of Bachmann's bundle: results of a multicenter randomized trial.
        J Cardiovasc Electrophysiol. 2001; 12: 912-917
      2. Infield M, Habel N, Meager S, Wahlberg K, Meager S, Meyer M, Lustgarten D Bachmann’s bundle potential during atrial lead placement: a case series 2021: Heart Rhythm, (Reference needed)

      Linked Article

      • Bachmann’s bundle potential during atrial lead placement: a case series
        Heart Rhythm
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          In 1914 Sir Thomas Lewis observed that differences in the speed of atrial impulse propagation are influenced by myofiber orientation.1 Two years later Jean George Bachmann 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’s bundle (BB).2 Damage to BB results in interatrial conduction delay (IACD) manifesting as prolonged P-wave duration (PWD) >120 milliseconds (ms) on the surface electrocardiograph (ECG).
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