The role of pacing mode in the development of atrial fibrillation

Abstract

Asynchronous ventricular pacing has been shown to increase the risk of development of atrial fibrillation (AF) because of various mechanisms: retrograde atrioventricular (AV) conduction with increase in atrial pressure causing acute atrial stretch and reverse flow in the pulmonary veins, mitral regurgitation, reduced coronary blood flow, adverse neuroendocrine reactions, etc. Dual-chamber pacing preserves atrioventricular synchrony. However, in randomized multicentre trials comparing VVI(R) with DDD(R) pacing, AF is only slightly less frequent in the dual-chamber mode. This is most likely due to unnecessary ventricular pacing, which is frequent in dual-chamber pacing. At nominal values, dual-chamber devices usually do not permit intrinsic AV conduction but promote delivery of the ventricular stimulus at an inappropriate time in an inappropriate place. Programming of long AV delays facilitates spontaneous AV conduction but usually cannot completely avoid unnecessary ventricular pacing and causes other problems in the dual-chamber mode. Atrial septal lead placement can improve left-sided AV synchrony and promote spontaneous AV conduction. Programming of the AAI(R) mode is superior to the dual-chamber mode but cannot be used if AV conduction is impaired intermittently or permanently. Therefore, dedicated algorithms enhancing spontaneous AV conduction in the dual-chamber mode are desirable for a large proportion of pacemaker patients.

Combined Nonlinear Analysis of Atrial and Ventricular Series for Automated Screening of Atrial Fibrillation

“…This is frequent when AF is accompanied by AV block, as well as ventricular and AV junctional tachycardia [25,52]. Moreover, the incidence of AF is about 50% in patients with a paced ventricular rhythm over 2 years [57]. A negative outcome is also obtained when these algorithms deal with OR rhythms showcasing irregular RR interval series, such as sinus arrhythmia [52].…”

Near Elimination of Ventricular Pacing in SafeR Mode Compared to DDD Modes: A Randomized Study of 422 Patients

“…Recent observational and controlled studies in patients with SND have also suggested that ventricular dyssynchrony imposed by right ventricular apical pacing increases the risk of atrial fibrillation (AF), despite the preservation of AV synchrony. [4][5][6][7][8][9] Related observations were made in the PIPAF (Pacing In Prevention of Atrial Fibrillation) study where, after controlling for the percentage of ventricular pacing (Vp), AF prevention algorithms appeared to alleviate the AF burden only when spontaneous conduction was preserved. 10 The usual practice, nevertheless, consists of (1) implanting a dual chamber pacing system to eliminate the risk of ventricular standstill due to AV block and (2) programming a long AV delay, although the latter is mostly ineffective and associated with a high rate of pacemaker-mediated tachycardia.…”

“…The main advantages of AAI pacing are (1) the preservation of hemodynamic function by enabling spontaneous ventricular activation and (2) sparing of the pulse generator battery. Recent observational and controlled studies in patients with SND have also suggested that ventricular dyssynchrony imposed by right ventricular apical pacing increases the risk of atrial fibrillation (AF), despite the preservation of AV synchrony 4–9 . Related observations were made in the PIPAF (Pacing In Prevention of Atrial Fibrillation) study where, after controlling for the percentage of ventricular pacing (Vp), AF prevention algorithms appeared to alleviate the AF burden only when spontaneous conduction was preserved 10 .…”

Pacing From the Right Ventricular Septum and Development of New Atrial Fibrillation in Paced Patients With Atrioventricular Block and Preserved Left Ventricular Function

“…Specifically, only patients with preserved LV function and who did not present with AF within 3 months after pacemaker implantation were included; moreover, patients with ventriculoatrial conduction were excluded, as this condition is known to increase the risk of RV pacing-induced AF. 19 In previous studies of sinus node disease, high cumul%VP was found to be associated with an increased incidence of AF, 1,2,20 but the relationship between cumul%VP and the incidence of RV pacing-induced AF had not been confirmed in patients presenting with AV block. To the best of our knowledge, the present study is the longest follow-up analysis in patients who received RV septal pacing for AV block.…”