Electrophysiologic assessment in selecting patients for multisite atrial pacing

Electrophysiologic mechanisms of atrial fibrillation (AF) initiation are being actively studied. Multisite atrial pacing has shown, in acute studies, significant potential for prevention of AF. Dual site pacing reduces of intra and inter-atrial conduction time, atrial refractoriness dispersion, and to a limited extent atrial premature beats which modify the atrial remodelling induced by AF. Recently, two clinical trials have shown long term efficacy of multisite atrial pacing. At 3 years of follow-up, 56% of patients are free of AF recurrence with dual site right atrial pacing. Rhythm control was achieved in 86 of patients. Similar results are observed with biatrial resynchronization. In both studies, primary indication for multisite atrial pacing was AF prevention in more than 50% of patients. Selection of patients based solely on long P wave duration and prolonged interatrial conduction is not necessary as clinical outcome and comparable. These patients are comparable to patients who did not have these characteristics. Ongoing multicenter trials will likely definitively answer this question. However, preexcitation of diseased atrial regions or site of ectopic activity previously selected by high density atrial mapping or suppression of inducible AF may offer an interesting future development of multisite atrial pacing.