[Atrial fibrillation: stimulation and pacemaker therapy]

Pacing therapy is well established in all cases of symptomatic bradyarrhythmic atrial fibrillation. In paroxysmal or persistent atrial fibrillation, the implanted dual chamber pacemaker device should incorporate an automatic mode switching algorithm. Mode switch in case of atrial fibrillation detection avoids pacemaker mediated rapid ventricular pacing during an atrial tachyarrhythmia and allows to perform dual chamber pacing during phases of sinus rhythm which is the preferable mode due to improved hemodynamics, rate adaptation, lower progress in atrial fibrillation burden and a lower rate of thromboembolic events as compared to ventricular pacing.

The possibility to prevent from atrial fibrillation recurrencies by pacing is currently under investigation. Various methodological approaches, for example multisite or alternate single site pacing, preventive pacing algorithms or hybrid- and even triple-therapy concepts are used for that purpose. Due to the theoretical point of view, that all these pacing interventions may reduce atrial fibrillation but also have the potential to act in a proarrhythmic manner, the data from adequately designed trials is of major importance: Septal pacing and preventive pacing algorithms seem to have a beneficial effect in a limited number of so far available studies.

In clinical practice, preventive pacing and/or placement of the atrial lead in a septal position should therefore be available in those patients with a conventional pacing indication in addition to symptomatic recurrent atrial fibrillation. Preventive pacing is so far with a significant and not-predictable amount of non-responders no "early" stage of therapy in patients with recurrent symptomatic atrial fibrillation and no additional conventional pacing indication.