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Minimizing ventricular pacing to reduce atrial fibrillation in sinus-node disease
Michael O Sweeney1, Alan J Bank, Emmanuel Nsah
1Cardiac Arrhythmia Service, Brigham and Women's Hospital, Boston, MA 02115, USA. mosweeney@partners.org
Insights
Dual-chamber minimal ventricular pacing significantly reduces the risk of persistent atrial fibrillation in patients with sinus-node disease by preventing ventricular desynchronization. This new pacing strategy offers a safer alternative to conventional dual-chamber pacing.
Area of Science:
- Cardiology
- Biomedical Engineering
- Clinical Electrophysiology
Background:
- Conventional dual-chamber pacing can lead to ventricular desynchronization and increased atrial fibrillation risk in patients with sinus-node disease.
- High percentages of ventricular pacing are common with traditional methods, despite maintaining atrioventricular synchrony.
Purpose of the Study:
- To evaluate the efficacy of dual-chamber minimal ventricular pacing in reducing persistent atrial fibrillation.
- To compare a novel pacing strategy aimed at preserving ventricular conduction against conventional dual-chamber pacing.
Main Methods:
- 1065 patients with sinus-node disease were randomized to conventional dual-chamber pacing or dual-chamber minimal ventricular pacing.
- The study primary endpoint was the time to persistent atrial fibrillation.
- New pacemaker features were utilized in the minimal ventricular pacing group to promote atrioventricular conduction and prevent desynchronization.
Main Results:
- Dual-chamber minimal ventricular pacing resulted in a significantly lower percentage of ventricular pacing (9.1% vs. 99.0%).
- A 40% relative risk reduction in persistent atrial fibrillation was observed with minimal ventricular pacing (7.9% vs. 12.7%).
- Mortality rates were similar between the two pacing groups.
Conclusions:
- Dual-chamber minimal ventricular pacing effectively prevents ventricular desynchronization.
- This pacing strategy moderately reduces the risk of persistent atrial fibrillation in patients with sinus-node disease.
- The findings support dual-chamber minimal ventricular pacing as a beneficial alternative for managing patients with sinus-node disease.
Background:
Conventional dual-chamber pacing maintains atrioventricular synchrony but results in high percentages of ventricular pacing, which causes ventricular desynchronization and has been linked to an increased risk of atrial fibrillation in patients with sinus-node disease.
Methods:
We randomly assigned 1065 patients with sinus-node disease, intact atrioventricular conduction, and a normal QRS interval to receive conventional dual-chamber pacing (535 patients) or dual-chamber minimal ventricular pacing with the use of new pacemaker features designed to promote atrioventricular conduction, preserve ventricular conduction, and prevent ventricular desynchronization (530 patients). The primary end point was time to persistent atrial fibrillation.
Results:
The mean (+/-SD) follow-up period was 1.7+/-1.0 years when the trial was stopped because it had met the primary end point. The median percentage of ventricular beats that were paced was lower in dual-chamber minimal ventricular pacing than in conventional dual-chamber pacing (9.1% vs. 99.0%, P<0.001), whereas the percentage of atrial beats that were paced was similar in the two groups (71.4% vs. 70.4%, P=0.96). Persistent atrial fibrillation developed in 110 patients, 68 (12.7%) in the group assigned to conventional dual-chamber pacing and 42 (7.9%) in the group assigned to dual-chamber minimal ventricular pacing. The hazard ratio for development of persistent atrial fibrillation in patients with dual-chamber minimal ventricular pacing as compared with those with conventional dual-chamber pacing was 0.60 (95% confidence interval, 0.41 to 0.88; P=0.009), indicating a 40% reduction in relative risk. The absolute reduction in risk was 4.8%. The mortality rate was similar in the two groups (4.9% in the group receiving dual-chamber minimal ventricular pacing vs. 5.4% in the group receiving conventional dual-chamber pacing, P=0.54).
Conclusions:
Dual-chamber minimal ventricular pacing, as compared with conventional dual-chamber pacing, prevents ventricular desynchronization and moderately reduces the risk of persistent atrial fibrillation in patients with sinus-node disease. (ClinicalTrials.gov number, NCT00284830 [ClinicalTrials.gov].).
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