Regional right and left atrial activation patterns during single- and dual-site atrial pacing in patients with atrial fibrillation

Abstract

We examined the activation of the right atrium and left atrium by pacing from different atrial sites using several single- and dual-site atrial pacing modes in patients with atrial fibrillation or flutter. We also analyzed the effect of these pacing modes on fixed coupled extrastimuli in this population. Patients underwent detailed mapping of regional right atrial (RA) and left atrial (LA) sites. Bipolar pacing was performed individually from the high right atrium, coronary sinus ostium, and the distal coronary sinus, and simultaneously from the high right atrium and coronary sinus ostium (dual-site RA pacing) or high right atrium and distal coronary sinus (biatrial pacing). Extrastimuli were delivered from the high right atrium at fixed coupling intervals of 350 and 250 ms. Twenty patients with atrial fibrillation were studied. P-wave duration during pacing was significantly abbreviated by both dual-site RA and biatrial pacing (p < 0.001 vs high RA pacing, respectively) but not by any other single-site atrial pacing method. Both dual-site atrial pacing modes also significantly abbreviated P wave durations for closely coupled high RA premature beats (p < 0.001) in contrast to high RA pacing. During the basic pacing drive and for high RA extrastimuli, RA activation at the crista terminalis and atrial septum was comparable in sinus rhythm, high RA pacing, and in both dual-site atrial pacing methods, but was significantly delayed by coronary sinus ostial and distal coronary sinus pacing. In contrast, proximal coronary sinus activation was delayed with high RA pacing compared with all other pacing modes, and high RA extrastimuli encountered reduced conduction delay at this location with dual-site atrial pacing modes. LA activation was advanced superiorly by both single-site coronary sinus pacing methods and both dual-site atrial pacing techniques. Inferior and lateral LA activation was advanced by all pacing modes using a coronary sinus pacing site. However, earlier activation of LA sites occurred for high RA premature beats after both dual-site pacing methods (p < 0.05) compared with single-site pacing modes. Incremental conduction delay at different atrial regions for closely coupled high RA extrastimuli ranged from 33% to 120% during high RA pacing and was significantly attenuated at multiple RA and LA sites by dual-site RA and biatrial pacing. Distinct global, as well as regional electrophysiologic effects, may mediate the variable antiarrhythmic effects of different and novel atrial pacing methods.