Interatrial Septum Pacing Research Articles

In memoriam Luigi Padeletti: a cardiologist with many human and scientific qualities

In memoriam Luigi Padeletti: a cardiologist with many human and scientific qualities

GW28-e1229 Interatrial septum versus right atrial appendage pacing for prevention of atrial fibrillation: a meta-analysis of randomized controlled trials

GW28-e1229 Interatrial septum versus right atrial appendage pacing for prevention of atrial fibrillation: a meta-analysis of randomized controlled trials

Interatrial septum versus right atrial appendage pacing for prevention of atrial fibrillation

Interatrial septum (IAS) pacing seems to be apromising strategy for the prevention of atrial fibrillation (AF); however, studies have yielded conflicting results. This meta-analysis was to compare IAS with right atrial appendage (RAA) pacing on the prevention of postpacing AF occurrence. Pubmed, MEDLINE, EMBASE and Web of Science databases were searched through October 2016 for randomized controlled trials comparing IAS with RAA pacing on the prevention of AF. Data concerning study design, patient characteristics and outcomes were extracted. Risk ratio (RR), weighted mean differences (WMD) or standardized mean differences (SMD) were calculated using fixed or random effects models. A total of 12trials involving 1146 patients with dual-chamber pacing were included. Although IAS was superior to RAA pacing in terms of reducing the number of AF episodes (SMD= -0.29, P= 0.05), AF burden (SMD= -0.41, P= 0.008) and P-wave duration (WMD= -34.45 ms, P< 0.0001), neither permanent AF occurrence (RR= 0.94, P= 0.58) nor recurrences of AF (RR= 0.88, P= 0.36) were reduced by IAS pacing. Nevertheless, no differences were observed concerning all-cause death (RR= 1.04, P= 0.88), procedure-related events (RR= 1.17, P= 0.69) and pacing parameters between IAS and RAA pacing in the follow-up period. IAS pacing is safe and as well tolerated as RAA pacing. Although IAS pacing may fail to prevent permanent AF occurrence and recurrences of AF, it is able to not only improve interatrial conduction, but also reduce AF burden.

Interatrial Septum Pacing Decreases Atrial Dyssynchrony on Strain Rate Imaging Compared with Right Atrial Appendage Pacing

Interatrial septum pacing (IAS-P) decreases atrial conduction delay compared with right atrial appendage pacing (RAA-P). We evaluate the atrial contraction with strain rate of tissue Doppler imaging (TDI) during sinus activation or with IAS-P or RAA-P. Fifty-two patients with permanent pacemaker for sinus node disease were enrolled in the study. Twenty-three subjects were with IAS-P and 29 with RAA-P. The time from end-diastole to peak end-diastolic strain rate was measured and corrected with RR interval on electrocardiogram. It was defined as the time from end-diastole to peak end-diastolic strain rate (TSRc), and the balance between maximum and minimum TSRc at three sites (ΔTSRc) was compared during sinus activation and with pacing rhythm in each group. There were no significant differences observed in general characteristics and standard echocardiographic parameters except the duration of pacing P wave between the two groups. The duration was significantly shorter in the IAS-P group compared with the RAA-P group (95 ± 34 vs 138 ± 41; P = 0.001). TSRc was significantly different between sinus activation and pacing rhythm (36.3 ± 35.7 vs 61.6 ± 36.3; P = 0.003) in the RAA-P group, whereas no significant differences were observed in the IAS-P group (25.4 ± 12.1 vs 27.7 ± 14.7; NS). During the follow-up (mean 2.4 ± 0.7 years), the incidence of paroxysmal atrial fibrillation (AF) conversion to permanent AF was not significantly different between the two groups. IAS-P decreased the contraction delay on atrial TDI compared to RAA-P; however, it did not contribute to the reduction of AF incidence in the present study.

Does Bachmann's bundle pacing prevent atrial fibrillation in myotonic dystrophy type 1 patients? A 12 months follow-up study

Paroxysmal atrial arrhythmias occur in myotonic dystrophy type 1 (MD1) patients frequently. Pacemaker (PM) including detailed diagnostic functions may facilitate the diagnosis and management of frequent paroxysmal atrial tachyarrhythmias that may remain undetected during conventional clinical follow-up. Aim of our study was to evaluate the preventive effects of interatrial septum pacing in the Bachmann's Bundle region on atrial fibrillation (AF) in MD1 patients during 12 months follow up period. Thirty MD1 patients (age 50.3 +/- 7.3; 11 F) who underwent dual chamber PM implantation were randomized at implantation to receive right atrial appendage pacing (16 patients) or Bachmann's bundle pacing (14 patients). No statistically significant difference in the electrical parameters (P wave amplitude, pacing threshold and lead impedance) was found between the two groups at implantation. Patients were followed at 1 month, 3 months, and every 6 months thereafter. They underwent clinical assessment, a standard 12-lead ECG and assessment of device performance at every visit. We counted the number of episodes of atrial arrhythmia occurred during the collection period and the duration of each episode. At 12 months of follow-up, no statistically significant differences in the number of AF episodes or in AF duration were found. Lead parameters remained stable over time and there were no displacements of the electrodes after implantation. Implantation of an atrial-active fixation lead on the atrial septum is safe and feasible. However, this study showed no significant difference between septal pacing and high atrial pacing, using the endpoints of AF duration and number of AF episodes.

Prevalence of conduction delay of the right atrium in patients with SSS: implications for pacing site selection

To evaluate the prevalence of severe right atrial conduction delay in patients with sinus node dysfunction (SND) and atrial fibrillation (AF) and the effects of pacing in the right atrial appendage (RAA) and in the inter-atrial septum (IAS). Forty-two patients (15 male, 72 +/- 7 years) underwent electrophysiologic study to measure the difference between the conduction time from RAA to coronary sinus ostium during stimulation at 600 ms and after extrastimulus (DeltaCTos). Patients were classified as group A if DeltaCTos > 60 ms and group B if < 60 ms. Each Group was randomized to RAA/IAS pacing and algorithms ON/OFF. Fifteen patients (36%, group A) had DeltaCTos = 76 +/- 11 ms and 27 patients (64%, group B) had DeltaCTos = 36 +/- 20 ms. Twenty-two patients were paced at the RAA and 20 at the IAS. During the study, no AF recurrences were reported in 11 of 42 (26%) patients, independently of RAA or IAS pacing. Patients from group A and RAA pacing had 0.79 +/- 0.81 episodes of AF/day during DDD, which increased to 1.52 +/- 1.41 episodes of AF/day during DDDR + Alg (P = 0.046). Those with IAS pacing had 0.5 +/- 0.24 episodes of AF/day during DDD, which decreased to 0.06 +/- 0.08 episodes of AF/day during DDDR + Alg (P = 0.06). In group B, no differences were reported between pacing sites and pacing modes. Severe right atrial conduction delay is present in one-third of patients with SND and AF: continuous pacing at the IAS is superior to RAA for AF recurrences. In patients without severe conduction delay, no differences between pacing site or mode were observed.

Suppression of atrial fibrillation by interatrial septum pacing

Interatrial septum pacing seems efficient in synchronizing atrial depolarization in patients with delayed interatrial conduction, but its clinical role in preventing atrial fibrillation is still disputed. The aim of this study was to evaluate the clinical efficacy of interatrial septum pacing guided by electrophysiological testing. Thirty patients (22 male, 8 female, 70.2+/−3.4 years) were enrolled, with drug refractory paroxysmal atrial fibrillation, sinus bradycardia, prolonged P wave duration (132.5+/−8.4 ms), enlarged left atria (inner diameter 3.5+/−0.2 cm) and high atrial fibrillation burden (20+/−3%). Multipolar catheters were used for finding the most suitable site for synchronizing the atria. Then an active fixation atrial lead was positioned at this site. During the interatrial septum pacing, the P wave duration decreased significantly (from 132.5+/−8.4 to 80.0+/−8.5 ms, P<0.001) and interatrial conduction time reduced (from 101.5+/−1.1 to 17.1+/−3.9 ms, P<0.001). After three months follow-up, the atrial fibrillation burden of the patients was decreased (from 20+/−3% to 15+/−4%, P<0.05) and sinus rhythm duration increased (from 20+/−2 days to 25+/−4 days, P<0.05). The results suggest that interatrial septum pacing reduced the incidence of drug refractory paroxysmal atrial fibrillation.

P-379 Effects of interatrial septum pacing on interatrial conduction times and on systolic and diastolic ventricular function: An echo-doppler study

P-379 Effects of interatrial septum pacing on interatrial conduction times and on systolic and diastolic ventricular function: An echo-doppler study

P-379 Effects of interatrial septum pacing on interatrial conduction times and on systolic and diastolic ventricular function: An echo-doppler study

P-379 Effects of interatrial septum pacing on interatrial conduction times and on systolic and diastolic ventricular function: An echo-doppler study

8.1 ECHO-Doppler study of interatrial conduction times with interatrial septum pacing

8.1 ECHO-Doppler study of interatrial conduction times with interatrial septum pacing

8.1 ECHO-Doppler study of interatrial conduction times with interatrial septum pacing

8.1 ECHO-Doppler study of interatrial conduction times with interatrial septum pacing

8.1 Echo-Doppler study of interatrial conduction times with interatrial septum pacing

8.1 Echo-Doppler study of interatrial conduction times with interatrial septum pacing

Effects of septal pacing on P wave characteristics: the value of three-dimensional echocardiography.

Interatrial septum (IAS) pacing has been proposed for the prevention of paroxysmal atrial fibrillation. IAS pacing is usually guided by fluoroscopy and P wave analysis. The authors have developed a new approach for IAS pacing using intracardiac echocardiography (ICE), and examined its effects on P wave characteristics. Cross-sectional images are acquired during pullback of the ICE transducer from the superior vena cava into the inferior vena cava by an electrocardiogram- and respiration-gated technique. The right atrium and IAS are then three-dimensionally reconstructed, and the desired pacing site is selected. After lead placement and electrical testing, another three-dimensional reconstruction is performed to verify the final lead position. The study included 14 patients. IAS pacing was achieved at seven suprafossal (SF) and seven infrafossal (IF) lead locations, all confirmed by three-dimensional imaging. IAS pacing resulted in a significant reduction of P wave duration as compared to sinus rhythm (99.7 +/- 18.7 vs 140.4 +/- 8.8 ms; P < 0.01). SF pacing was associated with a greater reduction of P wave duration than IF pacing (56.1 +/- 9.9 vs 30.2 +/- 13.6 ms; P < 0.01). P wave dispersion remained unchanged during septal pacing as compared to sinus rhythm (21.4 +/- 16.1 vs 13.5 +/- 13.9 ms; NS). Three-dimensional intracardiac echocardiography can be used to guide IAS pacing. SF pacing was associated with a greater decrease in P wave duration, suggesting that it is a preferable location to decrease interatrial conduction delay.

Interatrial septum pacing guided bythree-dimensional intracardiac echocardiography

ObjectivesCurrently, the interatrial septum (IAS) pacing site is indirectly selected by fluoroscopy and P-wave analysis. The aim of the present study was to develop a novel approach for IAS pacing using intracardiac echocardiography (ICE). BackgroundInteratrial septum pacing may be beneficial for the prevention of paroxysmal atrial fibrillation. MethodsCross-sectional images are acquired during a pull-back of the ICE transducer from the superior vena cava into the inferior vena cava by an electrocardiogram- and respiration-gated technique. Both atria are then reconstructed using three-dimensional (3D) imaging. Using an “en face” view of the IAS, the desired pacing site is selected. Following lead placement and electrical testing, another 3D reconstruction is performed to verify the final lead position. ResultsTwelve patients were included in this study. The IAS pacing was achieved in all patients including six suprafossal (SF) and six infrafossal (IF) lead locations all confirmed by 3D imaging. The mean duration times of atrial lead implantation and fluoroscopy were 70 ± 48.9 min and 23.7 ± 20.6 min, respectively. The IAS pacing resulted in a significant reduction of the P-wave duration as compared to sinus rhythm (98.9 ± 19.3 ms vs. 141.3 ± 8.6 ms; p < 0.002). The SF pacing showed a greater reduction of the P-wave duration than IF pacing (59.4 ± 6.6 ms vs. 30.2 ± 13.6 ms; p < 0.004). ConclusionsThree-dimensional ICE is a feasible tool for guiding IAS pacing.

Interatrial septum pacing avoids the adverse effect of interatrial delay in biventricular pacing: an echo-Doppler evaluation.

Biventricular pacing (BVP) can improve haemodynamics in patients with dilated cardiomyopathy (DCM) and left bundle branch block by reducing interventricular delay (IVD). Since in DCM interatrial delay (IAD) and IVD frequently coexist, the aim of this study was to test the hypothesis that IVD reduction associated with IAD produces an imbalance between the programmed right atrioventricular (AV) delay and the effective AV delay on the left, and that interatrial septum pacing (IASP) combined with BVP overcomes this adverse effect. IAD, IVD, left and right mechanical atrioventricular delay (L-RMAVD) were measured by echo-Doppler in 29 patients with BVP: 17 patients (Group A) had the atrial lead in the right atrial appendage, 12 patients (Group B) who experienced paroxysmal atrial fibrillation had the atrial lead on the interatrial septum. In Group A, LMAVD was significantly shorter than RMAVD (172 +/- 24 vs 207 +/- 24 ms, P<0.002), IAD was significantly longer than IVD (52 +/- 24 vs 21 +/- 18 ms, P<0.0001). In Group B, no differences were observed between LMAVD and RMAVD (187 +/- 32 vs 185 +/- 28 ms, NS), and between IAD and IVD (11 +/- 12 vs 13 +/- 16 ms, NS). IAD produces different left and right atrioventricular sequences in BVP. IASP combined with BVP, by resynchronizing both atria and ventricles, is able to avoid this adverse effect.

Interatrial septum pacing guided by three-dimensional intracardiac echocardiography

Interatrial septum pacing guided by three-dimensional intracardiac echocardiography

Randomized crossover comparison of right atrial appendage pacing versus interatrial septum pacing for prevention of paroxysmal atrial fibrillation in patients with sinus bradycardia

Background New atrial pacing techniques and overdrive pacing algorithms have been introduced to prevent atrial fibrillation. This study was designed to test the hypotheses that (1) interatrial septum pacing (IASP) at the triangle of Koch would be more effective than right atrial appendage pacing (RAAP) in preventing paroxysmal atrial fibrillation (PAF) in patients with sinus bradycardia and (2) an algorithm (CAP) designed to achieve constant atrial capture would increase the efficacy of rate-responsive atrial pacing. Methods We studied 46 patients with PAF and sinus bradycardia implanted with a DDD(R) (Medtronic Thera) pacemaker. Twenty-four patients (6.0 ± 10.1 PAF episodes/month within 3 months before study) were randomized to RAAP and 22 patients (5.4 ± 7.1, not significant) to IASP. Within each arm 2 randomized crossover periods of CAP-OFF and CAP-ON function were programed. Results The PAF episodes per month significantly decreased in the RAAP (CAP-OFF: 2.1 ± 4.2, P < .05; CAP-ON: 1.9 ± 3.8, P < .05) and in the IASP group (CAP-OFF: 0.2 ± 0.5, P < .05; CAP-ON: 0.2 ± 0.5, P < .05). Values were significantly lower in the IASP group than in the RAAP group in both CAP-OFF (0.2 ± 0.5 vs 2.1 ± 4.2, P < .05) and CAP-ON (0.2 ± 0.5 vs 1.9 ± 3.8, P < .05) conditions. PAF burden was significantly lower in the IASP than in the RAAP group in CAP-OFF (47 ± 84 min/d vs 140 ± 217, P < .05) and in CAP-ON (41 ± 72 vs 193 ± 266, P < .05) conditions. No differences were observed within each arm in PAF burden between the 2 crossover CAP programing periods. Conclusions Rate-adaptive IASP at the triangle of Koch is more effective than RAAP in preventing PAF in patients with sinus bradycardia. In our sample of patients no additional clinical benefit is furnished by the CAP algorithm. (Am Heart J 2001;142:1047-55.)

Prevention of paroxysmal atrial fibrillation by permanent septal atrial pacing: long-term follow up

Background Inter-atrial septum pacing may prevent initiation or persistence of atrial fibrillation through suppression of premature beats and regularization of atrial rhythm; prolongation of the coupling interval of the premature beats in the abnormal substrate; and modification of the electrophysiological properties of the substrate. The aim of the present study was to evaluate the rate of progression to permanent atrial fibrillation in patients paced at the inter-atrial septum. Method A total of 70 patients (41 male, 29 female; mean age 72 ± 11 years) with a history of sinus bradycardia and paroxysmal atrial fibrillation (6 ± 10 episodes/month in the 3 months before implantation of a pacemaker) were enrolled. Twenty-six patients were ablated at the atrioventricular junction. Results Sinus rhythm was maintained in 79·8% of the group overall after 50 months. After 36 months, sinus rhythm was maintained in 87·9% of the non-ablated patients and in 61·0% of the ablated patients (P < 0·05). Conclusion These results encourage further evaluation of interatrial septum pacing for prevention of AF. (Eur Heart J Supplements 2001; 3 (Suppl P): P2‐P6)

Effect of atrial septal pacing on P-wave duration dispersion and atrial late potentials in patients with paroxysmal atrial fibrillation

Atrial fibrillation (AF) is a common type of arrhythmia and its incidence increases with aging. Long-term antiarrhythmic drug therapy was usually used for the maintenance of sinus rhythm in patients with paroxysmal AF. However, many patients with paroxysmal AF experience AF recurrence in the long term. 1 Fuchs T. Podrid P.J. Pharmacologic therapy for revision of atrial fibrillation and maintenance of sinus rhythm. in: Falk R.H. Podrid P.J. Atrial Fibrillation: Mechanism and Management. Raven Press, New York1992: 253-254 Google Scholar Nonpharmacologic therapies have been investigated, including maze surgery, internal defibrillators, catheter ablation, and pacemakers. 2 Barold S.S. The role of cardiac pacing in the prevention of atrial fibrillation. Cardiol Rev. 1992; 4: 353-365 Crossref Scopus (4) Google Scholar Chronic atrial pacing was known to be associated with a lower incidence of AF in patients with sick sinus syndrome. 3 Andersen H.R. Thussen L. Bagger J.P. Vesterlund T. Thomsen P.E.B. Prospective randomised trial of atrial versus ventricular pacing in sick sinus syndrome. Lancet. 1992; 344: 1523-1528 Abstract Scopus (423) Google Scholar Recently, atrial septal pacing has been reported to be effective in preventing AF recurrence. 4 Spencer W. Zhu D.W.X. Markowitz T. Badruddin S.M. Zoghbi W.A. Atrial septal pacing A method for pacing both atria simultaneously. PACE. 1992; 20: 2739-2745 Crossref Scopus (61) Google Scholar , 5 Katsivas A. Manolis A.G. Lazaris E. Vassilopoulos C. Louvros N. Atrial septal pacing to synchonize atrial depolarization in patients with delayed interatrial conduction. PACE. 1992; 21: 2220-2225 Crossref Scopus (59) Google Scholar , 6 Bailin S.J. Johnson W.B. Hoyt R. A prospective randomized trial of Bachmann’s bundle pacing for the prevention of atrial fibrillation (abstr). J Am Coll Cardiol. 1992; 29: 74A Google Scholar , 7 Bailin S.J. Adler S.W. Giudici M.C. Hill M.R.S. Solinger B. Bachmann’s bundle pacing for the atrial fibrillation: initial trends in a multi-center randomized prospective study (abstr). PACE. 1992; 22: 727 Google Scholar , 8 Padeletti L. Porciani C. Antonio M. Colella A. Ticci P. Vena S. Costoli A. Ciapetti C. Pieragnoli P. Gensini G.F. Interatrial septum pacing A new approach to prevent recurrent atrial fibrillation. J Intervent Cardiac Electrophysiol. 1992; 3: 35-43 Crossref Scopus (113) Google Scholar However, the electrophysiologic characteristics during atrial septal pacing in patients with and without AF have not adequately been investigated. Some investigators have shown that the electrophysiologic abnormalities of the atrial muscle in patients with paroxysmal AF could be detected by P-wave signal-averaged electrocardiography (P-SAE). 9 Fukunami M. Yamada T. Ohmori M. Kumagai K. Umemoto K. Sakai A. Kondoh N. Minamino T. Hoki N. Detection of patients at risk for paroxysmal atrial fibrillation during sinus rhythm by P wave-triggered signal-averaged electrocardiogram. Circulation. 1992; 83: 162-169 Crossref Scopus (288) Google Scholar , 10 Stafford P.J. Turner I. Vincent R. Quantitative analysis of signal-averaged P waves in idiopathic paroxysmal atrial fibrillation. Am J Cardiol. 1992; 68: 751-755 Abstract Full Text PDF Scopus (111) Google Scholar , 11 Yamada T. Fukunami M. Ohmori M. Kumagai K. Sakai A. Kondoh N. Minamino T. Hoki N. Characteristics of frequency content of atrial signal-averaged electrocardiograms during sinus rhythm in patients with paroxysmal atrial fibrillation. J Am Coll Cardiol. 1992; 19: 559-563 Abstract Full Text PDF PubMed Scopus (57) Google Scholar , 12 Guidera S.A. Steinberg J.S. The signal-averaged P wave duration A rapid and noninvasive marker of risk of atrial fibrillation. J Am Coll Cardiol. 1992; 21: 1645-1651 Abstract Full Text PDF Scopus (200) Google Scholar Recently, it has also been reported that the risk of AF recurrence could be assessed by P-wave duration dispersion (P-dispersion) and atrial late potentials on the P-SAE. 13 Yamada T. Fukunami M. Shimonagata T. Kumagai K. Sanada S. Ogita H. Asano Y. Hori M. Hoki N. Dispersion of signal-averaged P wave duration on precordial body surface in patients with paroxysmal atrial fibrillation. Eur Heart J. 1992; 20: 211-220 Crossref Scopus (79) Google Scholar , 14 Abe Y. Fukunami M. Yamada T. Shimonagata T. Kumagai K. Kim J. Sanada S. Hori M. Hoki N. Prediction of transition to chronic atrial fibrillation in patients with paroxysmal atrial fibrillation by signal-averaged electrocardiography A prospective study. Circulation. 1992; 96: 2612-2616 Crossref Scopus (104) Google Scholar The aim of this study was to clarify the electrophysiologic mechanism for preventing AF recurrence by atrial septal pacing from the viewpoint of P-dispersion and atrial late potentials.

Effects of cavotricuspid isthmus ablation on atrioventricular node electrophysiology in patients with typical atrial flutter.

The atrial musculature in the cavotricuspid isthmus is a part of posterior inputs to the AV node. In patients with typical atrial flutter, effects of radiofrequency ablation of this isthmus on AV node conduction are still unknown. This study included 16 patients with clinically documented typical atrial flutter. Group 1 had 8 patients without and group 2 had 8 patients with dual AV nodal pathway physiology. Electrical pacing from the interatrial septum and low right atrium was performed to evaluate antegrade AV node function before and after ablation of the cavotricuspid isthmus. In group 1, the AV node conduction properties were similar before and after ablation. In group 2, the AV node Wenckebach cycle length and maximal AH interval during low right atrium (356+/-58 versus 399+/-49 ms, P=0.008; 303+/-57 versus 376+/-50 ms, P=0.008) and interatrial septum (365+/-62 versus 393+/-59 ms, P=0.008; 324+/-52 versus 390+/-60 ms, P=0.008) pacing were significantly longer after ablation. Elimination of the slow pathway after ablation was noted in 2 patients, including 1 with AV nodal reentrant echo beats. Radiofrequency ablation of the cavotricuspid isthmus was effective in eliminating typical atrial flutter without injury of antegrade fast AV node conduction. The atrial musculature in the cavotricuspid isthmus significantly contributed to the slow AV node conduction.