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

A meta-analysis of randomized controlled trials

Schrittmacherstimulation am Vorhofseptum oder am rechten Herzohr zur Prävention von Vorhofflimmern

Eine Metaanalyse randomisierter, kontrollierter Studien

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Abstract

Background

Interatrial septum (IAS) pacing seems to be a promising 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.

Methods

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.

Results

A total of 12 trials 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.

Conclusions

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.

Zusammenfassung

Hintergrund

Die Schrittmacherstimulation am Vorhofseptum (VHS) scheint ein vielversprechender Ansatz zur Prävention von Vorhofflimmern („atrial fibrillation“ [AF]) zu sein. Die vorliegenden Studienergebnisse sind allerdings widersprüchlich. In der vorliegenden Metaanalyse sollte die Stimulation des VHS mit der des rechten Herzohrs (RHO) bezüglich der Prävention von AF-Ereignissen nach Schrittmacherstimulation verglichen werden.

Methoden

Die Datenbanken PubMed, MEDLINE, EMBASE und Web of Science wurden bis Oktober 2016 nach randomisierten, kontrollierten Studien durchsucht, welche die VHS- und RHO-Stimulation mit Blick auf die AF-Prävention verglichen. Daten zu Studiendesign, Patientencharakteristika und Ergebnissen wurden extrahiert. Das relative Risiko (RR), die gewichteten Mittelwertdifferenzen („weighted mean differences“ [WMD]) oder die standardisierten Mittelwertdifferenzen (SMD) wurden mit Fixed- oder Random-effects-Modellen berechnet.

Ergebnisse

Es wurden 12 Studien eingeschlossen, die 1146 Patienten mit 2‑Kammer-Stimulation umfassten. Obwohl die VHS- der RHO-Stimulation in Bezug auf die Reduktion der AF-Episoden-Zahl (SMD = −0,29, p = 0,05), die AF-bedingte Belastung (SMD = −0,41, p = 0,008) und die P‑Wellen-Dauer (WMD = −34,45 ms, p < 0,0001) überlegen war, verringerte sie weder das Auftreten von permanentem AF (RR = 0,94, p = 0,58) noch AF-Rezidive (RR = 0,88, p = 0,36). Dennoch wurden zwischen der VHS- und RHO-Stimulation über die Dauer des Follow-ups keine Unterschiede in den Sterbefällen insgesamt (RR = 1,04, p = 0,88), den eingriffsbezogenen Ereignissen (RR = 1,17, p = 0,69) und den Stimulationsparametern beobachtet.

Schlussfolgerungen

Die VHS-Stimulation ist sicher und wird so gut vertragen wie die RHO-Stimulation. Auch wenn es mit der VHS-Stimulation vielleicht nicht gelingt, permanentes AF und AF-Rezidive zu vermeiden, kann sie doch die interatriale Erregungsleitung verbessern und könnte zudem die AF-bedingte Belastung senken.

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Funding

This study was supported by the National Natural Science Foundation of China (No. 81400193 and 81671934) and the Specialized Research Fund for the Doctoral Program of Higher Education (No. 20130071120100).

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Authors and Affiliations

  1. Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Shanghai Medical College of Fudan University, 1069 Xietu Road, 200032, Shanghai, China

    L. Zhang, H. Jiang, W. Wang, J. Bai, Y. Liang,  Y. Su &  J. Ge

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  1. L. Zhang
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  2. H. Jiang
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Correspondence to Y. Su or J. Ge.

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Conflict of interest

L. Zhang, H. Jiang, W. Wang, J. Bai, Y. Liang, Y. Su and J. Ge declare that they have no conflicts of interest.

This article does not contain any studies with human participants or animals performed by any of the authors.

Additional information

Drs Lei Zhang and Hong Jiang contributed equally to this work.

Caption Electronic Supplementary Material

59_2017_4589_MOESM1_ESM.doc

Supplement. Fig. 1 Publication bias. (a) Egger’s test (linear regression) and (b) Begg’s funnel plot for permanent atrial fibrillation occurrence. RR risk ratio

Supplement. Table 1 Quality assessment of included studies

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Zhang, L., Jiang, H., Wang, W. et al. Interatrial septum versus right atrial appendage pacing for prevention of atrial fibrillation . Herz 43, 438–446 (2018). https://doi.org/10.1007/s00059-017-4589-7

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