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Bifocal versus unifocal right atrial pacing under plasma level controlled sotalol to prevent atrial fibrillation in patients with symptomatic sinus bradycardia and paroxysmal atrial fibrillation

Bifokale versus unifokale rechtsatriale Stimulation unter plasmaspiegelkontrollierter Sotaloltherapie zur Prävention von Vorhofflimmern bei Patienten mit symptomatischer Sinusbradykardie und paroxysmalem Vorhofflimmern

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Zusammenfassung

Hintergrund

In vorangehenden Studien zur präventiven Therapie von Patienten mit paroxysmalem Vorhofflimmern (VHF) wurde bifokale rechtsatriale Stimulation (BS) bei gleichzeitiger antiarrhythmischer Therapie als effektive Strategie zur Verlängerung des rezidivfreien Intervalls beschrieben. Die vorliegende Studie vergleicht prospektiv die kumulative Prävalenz von VHF (AF Burden) während unifokaler (US) und bifokaler rechtsatrialer Stimulation unter spiegelkontrollierter Sotaloltherapie.

Methoden

Bei 19 Patienten mit symptomatischer Sinusknotendysfunktion und paroxysmalem Vorhofflimmern wurde ein DDDR-Schrittmachersystem mit einer rechtsatrial lateralen und einer tief septal am Koronarsinusostium platzierten Vorhofsonde implantiert. Eine anhand des Plasmaspiegels kontrollierte Sotaloltherapie wurde begonnen. Nach einer dreimonatigen Phase mit zurückhaltender rein antibradykarder Stimulation (Back-up-Phase) wurden die Patienten für 3 Monate auf kontinuierliche rechtsatrial BS oder US randomisiert. Im Anschluss wurde für weitere 3 Monate der komplementäre Modus programmiert. Primärer Studienendpunkt war AF Burden. Als sekundäre Endpunkte wurden die Anzahl von Episoden, das rezidivfreie Intervall und die Therapiesicherheit definiert.

Ergebnisse

Während der Back-up-Phase trat zu 12,4% der Zeit und während US und BS zu je 6,2% Vorhofflimmern auf. (p = 0,91 US vs. BS, p = 0,08 Back-up vs. US und p = 0,07 Back-up vs. BS, "Intention- to-treat"-Analyse.) Auch die „per-protocol“-Analyse ergab keinen Vorteil für eine der beiden Stimulationskonfigurationen. (US 4,8% und BS 5,4% VHF, p = 0,64). Atriale Stimulation verminderte tendenziell die Vorhofflimmerlast im Vergleich zur Back-up-Phase (US oder BS 6,2% vs. Back-up 8,8%, p = 0,09). Bei 3 Patienten kam es zur Dislokation der atrial septalen Sonde.

Schlussfolgerung

Atriale Stimulation unter Sotaloltherapie reduziert tendenziell die Vorhofflimmerlast bei Patienten mit Sinusknotendysfunktion und paroxysmalem VHF. Ein zusätzlicher präventiver Effekt von BS vs. US kann nicht bestätigt werden. Rechtsatrial BS ist möglicherweise mit einer höheren Sondendislokationsrate verbunden.

Abstract

Aims

Bifocal right atrial pacing (BP) has been reported to increase arrhythmia-free intervals in patients with paroxysmal atrial fibrillation (PAF) under antiarrhythmic drugs. This study compares AF burden with unifocal pacing (UP) vs BP under sotalol.

Methods

In 19 patients with PAF a DDDR pacemaker with right atrial lateral and CS ostial leads was implanted. Sotalol was initiated. After a 3 month back-up pacing period patients were randomized to continuous UP or BP for 3 months and crossed over for 3 more months. Primary endpoint was AF burden. Secondary endpoints included number of episodes, time to first recurrence and safety of BP.

Results

The intention to treat analysis revealed 12.4% AF during back-up, 6.2% during UP and BP (p = 0.91 UP vs BP, p = 0.08 back-up vs UP and p = 0.07 back-up vs BP). Per protocol analysis showed no advantage of either pacing mode (UP 4.8% and BP 5.4% AF, p=0.64). Overdrive pacing reduced AF burden to 6.2 vs 8.8% during back-up (p=0.09). Septal lead dislodgement occurred in 3 patients.

Conclusion

Atrial pacing tends to reduce AF burden in patients with PAF under sotalol. An incremental effect of BP vs UP cannot be confirmed. BP may be complicated by elevated lead dislodgement rates.

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Authors and Affiliations

  1. Charité – Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Department of Cardiology, Augustenburger Platz 1, 13353, Berlin, Germany

    Martin Stockburger & Lars Gerhardt

  2. Medtronic Australia, 386, Kew East Vic, 3102, Australia

    Stephan Helms

  3. Kardiologische Praxis Westend, Spandauer Damm 130, 14050, Berlin, Germany

    Michael Schlegl

  4. Department of Cardiology, Herzzentrum Brandenburg in Bernau, Immanuel Diakonie Group, Ladeburger Straße 17, 16321, Bernau, Germany

    Christian Butter

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  1. Martin Stockburger
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Correspondence to Martin Stockburger.

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Stockburger, M., Gerhardt, L., Helms, S. et al. Bifocal versus unifocal right atrial pacing under plasma level controlled sotalol to prevent atrial fibrillation in patients with symptomatic sinus bradycardia and paroxysmal atrial fibrillation. Herzschr. Elektrophys. 18, 250–258 (2007). https://doi.org/10.1007/s00399-007-0582-9

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  • DOI: https://doi.org/10.1007/s00399-007-0582-9

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