[The role of cardiac pacing in the treatment of atrial arrhythmias]

Abstract

The role of cardiac pacing in the treatment of atrial arrhythmias can be analysed from the angle of prevention or treatment in a strategy of rhythm control or heart rate control. From the heart rate control viewpoint, "ablate and place" is a validated method, especially in terms of mortality based on the results of large registers, in cases of uncontrolled ventricular rhythms causing symptoms or left ventricular dysfunction. In a strategy of rhythm control, the theoretical bases of prevention of atrial fibrillation (AF) by atrial pacing are convincing but the clinical results of different prospective clinical trials, though encouraging, do not provide formal proof of the efficacy of preventive pacing. Permanent 100% atrial pacing remains the objective which has led to the development of many algorithms evaluated in the ADOPT, AF Therapy, PIPAF, ATTEST...trials, with contradictory results. The choice of atrial pacing site seems to be a determining factor for the success of the method with better results seemingly with the high or low septal positions. The results of the OASES trial support this hypothesis but they were not confirmed by the ASPECT trial. An interesting observation was made in the PIPAF and a new Danish trial on the deleterious effects of ventricular capture when not required which is the rule in patients paced for brady-tachycardia syndromes. As for the role of anti-tachycardia pacing, the technique remains to be validated. Perhaps, the association of different techniques evaluated--the site of pacing, the prevention algorithms, respect of the ventricular rhythms, reduction by anti-tachycardia stimulation--will provide multifunction devices capable of best managing atrial arrhythmias which do not require "curative" therapy, and in particular, endocavitary ablation. In practice, it is generally when faced with brady-tachycardia syndromes that the question of the preventive role of pacing is raised. The problem is to choose the site of stimulation and the most appropriate pacing device in the light of current knowledge.