The role of pacing in rhythm control and management of atrial fibrillation

Atrial fibrillation is the most common sustained cardiac arrhythmia and is increasing in prevalence with an ageing population. As the arrhythmia is often asymptomatic the true prevalence is likely even higher. Largely because of stroke this arrhythmia places a huge financial burden on the health economy. Despite this, large studies assessing rate versus rhythm control have been equivocal. Because of the ineffectiveness of pharmacological therapy much research effort has been undertaken in device and ablative approaches to rhythm management. Although catheter ablation has gained favour because of the high success rates the technique requires considerable expertise and still has a significant complication profile maintaining interest in pacing therapies for atrial fibrillation. Dual chamber versus single-chamber ventricular pacing has been shown to significantly reduce the incidence of atrial fibrillation. Research is currently underway to see if minimising the deleterious effects of right ventricular apical pacing could further increase the benefits of atrioventricular synchronous pacing. Several studies show some (albeit variable) reduction in AF burden with anti-AF algorithms in the setting of bradycardia. Antitachycardia pacing, on the other hand, has not been shown to treat AF in a randomised trial despite the successful termination of co-existent atrial tachycardias. There is increasing evidence that alternative atrial pacing sites may treat AF by improving atrial function. Furthermore, these strategies coupled with other therapies in a 'hybrid approach' have also showed promising results.