Device-based therapies for atrial fibrillation.

Ablation of the atrioventricular conduction system and pacemaker implantation is the preferred procedure for patients with atrial fibrillation (AF) in whom a rate control strategy has been selected but in whom rate-controlling medications are intolerable or ineffective. Selection of standard right ventricular (RV) pacing versus biventricular pacing is individualized, based on the degree and etiology of left ventricular dysfunction. Atrial-based pacing is clearly preferable to ventricular-based pacing in patients with sick sinus syndrome, because it leads to a reduction in the development of AF. Emerging evidence indicates that excess RV pacing is deleterious, increasing AF, heart failure, and possibly mortality. Therefore, physiologic pacing with minimization of RV pacing is desirable. Atrial pacing algorithms that increase the frequency of atrial pacing have shown modest efficacy in the prevention of AF. Use of atrial pacing algorithms is reasonable for patients with a history of AF and standard bradycardia indications for permanent pacing in whom maintenance of sinus rhythm is desirable. Studies assessing novel and multiple site atrial pacing therapies have mixed results, without compelling evidence of clinically important benefit. The exceptions are biatrial and right atrial overdrive pacing immediately after cardiac surgery. Several studies have shown effective suppression of postoperative AF with their use. Device therapy (eg, atrial antitachycardia pacing and defibrillation) for the termination of AF is effective in reducing arrhythmia burden. However, improvement in clinically relevant end points is not established and indications are not clearly defined. If a patient lacks an indication for an implantable cardioverter-defibrillator, we do not offer atrial defibrillation as a treatment option. Atrial arrhythmias may be better prevented by programming to avoid ventricular pacing than by specific atrial interventions.