Misier Anand Ramdat, Beukema Willem P, Willems Roger
Department of Cardiology, Isala Clinics, Location Weezenlanden, Zwolle, The Netherlands.
Card Electrophysiol Rev. 2003 Dec;7(4):329-32. doi: 10.1023/B:CEPR.0000023132.72125.ca.
Atrial fibrillation (AF) is a common arrhythmia associated with stroke, increased mortality and with a negative impact on quality of life. Pharmacologic treatments for AF have not provided long-term relief from arrhythmia recurrence. Multi-site atrial pacing was introduced by Daubert and colleagues about 10 years ago for the treatment of severe atrial conduction delays in patients with sick sinus syndrome. They found that this type of atrial stimulation reduced or prevented AF. Multi-site atrial pacing results in reduction of intra-atrial and interatrial conduction differences and diminishes heterogeneity of refractoriness, i.e. atrial resynchronization. Acute electrophysiological studies have shown that biatrial stimulation reduced AF inducibility. The Dutch Dual-site Right Atrial Pacing for Prevention of Atrial Fibrillation study was a prospective randomized crossover trial comparing the recurrences of AF in dual-site right atrial and single-site high right atrial pacing in patients with symptomatic medically refractory AF, without or with minimal structural heart disease. Patients were randomized to initial dual-site pacing (Group I n = 18) or initial single-site (Group II n = 22) pacing. After 6 months or after a study endpoint was reached patients were crossed over to the other pacing modality.Although, the arrhythmia free intervals were longer for dual-site pacing during both treatments periods (Group I 162 +/- 12 and Group II 114 +/- 15 days) compared to single-site pacing (Group I 143 +/- 16 and Group II 97 +/- 10 days) the difference was not statistically significant (p = 0.061). However, the sequence of the randomized treatment periods had a significant effect on outcome (p < 0.02). Event free intervals (AF > 48 hours requiring electrical cardioversion) were longer during dual-site pacing in both groups compared to single-site stimulation but the difference was statistically not significant (p = 0.055) because of treatment interaction (P < 0.05). To establish the clinical benefits of multi-site pacing for the treatment of patients with medically refractory symptomatic AF, additional prospective randomized studies are needed. Trials with a parallel design are necessary to avoid carry-over effects of different stimulation protocols.
心房颤动（AF）是一种常见的心律失常，与中风、死亡率增加以及对生活质量产生负面影响相关。用于治疗AF的药物治疗未能长期缓解心律失常的复发。大约10年前，Daubert及其同事引入了多部位心房起搏，用于治疗病态窦房结综合征患者的严重心房传导延迟。他们发现这种类型的心房刺激可减少或预防AF。多部位心房起搏可减少心房内和心房间的传导差异，并减少不应期的异质性，即心房再同步化。急性电生理研究表明，双心房刺激可降低AF的诱发率。荷兰双部位右心房起搏预防心房颤动研究是一项前瞻性随机交叉试验，比较了有症状的药物难治性AF患者（无或有轻微结构性心脏病）双部位右心房起搏和单部位高位右心房起搏时AF的复发情况。患者被随机分为初始双部位起搏组（I组，n = 18）或初始单部位起搏组（II组，n = 22）。6个月后或达到研究终点后，患者交叉至另一种起搏方式。尽管在两个治疗期内，双部位起搏的无心律失常间期（I组162±12天，II组114±15天）均比单部位起搏（I组143±16天，II组97±10天）长，但差异无统计学意义（p = 0.061）。然而，随机治疗期的顺序对结果有显著影响（p < 0.02）。与单部位刺激相比，两组在双部位起搏期间的无事件间期（AF>48小时需要电复律）均更长，但由于治疗相互作用（P < 0.05），差异无统计学意义（p = 0.055）。为了确定多部位起搏治疗药物难治性有症状AF患者的临床益处，需要进行更多的前瞻性随机研究。需要采用平行设计的试验来避免不同刺激方案的残留效应。
