Habel Nicole, Kabir Raihan, Meyer Markus, Lustgarten Daniel L
Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA.
Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA.
JACC Case Rep. 2025 Aug 6;30(22):104421. doi: 10.1016/j.jaccas.2025.104421.
Elevated intracardiac filling pressures create a proarrhythmic environment that facilitates the development or progression of atrial fibrillation (AF). Accelerated lower rate pacing results in atrial decongestion by lowering intracardiac filling pressure and therefore may have an antiarrhythmic effect.
A 70-year-old woman with paroxysmal AF on flecainide progressed to symptomatic rate-controlled persistent AF 5 months ago. She underwent a dual-chamber pacemaker placement with an atrial lead to the Bachmann bundle area and a ventricular lead to the His bundle, and individualized accelerated resting heart rate pacing at 80 beats/min was implemented. She converted to sinus rhythm 18 days post-implant and has maintained sinus rhythm for 8 months, eliminating the need for atrioventricular node ablation.
The "pace-and-wait" approach offers a primary antiarrhythmic treatment strategy for patients with paroxysmal or persistent AF by correcting interatrial conduction delay via Bachmann bundle pacing, correcting interventricular dyssynchrony via conduction system pacing, and optimizing cardiac hemodynamics by individualizing the lower rate limit. As such, the pace-and-wait approach can provide a treatment strategy that allows for sustained rhythm control and treatment of symptoms related to elevated intracardiac filling pressures, as well as offsets the side effects of pharmacologic rate control.
TAKE-HOME MESSAGES: The current era of pacemaker technology allows for the treatment of cardiac conditions beyond electrical impulse formation or conduction alone. In this report we highlight that comprehensive atrial and ventricular conduction system pacing along with accelerated pacing can provide atrial decongestion and atrial resynchronization for a patient with persistent AF.
心腔内充盈压升高会营造一种促心律失常的环境，促进心房颤动（AF）的发生或进展。加速降低心率起搏可通过降低心腔内充盈压实现心房解充血，因此可能具有抗心律失常作用。
一名70岁女性，服用氟卡尼治疗阵发性AF，5个月前进展为有症状的心率控制的持续性AF。她接受了双腔起搏器植入，心房导线置于巴赫曼束区域，心室导线置于希氏束，实施个体化的静息心率加速起搏，频率为80次/分钟。植入后18天她转为窦性心律，并维持窦性心律8个月，无需进行房室结消融。
“起搏并等待”方法为阵发性或持续性AF患者提供了一种主要的抗心律失常治疗策略，通过巴赫曼束起搏纠正心房内传导延迟，通过传导系统起搏纠正心室间不同步，并通过个体化下限频率优化心脏血流动力学。因此，“起搏并等待”方法可提供一种治疗策略，实现持续的节律控制，治疗与心腔内充盈压升高相关的症状，同时抵消药物心率控制的副作用。
当前的起搏器技术时代能够治疗的心脏疾病不仅仅局限于电冲动形成或传导方面。在本报告中，我们强调，对于持续性AF患者，全面的心房和心室传导系统起搏以及加速起搏可实现心房解充血和心房再同步化。
