Schuchert A, Meinertz T
Medizinische Klinik und Poliklinik, Abteilung für Kardiologie, Universitäts-Krankenhaus Hamburg-Eppendorf.
Herz. 1998 Jun;23(4):260-8. doi: 10.1007/BF03044321.
Pacemaker therapy in patients with atrial fibrillation means the best current pacemaker therapy for patients with bradycardias with the aim to avoid the onset of atrial fibrillation and to establish DDD pacing despite of a history of atrial tachyarrhythmias. The newer application of pacing is the suppression of atrial arrhythmias in patients with medical refractory atrial tachyarrhythmias. Patients with slow ventricular rates and permanent atrial fibrillation should receive a VVI-pacemaker, if the bradycardias causes syncope, dizziness or a decrease of their exercise tolerance. In case of chronotropic incompetence the pacemaker should provide rate responsive pacing. Patients with sick sinus syndrome should receive an atrial (AAI) or dual-chamber (DDD) pacemaker, because patients with these in contrast to VVI-pacemakers develop less often atrial fibrillation and subsequent complications such as atrial thromboembolism. A dual-chamber or VDD-pacemaker--the latter connected to a VDD-single-lead--is indicated in patients with advanced AV-block. Atrial fibrillation occurs in 3 to 6% of the patients with no history of arrythmia and is, if pacemakers have no automatic mode switch, an often reason to program the devices to the VVI-pacing mode. Nowadays, most DDD(R)-pacemakers provide an automatic mode switch: During an atrial tachycardia the pacemaker switches to a VVI/VVIR mode and restores the initial DDD(R)-pacing mode with termination of the arrhythmia. In respect to the newer applications, one approach to prevent atrial tachyarrhythmias is permanent atrial pacing. As lower pacing rates of 80 to 90 ppm are usually needed and many patients hardly tolerate these pacing rates, new algorithms are under clinical investigation. Another approach is the simultaneous depolarization of the right and left atrium. Biatrial pacing is performed with one lead in the high right atrium and another lead in the coronary sinus. Another solution is bifocal atrial pacing with leads placed in the high right atrium and in the coronary sinus ostium. One effect of the new pacing techniques is to shorten interatrial conduction times. Therefore, biatrial pacing has become a therapy to prevent atrial arrhythmias deriving from delayed interatrial conduction times. As atrial reentry circuits seem to be important in atrial fibrillation, multisite atrial pacing is also performed in patients with medical refractory paroxysmal atrial fibrillation. Preliminary results suggest a more effective prevention of atrial fibrillation; nevertheless, these techniques should be still restricted to patients enrolled in clinical studies.
心房颤动患者的起搏器治疗是指针对心动过缓患者目前最佳的起搏器治疗方法，旨在避免心房颤动的发作，并在有房性快速心律失常病史的情况下建立DDD起搏。起搏的新应用是抑制药物难治性房性快速心律失常患者的房性心律失常。心室率缓慢且患有永久性心房颤动的患者，如果心动过缓导致晕厥、头晕或运动耐量下降，应接受VVI起搏器治疗。在变时功能不全的情况下，起搏器应提供频率应答起搏。病态窦房结综合征患者应接受心房（AAI）或双腔（DDD）起搏器治疗，因为与VVI起搏器相比，这些患者发生心房颤动及随后诸如心房血栓栓塞等并发症的情况较少。双腔或VDD起搏器（后者连接到VDD单极导线）适用于晚期房室传导阻滞患者。在无心律失常病史的患者中，有3%至 6%会发生心房颤动，如果起搏器没有自动模式转换功能，这通常是将设备编程为VVI起搏模式的原因。如今，大多数DDD（R）起搏器都具备自动模式转换功能：在房性心动过速期间，起搏器会切换到VVI/VVIR模式，并在心律失常终止时恢复初始的DDD（R）起搏模式。关于新应用，预防房性快速心律失常的一种方法是永久性心房起搏。由于通常需要80至90 ppm的较低起搏频率，而许多患者很难耐受这些起搏频率，新算法正在进行临床研究。另一种方法是同时使右心房和左心房去极化。双心房起搏通过一根导线置于高位右心房，另一根导线置于冠状窦来进行。另一种解决方案是双焦点心房起搏，导线分别置于高位右心房和冠状窦口。新起搏技术的一个作用是缩短心房传导时间。因此，双心房起搏已成为一种治疗因心房传导时间延迟而导致的房性心律失常的方法。由于心房折返环路在心房颤动中似乎很重要，对于药物难治性阵发性心房颤动患者也会进行多部位心房起搏。初步结果表明对心房颤动的预防更有效；然而，这些技术仍应仅限于参加临床研究的患者。
