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Evaluation of right atrial and biatrial temporary pacing for the prevention of atrial fibrillation after coronary artery bypass surgery

Edward P. Gerstenfeld, MS, MD^*, Michael R. S. Hill, PhD, Steven N. French, PhD, Rahul Mehra, PhD, Karen Rofino, RN^*, Thomas J. Vander Salm, MD^* and Robert S. Mittleman, MD, FACC^*

^* Department of Medicine and Department of Cardiothoracic Surgery, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
Medtronic, Inc., Minneapolis, Minnesota, USA

View larger version (47K): [in a new window]   Figure 1 Sample Holter monitor tracings recorded from one patient during the onset and termination of atrial fibrillation (AF). In each figure the top tracing is a bipolar recording from the right atrial epicardial wires, and the bottom tracing is a recording from surface lead I. In A, the second atrial premature beat (arrow) initiates a rapid atrial rhythm of varying morphology which can easily be identified by the atrial electrograms. On the surface electrocardiogram this rhythm appeared to be AF. B demonstrates the spontaneous conversion of AF to sinus rhythm in the same patient.

View larger version (28K): [in a new window]   Figure 2 The proportion of patients developing atrial fibrillation (AF) among all the patients, and among the subset of patients on beta-blockers using an intention-to-treat analysis. There was a trend toward a reduction in the incidence of AF among the patients on beta-blockers receiving biatrial pacing (BAP). The one patient who developed AF in the BAP group (asterisk) was never actually paced because of postoperative complications. The numbers above the bars indicate the absolute number of patients in each category. Hatched bars = no atrial pacing; black bars = right atrial pacing; white bars = BAP.

View larger version (13K): [in a new window]   Figure 3 Cumulative incidence of atrial fibrillation (AF) throughout the study. Each bar represents the cumulative incidence of AF through 24, 48, 72 and 96 h, respectively. Although the peak incidence of AF was during the 24 to 48 h period, patients continued to develop AF until the study was completed after 96 h.

View larger version (74K): [in a new window]   Figure 4 Holter monitor tracings recorded from three patients in whom atrial fibrillation (AF) appeared to be initiated by the pacemaker. The top tracing is a bipolar recording from the right atrial epicardial wires showing the atrial pacing spikes, and the bottom tracing is a recording from surface lead I. In A, a failure of pacemaker sensing caused the atrial pacing spike to fall progressively later after atrial depolarization until AF was initiated when a pacing spike (open arrow) occurred during a critical period of atrial repolarization. In B and C an atrial premature beat (filled arrow) occurs which is not sensed appropriately by the pacemaker. The next pacing spike (open arrow) occurs during atrial repolarization and the rhythm converts to AF. A ventricular spike also occurs due to safety pacing.