Implication of ventricular pacing burden and atrial pacing therapies on the progression of atrial fibrillation: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND Atrial fibrillation (AF) is common after pacemaker implantation. However, the impact of pacemaker algorithms in AF prevention is not well understood. OBJECTIVE The purpose of this study was to evaluate the role of pacing algorithms in preventing AF progression. METHODS A systematic search of articles using the PubMed and Embase databases resulted in a total of 754 references. After exclusions, 21 randomized controlled trials (8336 patients) were analyzed, comprising studies reporting ventricular pacing percentage (VP%) (AAI vs DDD, n = 1; reducing ventricular pacing [RedVP] algorithms, n = 2); and atrial pacing therapies (atrial preference pacing [APP], n = 14; atrial antitachycardia pacing [aATP] +APP, n = 3; RedVP+APP+aATP, n = 1). RESULTS Low VP% (< 10%) lead to a nonsignificant reduction in the progression of AF (hazard ratio [HR] 0.80; 95% confidence interval [CI] 0.57-1.13; P 5.21; I-2 = 67%) compared to high VP% (> 10%). APP algorithm reduced premature atrial complexes (PAC) burden ( mean difference [ MD] - 1117.74; 95% CI -1852.36 to -383.11; P = .003; I-2 = 67%) but did not decrease AF burden ( MD 8.20; 95% CI -5.39 to 21.80; P = .24; I-2 = 17%) or AF episodes ( MD 0.00; 95% CI -0.24 to 0.25; P = .98; I-2 = 0%). Similarly, aATP+APP programming showed no significant difference in AF progression ( odds ratio 0.65; 95% CI 0.36-1.14; P = .13; I-2 = 61%). No serious adverse events related to algorithm were reported. CONCLUSION This meta-analysis of randomized controlled trials demonstrated that algorithms to reduce VP% can be considered safe. Low burden VP% did not significantly suppress AF progression. The atrial pacing therapy algorithms could suppress PAC burden but did not prevent AF progression.