Comprehensive Conduction System Pacing as Antiarrhythmic Strategy in Atrial Fibrillation

Background: 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. Case Summary: 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. Discussion: 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.