title: How, why, and when may atrial defibrillation find a specific role in implantable devices? A clinical viewpoint.
abstract: This viewpoint article discusses the potential for incorporation of atrial defibrillation capabilities in modern multi-chamber devices. In the late 1990s, the possibility of using shock-only therapy to treat selected patients with recurrent atrial fibrillation (AF) was explored in the context of the stand-alone atrial defibrillator. The failure of this strategy can be attributed to the technical limitations of the stand-alone device, low tolerance of atrial shocks, difficulties in patient selection, a lack of predictive knowledge about the evolution of AF, and, last but not least, commercial considerations. An open question is how atrial defibrillation capability may now assume a specific new role in devices implanted for sudden death prevention or cardiac resynchronization. For patients who already have indications for implantable devices, device-based atrial defibrillation appears attractive as a "backup" option for managing AF when preventive pharmacological/electrical measures fail. This and several other personalized hybrid therapeutic approaches await exploration, though assessment of their efficacy is methodologically challenging. Achievement of acceptance by patients is an essential premise for any updated atrial defibrillation strategy. Strategies that are being investigated to improve patient tolerance include waveform shaping, pharmacologic modulation of pain, and patient-activated defibrillation (patients might also perceive the problem of discomfort somewhat differently in the context of a backup therapy). The economic impact of implementing atrial defibrillation features in available devices is progressively decreasing, and financial feasibility need not be a major issue. Future studies should examine clinically relevant outcomes and not be limited (as occurred with stand-alone defibrillators) to technical or other soft endpoints.
authors: Institute of Cardiology, University of Bologna, Azienda Ospedaliera S. Orsola-Malpighi, Bologna, Italy. giuseppe.boriani@unibo.it
authors: Giuseppe
authors: G
authors: Boriani
authors: Igor
authors: I
authors: Diemberger
authors: Mauro
authors: M
authors: Biffi
authors: Cristian
authors: C
authors: Martignani
authors: Matteo
authors: M
authors: Ziacchi
authors: Matteo
authors: M
authors: Bertini
authors: Cinzia
authors: C
authors: Valzania
authors: Gabriele
authors: G
authors: Bronzetti
authors: Claudio
authors: C
authors: Rapezzi
authors: Angelo
authors: A
authors: Branzi
mesh_terms: D001281:Atrial Fibrillation / Q000517:prevention & control*; D002304:Cardiac Pacing, Artificial / Q000639:trends*; D017147:Defibrillators, Implantable / Q000639:trends*; D004554:Electric Countershock / Q000295:instrumentation / Q000639:trends*; D006801:Humans; D010138:Pacemaker, Artificial / Q000639:trends*; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000639:trends