title: Association between ventricular pacing and persistent atrial fibrillation in patients indicated to elective pacemaker replacement: Results of the Prefer for Elective Replacement MVP (PreFER MVP) randomized study.
abstract: BACKGROUND
  Pacing in the right ventricle can cause a variety of detrimental effects, including atrial tachyarrhythmias (atrial tachycardia [AT]/atrial fibrillation [AF]).
  
  
  OBJECTIVE
  The purpose of this study was to evaluate the incidence and predictors of persistent AT/AF in patients with long-term exposure to ventricular pacing.
  
  
  METHODS
  In a multicenter international trial, 605 patients (age 75 ± 11 years, 240 women) referred for replacement of an implanted pacemaker or implantable cardioverter-defibrillator (ICD), with a history of high-percentage (>40%) ventricular pacing, were randomly allocated to standard dual-chamber pacing or managed ventricular pacing (MVP), a pacing modality that minimizes ventricular pacing. The main end-point of this secondary analysis of the PreFER MVP randomized study was persistent AT/AF, defined as ≥7 consecutive days with AT/AF or AT/AF interrupted by atrial cardioversion or AT/AF present during 2 consecutive follow-up visits.
  
  
  RESULTS
  Persistent AT/AF was observed in 71 patients (11.7%) after 2 years of follow-up. At multivariable Cox regression analysis, prior AT/AF (hazard ratio [HR] 2.85, 95% confidence interval [CI] 1.20-6.22, P = .017) and ventricular pacing percentage, estimated in the first 3 months, ≥10% (HR 3.24, 95% 95% CI 1.13-9.31, P = .029) were independent predictors for persistent AT/AF. MVP was associated with persistent AT/AF risk (HR 3.41, 95% 95% CI 1.10-10.6, P = .024) in the subgroup of patients with baseline long PR interval (PR >230 ms) but not in the whole population.
  
  
  CONCLUSIONS
  In pacemaker and ICD replacement patients, a high percentage of ventricular pacing is associated with higher risk of persistent AT/AF. Use of algorithms that minimize right ventricular pacing may benefit patients with normal spontaneous AV conduction but should be evaluated with caution in patients with long PR interval.
authors.affiliation: San Filippo Neri Hospital, Rome, Italy. Electronic address: renatopietroricci@tin.it.
authors.forename: Renato P
authors.initials: RP
authors.lastname: Ricci
authors.affiliation: S. Anna Hospital, Como, Italy.
authors.forename: Giovanni Luca
authors.initials: GL
authors.lastname: Botto
authors.affiliation: Hospital General de Ciudad Real, Ciudad Real, Spain.
authors.forename: Juan M
authors.initials: JM
authors.lastname: Bénézet
authors.affiliation: Aarhus University Hospital, Skejby, Aarhus N, Denmark.
authors.forename: Jens Cosedis
authors.initials: JC
authors.lastname: Nielsen
authors.affiliation: Cliniques Universitaires UCL de Mont-Godinne, Yvoir, Belgium.
authors.forename: Luc
authors.initials: L
authors.lastname: De Roy
authors.affiliation: Centre Cardiologique du Nord, Saint-Denis, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Piot
authors.affiliation: Consorcio Hospital General Universitario de Valencia, Valencia, Spain.
authors.forename: Aurelio
authors.initials: A
authors.lastname: Quesada
authors.affiliation: Policlinico Umberto I, Rome, Italy.
authors.forename: Raffaele
authors.initials: R
authors.lastname: Quaglione
authors.affiliation: Presidio Ospedaliero di Montebelluna, Montebelluna, Italy.
authors.forename: Diego
authors.initials: D
authors.lastname: Vaccari
authors.affiliation: Medtronic EMEA Regional Clinical Centre, Rome, Italy.
authors.forename: Lorenza
authors.initials: L
authors.lastname: Mangoni
authors.affiliation: Medtronic EMEA Regional Clinical Centre, Rome, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Grammatico
authors.affiliation: Fakultni nemocnice Brno Bohunice, Brno, Czech Republic.
authors.forename: Milan
authors.initials: M
authors.lastname: Kozák
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D002304:Cardiac Pacing, Artificial / Q000009:adverse effects / Q000379:methods*; D016001:Confidence Intervals; D017147:Defibrillators, Implantable / Q000009:adverse effects*; D020878:Device Removal / Q000379:methods; D017558:Elective Surgical Procedures / Q000379:methods; D004562:Electrocardiography / Q000379:methods; D006801:Humans; D053208:Kaplan-Meier Estimate; D008875:Middle Aged; D015999:Multivariate Analysis; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012086:Reoperation / Q000379:methods; D019233:Retreatment; D018570:Risk Assessment; D012720:Severity of Illness Index; D012737:Sex Factors; D016037:Single-Blind Method; D015996:Survival Rate; D017180:Tachycardia, Ventricular / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D016896:Treatment Outcome
keywords: Atrial fibrillation; Cardiac pacing; Managed ventricular pacing; PR interval; Randomized controlled trial