Atrial pacing should be used more frequently in sinus node disease

Background: Single lead atrial (AAI(R)) pacing for sick sinus syndrome provides physiological pacing and is less expensive than a dual chamber system. Compared with ventricular-based pacing, it maintains the normal cardiac depolarization sequence, is associated with less atrial fibrillation and heart failure, and avoids pacemaker syndrome. We sought whether it is possible to select patients for AAI(B) pacing with a low likelihood of subsequent ventricular pacing, and whether this approach was cost-effective. Methods: A retrospective review was conducted of AAI(R) pacemaker implantations. Patients requiring a further procedure for insertion of a ventricular lead (for DDD(R) or VVI(R) pacing) were compared with those who remained atrially paced. Results: 2.7% (117 of 4,366) of implants were AAI(R), compared with less than 1% overall for New Zealand and Australia. During follow-up of 3.5 (2.3, 7.7) years, insertion of a ventricular lead was required in 14 (12%), and was more likely in those with pre-existing PR interval > 0.20 seconds (odds ratio 7.8, P = 0.003) or left bundle branch block (LBBB, odds ratio 17, P = 0.037). Right bundle branch block, left anterior fascicular block, or history of paroxysmal atrial fibrillation were not more frequent in the group requiring ventricular pacing, and preimplantation Wenckebach point was not different. The most efficient strategy was initial AAIR implantation in all except those with LBBB or PR interval > 0.20 seconds. Compared with routine DDDR implantation, cost was reduced by 20%, with a 1.4% annual incidence of further procedures. Conclusion: AAIR is the appropriate pacing choice for sick sinus syndrome without LBBB or PR interval > 0.20 seconds.