(Circulation. 2000;102:755.)
© 2000 American Heart Association, Inc.
Clinical Investigation and Reports |
Effects of Biatrial Pacing in Prevention of Postoperative Atrial Fibrillation After Coronary Artery Bypass Surgery
From the Cardiac Medical Unit (K.F.) and the Cardiothroacic Surgical Unit (C.S.W.C., J.W.T.L., G.W.H., D.C., M.P.S.), Grantham Hospital and the Division of Cardiology, Queen Mary Hospital (K.L.L., C.P.L.), Hong Kong, China.
Correspondence to Dr Katherine Fan, Cardiac Medical Unit, Grantham Hospital, 125 Wong Chuk Hang Road, Hong Kong, China. E-mail fankatherine{at}hotmail.com
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Background—Atrial fibrillation (AF) is common after coronary artery bypass surgery (CABG) and results in prolonged hospitalization. The purpose of this study was to evaluate the efficacy of biatrial pacing in preventing post-CABG AF compared with single-site atrial pacing.
Methods and Results—A total of 132 patients who had no history of AF and who underwent CABG were randomized to 1 of the following 4 groups: biatrial pacing (BiA), left atrial pacing (LA), right atrial pacing (RA), or no pacing (control) in postoperative period. Overdrive atrial pacing was performed for 5 days. The incidence of AF was significantly reduced in the BiA group (12.5%) compared with the other 3 groups (LA, 36.4%; RA, 33.3%; control, 41.9%; P<0.05). The mean length of hospital stay was significantly reduced in the BiA group. At baseline, the mean P-wave duration (Pdur) and dispersion (Pdis) were not prolonged. BiA pacing resulted in the most significant percentage of reduction in Pdis when compared with the LA or RA groups (BiA, 42±8%; LA, 13±6%; RA, 10±9%; P<0.05 for BiA versus LA or RA). No significant differences existed in mean Pdur and Pdis between patients who developed AF and those who remained in sinus rhythm at baseline. However, only those patients who remained in sinus rhythm had a significant reduction in mean Pdur and Pdis after pacing therapy.
Conclusions—Biatrial overdrive pacing is more effective in preventing post-CABG AF than single-site atrial pacing; this therapy also results in a shortened hospital stay. The overall reduction in atrial activation time with BiA pacing was reflected in the reduction in Pdis.
Key Words: arrhythmia • electrocardiography • pacing • surgery
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Atrial fibrillation (AF) after coronary artery bypass surgery (CABG) constitutes the most common sustained arrhythmia.1 2 3 4 5 Postoperative AF is associated with strokes and a prolonged hospital stay.6 7 8 9 ß-Adrenergic receptors and class III agents such as amiodarone confer some benefits in preventing post-CABG AF, but its incidence is still as high as 30% with these therapies.10 11 12 13 14
The pathogenesis of postoperative AF remains unclear and is presumably multifactorial. The transient nature of this problem when seen after cardiac surgery suggests a reversible trigger; abnormal automaticity and atrial conduction delay are possible electrophysiological substrates. These would result in the occurrence of atrial ectopy and prolonged atrial activation, with lengthening of the P wave recorded by the ECG.15 16 However, a signal-averaged ECG of the P wave, which is a measure of regions of delayed atrial activation, is only moderately sensitive in predicting AF after CABG.17 18 19 Signal-averaged ECG P-wave dispersion has also been recently advocated as a novel measurement of the heterogeneity of atrial depolarization.20
High right atrial overdrive pacing for patients with paroxysmal AF reduces the recurrence of AF when compared with ventricular demand pacing in observational and controlled clinical trials.21 22 23 Biatrial pacing has been shown to be effective in preventing AF among patients with AF and advanced interatrial block through atrial resynchronization.24
The purpose of this prospective study was to evaluate the efficacy of biatrial pacing as a prophylactic measure against AF after CABG when compared with no (control) or single-site atrial pacing in either the left or right atrium. The impact of therapy on length of hospitalization was also examined. We also evaluated the effect of atrial pacing on mean P wave duration (Pdur) and dispersion (Pdis), as measured by 12-lead ECG.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The study protocol was approved by the institution ethical research committee. From April 1998 to May 1999, 132 patients scheduled for CABG with cardiopulmonary bypass were enrolled. All patients gave informed consent. The diastolic left atrial diameter was measured from the M-mode echocardiogram at the level of the aortic root using electronic callipers. Ejection fraction was measured from the left ventriculogram obtained during preoperative cardiac catheterization. Patients were excluded if they had a history of supraventricular (including atrial flutter or AF) or ventricular tachyarrhythmias, if they required the use of antiarrhythmic therapy other than ß-blockers, or if they postoperatively developed significant events such as cardiogenic shock or ventricular tachyarrhythmias that precluded the use of atrial pacing. All medications, including ß-blockers, were continued until surgery. Postoperatively, these medications were used according to clinical indications. In our institute, ß-blocker therapy was contraindicated after CABG for those who had a radial arterial graft inserted.
Patients underwent CABG on standard cardiopulmonary bypass with myocardial protection provided by blood cardioplegia. Epicardial pacing wires (Flexon-0, Davis-Geck) were placed at the epicardium of the right atrial appendage and at the roof of the left atrium at the end of surgery. Patients were randomly assigned to 1 of the following 4 groups: biatrial pacing (BiA), right atrial pacing (RA), left atrial pacing (LA), or no pacing (control). On arrival in the surgical intensive care unit, the sensing and pacing thresholds of the pacing wires were measured. The configuration of atrial pacing for BiA pacing was as follows: the LA pacing wire was connected to the negative pole of the pulse generator (Medtronic 5375, Medtronic), and the RA pacing wire was connected to the positive pole. For single-site atrial pacing, left or right atrial pacing wires were connected to the negative pole, and the pacing wire connected to skin (ground) was connected to the positive pole of the pulse generator. Patients with a capture threshold >6 mA or a sensing threshold <1 mV were excluded from the study. Overdrive atrial inhibited pacing was initiated, with output programmed at 3 times the capture thresholds. Sensitivity was set at 1 mV. The lowest rate was 90 beats per minute or 10 beats above the intrinsic heart rate should it be >90 beats per minute. The maximum pacing rate allowed was 120 beats per minute. Overdrive pacing was continued for 5 days, with continuous telemetry monitoring. The pacing and sensing thresholds were checked daily, and the output was adjusted accordingly. The 12-lead ECG was performed daily for 5 days at baseline and during pacing. The pacing wires were removed by simple transcutaneous retraction by day 6 in the absence of a clinical end point.
The primary end point was AF lasting >10 minutes or the requirement for urgent intervention because the patient became symptomatic or hemodynamically unstable.
Postoperative Standard ECG Measurement Methodology
In the immediate postoperative period, ECGs were obtained with
12 leads simultaneously at a signal size of 10 mm/mV
and paper speeds of 25 mm/s and 50 mm/s during sinus rhythm
(SR) and atrial pacing, respectively. P-wave analysis
was manually measured by a single investigator who was blinded to the
clinical outcome of the patients. The P-wave onset was defined as the
first atrial deflection from the isoelectric line, and the offset was
the return of the atrial signal to the baseline. Mean
Pdur was calculated as the mean value of P-wave
duration in each lead. The difference between the maximum and minimum
Pdur, expressed as a percentage of mean
Pdur, was defined as P-wave dispersion
(Pdis).
Statistical Analysis
All continuous variables were expressed as mean±SD.
Continuous variables were compared by means of 2-tailed Student’s
t-tests, and discrete variables were compared using the
2 test. For univariate predictors
associated with P<0.1, stepwise logistic regression
analysis was performed; the odds ratio and 95%
confidence interval were calculated to ascertain significant predictors
of AF. Linear regression models for length of hospital stay were
performed to identify important independent predictors. Effects of
possible outliers on length of hospital stay were examined and
identified as standardized residuals beyond 3 SDs from the mean.
P<0.05 was considered statistically significant.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Patient Data
Of the 132 patients, 32, 33, 36, and 31 were assigned to the BiA, LA, RA, and control groups, respectively. However, premature termination of pacing was required in 12 patients, either because of markedly raised pacing thresholds (n=7), poor sensing (n=3), or both (n=2). All patients were included in an intention-to-treat analysis. The mean age was 64.6±7.8 years, and 70% of the patients were male. The mean ejection fraction was 46.3±10.6%. The clinical characteristics in each group were similar and well matched (Table 1
). A total of 66% and 54% of
patients were taking ß-blockers before and after the operation,
respectively, and this was not significantly different among the 4
groups.
|
The mean maximum sinus rate per day was 99±13 beats/min, and this was not significantly different from the mean maximum sinus rate in the control group (100±12 beats/min; P>0.05). A progressive increase in pacing thresholds and a decrease in atrial sensing amplitude occurred with time, but adequate pacing was possible in all patients during the study period.
Incidence of Post-CABG AF
A total of 41 patients developed AF, with an overall incidence of
31.1%. There was a significantly reduced incidence of postoperative AF
in the BiA group (12.5%) when compared with the other 3 groups (LA,
36.4%; RA ,33.3%; and control, 41.9%; P<0.05) (Figure 1). AF developed a mean of 2.8±1.2 days
after surgery. If AF was not converted spontaneously to SR, either
pharmacological means or electrical cardioversion was used to restore
SR before discharge. After 4 weeks of follow-up, all patients remained
in SR.
|
Length of Hospital Stay and Postoperative Outcomes
The mean hospital stay was 10.6±4.0 days; the median stay was 8.2
days. The length of stay was most significantly reduced in the BiA
group (7.0±1.4 versus 9.6±4.2 days in the control group;
P=0.003). The mean length of stay in the intensive care unit
was also significantly reduced in the BiA group (2.8±0.7 versus
4.6±4.5 days in the control group; P=0.04). Postoperative
complications are shown in Table 2.
Adverse cerebral events (including nonfatal stroke or transient
ischemic attacks) occurred in 6 patients (4.5%); cerebral
hemorrhage was excluded by brain CT examinations. The causes of
cerebral events were believed to be embolic in 4 patients and secondary
to cerebral hypoperfusion in 2 patients (who also had AF). These events
were significantly higher in those patients who developed AF (SR group,
1.1%; AF group, 12.2%; P=0.005). Two patients (1.5%) with
a disabling stroke received long-term anticoagulation.
|
Age was identified as the only significant predictor of the development
of post-CABG AF (odds ratio, 1.06; 95% confidence interval, 1.01 to
1.12; P=0.02). AF remained an important correlate for both
intensive care unit stay and nursing ward stay. Patients with post-CABG
AF stayed, on average, 1.8 more days in the intensive care unit and 2.1
more days in the nursing ward than those without AF (Table 3). No significant effects of outliers
could be identified (standardized residuals ranged from -1.62 to 2.97
from the mean length of hospitalization). The median hospital charges
in the BiA group (estimated at $12 087 per patient), inclusive of
direct surgical procedural charges, was significantly reduced by 14%
compared with the median charges in the control group (estimated at
$14 047 per patient; P<0.001).
|
Effect of Atrial Pacing on P-Wave Analysis
The baseline mean Pdur was 74.7±9.6 ms, and
the mean Pdis was 66±24%. The mean
Pdur and mean Pdis were
significantly reduced with atrial pacing, irrespective of the mode of
pacing (Figure 2). The percentage of
reduction in mean Pdur among the 3 pacing groups
was not significantly different (BiA, 19±17%; LA, 17±18%; and RA,
13±21%; P>0.3 for BiA versus LA or RA). BiA pacing
resulted in the most significant percentage of reduction in mean
Pdis when compared with the LA or RA groups (BiA,
42±8%; LA, 13±6%; and RA, 10±9%; P<0.05 for BiA
versus LA or RA), as shown in Figure 3.
|
|
At baseline, no significant differences existed in the mean
Pdur and Pdis between
patients who developed AF and those who remained in SR for all 3 modes
of atrial pacing. However, only those patients who remained in SR had a
significant reduction in mean Pdur and
Pdis after pacing therapy (Figure 4).
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Major Findings
We demonstrated that biatrial overdrive pacing is more effective in reducing the incidence of AF after CABG than control and single-site atrial pacing. This type of pacing was also associated with a significantly reduced length of hospitalization. Atrial overdrive pacing reduced the mean Pdur and mean Pdis significantly. BiA pacing resulted in the most significant reduction in Pdis. Prevention of AF was not effective for patients whose mean Pdur and Pdis could not be reduced significantly, despite atrial overdrive pacing.
Prophylaxis Strategy for Post-CABG AF
Previous trials of prophylaxis for postoperative AF have mainly
used ß-blockers and sotalol; they have shown some
benefits.9 10 11 12 13 Daoud et al14 demonstrated
that preoperative oral amiodarone therapy was effective in
reducing postoperative AF; this reduction was associated with a
reduction in the duration and cost of hospitalization in patients
undergoing cardiac surgery. Their study group included a
heterogenous group of patients; 57% of these patients
were undergoing valvular surgery, and the incidence of AF was
still 25%, despite the use of amiodarone. Medical therapy as a
prophylactic agent against post-CABG AF may be limited by
other medical diseases, such as asthma, thyroid dysfunction, or liver
function derangement.
Overdrive atrial pacing has been proposed for the prevention of AF recurrence in patients with bradycardia and paroxysmal AF.21 Single-site pacing in AF prevention, however, has not been shown to be effective in patients with paroxysmal AF.25 Dual-site atrial pacing, wholly from the right atrium, is effective in patients with drug-refractory AF and reduces AF recurrence.26 Biatrial pacing was introduced as a new pacing modality for the prevention of atrial tachyarrhythmias in patients with AF and advanced interatrial conduction block,24 but the actual incidence of advanced interatrial conduction block is rare in the general population, with a prevalence estimated at 1%.27 Because temporary pacing leads are routinely used after open-heart surgery, there have been some preliminary reports on the effectiveness of atrial pacing in preventing post-CABG AF.28 29 To our knowledge, this is the first study reported that compares BiA pacing with single atrial pacing from either chamber.
Role of Atrial Pacing in AF Prevention
Previous animal studies demonstrated that dispersion of
refractoriness and anisotropic conduction are 2 essential elements for
sustaining atrial arrhythmia,30 31 and both have
been implicated in the pathogenesis of postoperative AF.32
Pacing at a higher rate can suppress bradycardia-induced atrial
premature contractions and may reduce the dispersion of
refractory periods.33 The factor that distinguishes
single- and dual-site pacing is the effect of each on the activation
sequence. Unique pacing sites can "pre-excite" the abnormal
substrate and, subsequently, increase the coupling interval of
activation by a premature beat, thus preventing the initiation of
reentry. Earlier excitation could potentially advance repolarization
and the recovery of excitability. Papageorgiou and
colleagues34 35 noted a conduction delay around the
triangle of Koch and attributed this to nonuniform anisotropy in the
region; they demonstrated that coronary sinus pacing eliminated
the propensity of high right atrial extrasystoles to induce AF. Others
have shown that slow conduction in either atrium with subsequent
retrograde activation resulted in greatly delayed and
inhomogeneous activation of the contralateral atrium and
major intraatrial and interatrial asynchrony with prolonged regional
refractoriness.36 37 Therefore, multisite pacing would
provide the additional benefits of both improving local excitability
and reducing the window of opportunity for AF initiation.
Analysis of Pdur and Pdis
The relationship between delayed atrial conduction times and
Pdur has led to an analysis of standard
or signal-averaged ECG Pdur as a prognostic index
for the development of AF after cardiac surgery.16 17 18 19 We
sought to determine if mean Pdur and
Pdis from a standard ECG could provide a simple
yet effective measurement of delayed and nonuniform atrial conduction
in post-CABG AF. Because our group of patients, who had no clinical
history of atrial dysrhythmia, did not demonstrate baseline
intra-atrial conduction delay, atrial pacing of all 3 modes resulted in
only a further shortening of mean Pdur, but no
significant reduction among the 3 pacing modalities.
Previous studies have demonstrated that an abnormally prolonged and fractionated atrial electrogram is characteristic of patients with AF, suggesting that the inhomogeneity of electrical activity is related to delayed and nonuniform anisotropic conduction.38 By measuring P waves in different electrographic planes and calculating mean Pdis from the surface ECG, we found that BiA pacing resulted in the most significant reduction in mean Pdis when compared with single-site atrial pacing, which suggests that the most significant decrease in overall atrial activation time could be achieved by BiA pacing. Furthermore, patients who developed AF during atrial pacing did not achieve a significant reduction of mean Pdur and Pdis, which may reflect a failure of atrial pacing to pre-excite abnormal substrate in these cases, allowing for the initiation of AF.
Length of Hospital Stay and Estimated Economic Impact
The increased costs associated with the development of
postoperative AF are largely related to the prolongation of hospital
stay. With BiA pacing, the mean length of stay and its associated
impact on cost were significantly reduced. Hospital resource use and
the financial impact arising from elective CABG and its length of stay
have been studied.8 39 40 Taylor et al40
examined the economic consequences of post-CABG complications and
showed that AF was one of the least expensive but most common
complications, occurring in 20% of patients. Respiratory failure and
sternal wound infection were the most expensive complications, but they
occurred in only 3% and 0.4% of patients, respectively. Aranki and
colleagues8 examined the impact of post-CABG AF on
hospital resources in 570 patients in whom the adjusted length of
hospital stay attributable to AF was 4.9 days, which corresponded to an
extra $10 055 to $11 500 per patient in hospital charges, or 
2
million dollars for that cohort of patients. In this study, the finding
of a significant excess of cerebral events among patients with
postoperative AF confirms similar observations in other
studies.6 7 9 Hogue et al41 determined that
AF had no impact on the postoperative stroke rate unless it was
combined with low cardiac output syndrome; this was evident in our 2
patients as well.
Study Limitations
Loss of capture from either atrial pacing wire during BiA pacing
may be difficult to identify on ECG or telemetry monitoring; therefore,
we performed daily assessments of the capture and sensing thresholds to
ensure continuous capture by using an energy output 3 times the
thresholds and by excluding those with marginal capture thresholds.
Because the benefit of BiA pacing was superior to LA or RA pacing, any
failure of BiA pacing would only have reduced the observed benefit of
the BiA pacing mode. A transient period of incomplete overdrive pacing
may be overlooked before adjusting the pacing rate should the
patient’s intrinsic rate exceed the overdrive rate. The mean maximum
sinus rate among the pacing groups, however, was not significantly
different from the intrinsic rate of the control group. The P-wave
analysis from surface ECG was performed manually and, with
atrial pacing, the onset of the P wave may become more obvious, leading
to the observed values of Pdur and
Pdis reduction. However, a more substantial
reduction of Pdis on the pacing ECGs was observed
in BiA pacing compared with other pacing modes, and
Pdis was only reduced in those patients whose AF
was prevented by pacing therapy.
Conclusions
AF is commonly encountered after CABG, and it results in an
increased hospital stay. BiA overdrive pacing is more effective in
preventing post-CABG AF than single-site atrial pacing, and it results
in a shortened length of hospitalization. Identifying patients at risk
for developing post-CABG AF and using intensive
prophylactic measures may be the optimal cost-effective
strategy.
Received January 7, 2000; revision received March 24, 2000; accepted March 29, 2000.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
1. Leitch JW, Thomson D, Baird DK, et al. The importance of age as a predictor of atrial fibrillation and flutter after coronary artery bypass grafting. J Thorac Cardiovasc Surg. 1990;100:338–342.[Abstract]
2. Lauer MS, Eagle KA, Buckley MJ, et al. Atrial fibrillation following coronary artery bypass surgery. Prog Cardiovasc Surg. 1989;31:367–378.
3. Crosby LH, Pifalo WB, Woll KR, et al. Risk factors for atrial fibrillation after coronary artery bypass grafting. Am J Cardiol. 1990;66:1520–1522.[Medline] [Order article via Infotrieve]
4. Fuller JA, Adams GC, Buxton B. Atrial fibrillation after coronary bypass grafting: is it a disorder of the elderly? J Thorac Cardiovasc Surg. 1989;64:826–830.[Medline] [Order article via Infotrieve]
5.
Mathew JP, Parks R, Savino JS, et al, for the
Multicenter Study of Perioperative Ischemia
Research Group. Atrial fibrillation following coronary artery
bypass graft surgery. JAMA. 1996;276:300–306.
6. Cresewell LL, Schuessler RB, Rosenbloom M, et al. Hazards of post-operative atrial arrhythmias. Ann Thorac Surg. 1993;56:539–549.[Abstract]
7. Taylor GJ, Malik SA, Coliver JA, et al. Usefulness of atrial fibrillation as a predictor of stroke after isolated coronary artery bypass grafting. Am J Cardiol. 1987;60:905–907.[Medline] [Order article via Infotrieve]
8.
Aranki SF, Shaw DH, Adams DH, et al. Predictors of
atrial fibrillation after coronary artery surgery: current
trends and impact on hospital resources. Circulation. 1996;94:390–397.
9.
Wolman RL, Nussmeier NA, Aggarwal A, et al. Cerebral
injury after cardiac surgery: identification of a group at
extraordinary risk. Stroke. 1999;30:514–522.
10.
Lamb RK, Prabhakar G, Thorpe JAC, et al. The use of
atenolol in the prevention of supraventricular
arrhythmias following coronary artery surgery.
Eur Heart J. 1988;9:32–36.
11.
Gomes JA, Ip J, Santoni-Rigiu F, et al. Oral d, l
sotalol reduces the incidence of postoperative atrial fibrillation in
coronary artery bypass surgery patients: a randomized,
double-blinded, placebo-controlled study. Am J Coll
Cardiol. 1999;34:334–339.
12. Nystrom U, Edvardsson N, Berggren H, et al. Oral sotalol reduces the incidence of atrial fibrillation after coronary artery bypass surgery. Thorac Cardiovasc Surg. 1993;41:34–37.[Medline] [Order article via Infotrieve]
13. Martinussen HJ, Lolk A, Szczepanski C, et al. Supraventricular tachyarrhythmias after coronary bypass surgery- a double-blind randomized trial of prophylactic low dose propranolol. Thorac Cardiovasc Surg. 1988;36:206–207.[Medline] [Order article via Infotrieve]
14.
Daoud EG, Strickberger SA, Man KC, et al. Preoperative
amiodarone as prophylaxis against atrial fibrillation after
heart surgery. N Engl J Med. 1997;337:1785–1791.
15.
Buxton AE, Josephson ME. The role of P wave duration as
a predictor of postoperative atrial arrhythmias.
Chest. 1981;80:68–73.
16.
Stafford PJ, Kolvekar S, Cooper J, et al. Signal
averaged P wave compared with standard
electrocardiography or
echocardiography for prediction of atrial
fibrillation after coronary bypass grafting. Heart. 1997;77:417–422.
17.
Steinberg JS, Zelenkofske S, Wong SC, et al. The value
of P-wave signal averaged electrocardiogram for
predicting atrial fibrillation after cardiac surgery.
Circulation. 1993;88:2618–2622.
18.
Frost L, Lund B, Pilegaard H, et al. Re-evaluation of
the role of P-wave duration and morphology as predictors of atrial
fibrillation and flutter after coronary artery bypass surgery.
Eur Heart J. 1996;17:1065–1071.
19.
Seifert M, Josephson ME. P-wave signal averaging: high
tech or an expensive alternative to standard ECG?
Circulation. 1993;88:2980–2982. Editorial.
20. Kubara I, Ikeda H, Horaki T, et al. Dispersion of filtered P wave duration by P wave signal-averaged ECG mapping system: its usefulness for determining efficacy of disopyramide on paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol. 1999;10:670–679.[Medline] [Order article via Infotrieve]
21. Garrigue S, Barold SS, Cazeau S, et al. Prevention of atrial arrhythmias during DDD pacing by atrial overdrive. Pacing Clin Electrophysiol. 1998;21:1751–1759.[Medline] [Order article via Infotrieve]
22.
Sgarbossa EB, Pinski SL, Maloney JD, et al. Chronic
atrial fibrillation and stroke in paced patients with sick sinus
syndrome: relevance of clincial characteristics and pacing modalities.
Circulation. 1993;88:1045–1053.
23. Andersen HR, Thuesen L, Bagger JP, et al. Prospective randomized trial of atrial versus ventricular pacing in sick-sinus syndrome. Lancet. 1994;344:1523–1528.[Medline] [Order article via Infotrieve]
24. Daubert C, Berder V, Gras D, et al. Atrial tachyarrhythmias associated with high degree interatrial conduction block: prevention by permanent atrial resynchronization. Eur J Card Pace Electrophysiol. 1994;1:35–44.
25.
Gillis AM, Wyse G, Connolly SJ, et al, for the Atrial
Pacing Periablation for Paroxysmal Atrial Fibrillation
(PA3) Study Investigators. Atrial pacing
periablation for prevention of paroxysmal atrial fibrillation.
Circulation. 1999;99:2553–2558.
26.
Delfault P, Saksena S, Prakash A, et al. Long-term
outcome of patients with drug refractory atrial flutter and
fibrillation after single and dual-site right atrial pacing for
arrhythmia prevention. J Am Coll Cardiol. 1998;32:1900–1908.
27.
Bayes de Luna A, Cladellas M, Oter R, et al.
Interatrial conduction block and retrograde activation of the left
atrium and paroxysmal supraventricular
tachyarrhythmia. Eur Heart J. 1988;9:1112–1118.
28.
Gerstenfeld EP, Hill MRS, French SN, et al. Evaluation
of right atrial and biatrial temporary pacing for the prevention of
atrial fibrillation after coronary artery bypass surgery.
J Am Coll Cardiol. 1999;33:1981–1988.
29. Kurz DJ, Naegeli B, Kunz M, et al. Epicardial biatrial synchronous pacing for prevention of atrial fibrillation after cardiac surgery. Pacing Clin Electrophysiol. 1999;22:721–726.[Medline] [Order article via Infotrieve]
30.
Spach MS, Dolber PC, Heidlage JF. Influence of the
passive anisotropic properties on directional differences in
propagation following modification of the sodium conductance on human
atrial muscle: a model of reentry based on anisotropic discontinuous
propagation. Circ Res. 1988;62:811–832.
31.
Allessie MA, Bonke FIM, Schopman FJG. Circus movement
in rabbit atrial muscle as a mechanism of tachycardia, II:
the role of nonuniform recovery of excitability in the occurrence of
unidirectional block, as studied with multiple microelectrodes.
Circ Res. 1976;39:168–177.
32. Sato S, Yamauchi S, Schuessler RB, et al. The effect of augmented atrial hypothermia on atrial refractory period, conduction, and atrial flutter/fibrillation in the canine heart. J Thorac Cardiovasc Surg. 1992;104:297–306.[Abstract]
33. Han J, Millet D, Chizzonitti B, et al. Temporal dispersion of recovery of excitability in atrium and ventricle as a function of heart rate. Am Heart J. 1966;71:481–487.[Medline] [Order article via Infotrieve]
34.
Papageorgiou P, Monahan K, Boyle NG, et al.
Site-dependent intra-atrial conduction delay: relationship to
initiation of atrial fibrillation. Circulation. 1996;94:384–389.
35.
Papageorgiou P, Anselme F, Kirchhof CJHJ, et al.
Coronary sinus pacing prevents induction of atrial
fibrillation. Circulation. 1997;96:1893–1898.
36.
Yu WC, Chen SA, Tai CT, et al. Effects of different
atrial pacing modes on atrial electrophysiology.
Circulation. 1997;96:2992–2996.
37. Prakash A, Delfaut P, Ryszard BK, et al. Regional right and left atrial activation patterns during single- and dual-site atrial pacing in patients with atrial fibrillation. Am J Cardiol. 1998;82:1197–1204.[Medline] [Order article via Infotrieve]
38. Tanigawa M, Fukatani M, Konoe A, et al. Prolonged and fractionated right atrial electrograms during sinus rhythm in patients with paroxysmal atrial fibrillation and sick sinus node syndrome. J Am Coll Cardiol. 1991;17:403–408.[Abstract]
39. Mauldin PD, Weintraub WS, Becker ER. Predicting hospital costs for first time coronary artery bypass grafting from preoperative and postoperative variables. Am J Cardiol. 1994;74:772–775.[Medline] [Order article via Infotrieve]
40. Taylor GJ, Mikell FL, Moses W, et al. Determinants of hospital charges for coronary artery bypass surgery: the economic consequences of postoperative complications. Am J Cardiol. 1990;65:309–313.[Medline] [Order article via Infotrieve]
41.
Hogue CW, Murphy SF, Schechtman KB, et al. Risk factors
for early or delayed stroke after cardiac surgery.
Circulation. 1999;100:642–647.
This article has been cited by other articles:
 |
|
 |
|
  N. Echahidi, P. Pibarot, G. O'Hara, and P. Mathieu Mechanisms, Prevention, and Treatment of Atrial Fibrillation After Cardiac Surgery J. Am. Coll. Cardiol., February 26, 2008; 51(8): 793 - 801. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Writing Committee Members, V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: full text: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society Europace, September 1, 2006; 8(9): 651 - 745. [Full Text] [PDF]
|
|
|
|
|
|
V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society J. Am. Coll. Cardiol., August 15, 2006; 48(4): e149 - e246. [Full Text] [PDF]
|
|
|
|
 |
|
 V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society Circulation, August 15, 2006; 114(7): e257 - e354. [Full Text] [PDF]
|
|
|
|
 |
|
 C. W. Hogue Jr., L. L. Creswell, D. D. Gutterman, and L. A. Fleisher Epidemiology, Mechanisms, and Risks: American College of Chest Physicians Guidelines for the Prevention and Management of Postoperative Atrial Fibrillation After Cardiac Surgery Chest, August 1, 2005; 128(2_suppl): 9S - 16S. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. H. Maisel and A. E. Epstein The Role of Cardiac Pacing: American College of Chest Physicians Guidelines for the Prevention and Management of Postoperative Atrial Fibrillation After Cardiac Surgery Chest, August 1, 2005; 128(2_suppl): 36S - 38S. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. McKeown and A. E. Epstein Future Directions: American College of Chest Physicians Guidelines for the Prevention and Management of Postoperative Atrial Fibrillation After Cardiac Surgery Chest, August 1, 2005; 128(2_suppl): 61S - 64S. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Doi, M. Takagi, I. Toda, M. Yoshiyama, K. Takeuchi, and J. Yoshikawa Acute Hemodynamic Benefits of Bi-Atrial Atrioventricular Sequential Pacing With the Optimal Atrioventricular Delay J. Am. Coll. Cardiol., July 19, 2005; 46(2): 320 - 326. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. Kailasam, C. A. Palin, and C. W. Hogue Jr Atrial Fibrillation After Cardiac Surgery: An Evidence-Based Approach to Prevention Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2005; 9(1): 77 - 85. [Abstract] [PDF]
|
|
|
|
 |
|
 A. Ronald and J. Dunning Bi-atrial pacing significantly reduces the Incidence of atrial fibrillation post cardiac surgery Interactive CardioVascular and Thoracic Surgery, February 1, 2005; 4(1): 33 - 40. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Hakala, A. J.M. Valtola, A. K. Turpeinen, A. E. Hedman, R. E.U. Vuorenniemi, J. M. Karjalainen, I. S. Vajanto, J. Kouri, P. A. Jaakkola, and J. E.K. Hartikainen Right atrial overdrive pacing does not prevent atrial fibrillation after coronary artery bypass surgery Europace, January 1, 2005; 7(2): 170 - 174. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M Takagi, A Doi, N Shirai, K Hirata, Y Takemoto, K Takeuchi, and J Yoshikawa Acute improvement of atrial mechanical stunning after electrical cardioversion of persistent atrial fibrillation: comparison between biatrial and single atrial pacing Heart, January 1, 2005; 91(1): 58 - 63. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. E. Singer, G. W. Albers, J. E. Dalen, A. S. Go, J. L. Halperin, and W. J. Manning Antithrombotic Therapy in Atrial Fibrillation: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest, September 1, 2004; 126(3_suppl): 429S - 456S. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Lahtinen, F. Biancari, E. Salmela, M. Mosorin, J. Satta, P. Rainio, J. Rimpilainen, M. Lepojarvi, and T. Juvonen Postoperative atrial fibrillation is a major cause of stroke after on-pump coronary artery bypass surgery Ann. Thorac. Surg., April 1, 2004; 77(4): 1241 - 1244. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A Doi, M Takagi, I Toda, M Yoshiyama, K Takeuchi, and J Yoshikawa Acute haemodynamic benefits of biatrial atrioventricular sequential pacing: comparison with single atrial atrioventricular sequential pacing Heart, April 1, 2004; 90(4): 411 - 418. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R A Archbold and R J Schilling Atrial pacing for the prevention of atrial fibrillation after coronary artery bypass graft surgery: a review of the literature Heart, February 1, 2004; 90(2): 129 - 133. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Debrunner, B. Naegeli, M. Genoni, M. Turina, and O. Bertel Prevention of atrial fibrillation after cardiac valvular surgery by epicardial, biatrial synchronous pacing Eur. J. Cardiothorac. Surg., January 1, 2004; 25(1): 16 - 20. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J.F. M. Bechtel, J. F. Christiansen, H.-H. Sievers, and C. Bartels Low-energy cardioversion versus medical treatment for the termination of atrial fibrillation after CABG Ann. Thorac. Surg., April 1, 2003; 75(4): 1185 - 1188. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C.-P. Lau Pacing for atrial fibrillation Heart, January 1, 2003; 89(1): 106 - 112. [Full Text] [PDF]
|
|
|
|
|
|
A D Taylor, J G Groen, S L Thorn, C T Lewis, and A J Marshall New insights into onset mechanisms of atrial fibrillation and flutter after coronary artery bypass graft surgery Heart, December 1, 2002; 88(5): 499 - 504. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Saksena, A. Prakash, P. Ziegler, J. D. Hummel, P. Friedman, V. J. Plumb, D. G. Wyse, E. Johnson, S. Fitts, R. Mehra, et al. Improved suppression of recurrent atrial fibrillation with dual-site right atrial pacing and antiarrhythmic drug therapy J. Am. Coll. Cardiol., September 18, 2002; 40(6): 1140 - 1150. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. Crystal, S. J. Connolly, K. Sleik, T. J. Ginger, and S. Yusuf Interventions on Prevention of Postoperative Atrial Fibrillation in Patients Undergoing Heart Surgery: A Meta-Analysis Circulation, July 2, 2002; 106(1): 75 - 80. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. M. Cooper, M. S. Katcher, and M. V. Orlov Implantable Devices for the Treatment of Atrial Fibrillation N. Engl. J. Med., June 27, 2002; 346(26): 2062 - 2068. [Full Text] [PDF]
|
|
|
|
 |
|
 A. Shimizu and O. A. Centurion Electrophysiological properties of the human atrium in atrial fibrillation Cardiovasc Res, May 1, 2002; 54(2): 302 - 314. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Goette, G. Juenemann, B. Peters, H. U. Klein, A. Roessner, C. Huth, and C. Rocken Determinants and consequences of atrial fibrosis in patients undergoing open heart surgery Cardiovasc Res, May 1, 2002; 54(2): 390 - 396. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology Eur. Heart J., October 2, 2001; 22(20): 1852 - 1923. [PDF]
|
|
|
|
|
|
V. Fuster, L. E. Ryden, R. W. Asinger, D. S. Cannom, H. J. Crijns, R. L. Frye, J. L. Halperin, G. N. Kay, W. W. Klein, S. Levy, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology J. Am. Coll. Cardiol., October 1, 2001; 38(4): 1266 - 1266. [Full Text] [PDF]
|
|
|
|
|
|
P. E. Dilaveris, J. E. Gialafos, K. Fan, C. S.W. Chiu, J. W.T. Lee, G.-W. He, D. Cheung, M. P. Sun, K. L. Lee, and C. P. Lau P-Wave Duration and Dispersion Analysis: Methodological Considerations Response Circulation, May 29, 2001; 103 (21): e111 - e111. [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||