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...................... proposed, specifically aimed at reducing atrial tachyarrhythmias, and its efficacy in reducing the progression to permanent AF was validated in an RCT.162,164

In this trial,164 the primary composite outcome at 2 years (death, cardiovascular hospitalizations, or permanent AF) was significantly reduced in patients with a device combining ATP and algorithms for minimizing RV pacing [36% relative risk reduction compared with conventional DDD(R)]. The positive effect on the primary endpoint was due to a lower rate of progression to permanent AF. A post-hoc analysis indicated that this form of atrial ATP was an independent predictor of permanent or persistent AF reduction.162,164,165 In CHD, where re-entrant atrial arrhythmias are very common, use of DDD(R) pacemakers with atrial ATP may be considered (see section 8 on pacing in CHD).

SND

Persistent or paroxysmal

DDD(R)a

Optimal pacing mode in sinus node dysfunction and atrio-ventricular block

Y N

Sinus rhythm: DDD + AVM AF: VVI + rate hysteresis

DDDR + AVM

Single chamber AAI(R)a VVI(R)a

Any reason to avoid 2 leadsb

Significant comorbidity

Default option DDD + AVM DDD(R)a

+ AVM

Single chamber

AAIR Single chamber

AAI

VVIR VVI VVI + rate

hysteresis DDD VVIR

VVI(R)a VDD

VVI VDD

VVI + rate hysteresis

Chronotropic incompetence? Persistent or

paroxysmal

no SND AF

AV block SND

Paroxysmal Persistent Persistent Paroxysmal

Figure 5 Optimal pacing mode and algorithm selection in sinus node dysfunction and atrioventricular block. AF = atrial fibrillation; AV = atrioventricular; AVM = atrioventricular management [i.e. AV delay programming (avoiding values >230 ms) or specific algorithms to avoid/reduce unnecessary ventricular pacing]; CRT = cardiac resynchronization therapy; SND = sinus node dysfunction. a(R) indicates that the programming of such a pacing mode is preferred only in the case of chronotropic incompetence. bReasons to avoid two leads include young age and limited venous access. Note: in patients who are candidates for a VVI/VDD pacemaker, a leadless pacemaker may be considered (see section 7). For combined CRT indications, see section 6. Adapted from Brignole et al.62 Downloaded from academic.oup.com/eurheartj/article/42/35/3427/6358547 by guest on 07 October 2026