Low atrial septal pacing: advancing precision in atrial fibrillation prevention

Dear Editor,

I read with great interest the recent article by Wu et al on the short-term effect of low atrial septum (LAS) pacing in patients with sinus node dysfunction (SND). The study provides valuable prospective evidence that LAS pacing reduces the incidence of new-onset atrial fibrillation (AF) compared with the conventional right atrial appendage (RAA) approach, primarily through shortened postoperative P-wave duration and lower cumulative ventricular pacing percentages^[1].

The findings are significant in the setting that postoperative AF after pacemaker placement has been shown to be an independent risk factor for adverse cardiovascular outcomes^[1,2]. Nevertheless, some points are worth thinking over. First, LAS pacing was superior in preventing AF, but perhaps due to this improved outcome, the operative duration was significantly longer than with LBV pacing. This increases concerns about the complexity of the procedure, the expertise of the operators, and cumulative radiation exposure. Such wider use would necessitate simpler methods and generalized training to reduce those obstacles^[1,3].

Second, the design (single-center approach) and a rather narrow follow-up (1 year) restrict the scope of generalizing the findings. Precedent meta-analyses and multicentric trials have been contradictory as to the efficacy of septal pacing. Indeed, as shown by a study conducted by Shali et al, interatrial septal pacing did not demonstrate any consistent reduction in sustained AF in a wide range of populations^[4], though a study conducted by Verlato et al showed that it could be of benefit in highly selected patients with atrial conduction abnormalities^[5]. These differences indicate that LAS pacing does not universally confer any benefit but is especially splendid in patients with conduction delay or dilated atria^[5,6].

Moreover, the fact that prolonged postoperative P-wave duration is associated with the incidence of AF also supports the notion that electrophysiological parameters can be used as risk markers^[1,6]. In the future, P-wave length, dispersion measures, and atrial structural factors should be incorporated into customized selection approaches to sites. The precision pacing strategy has the potential to streamline the results and customize treatment as opposed to a one-size-fits-all approach.

In conclusion, Wu et al make a valuable contribution to the existing literature supporting the argument for physiological pacing strategies^[1]. However, to confirm that LAS pacing is superior to the traditional one, large-scale multicentric randomized trials with longer-term follow-up are needed to prove their efficiency and identify a patient selection criterion. Until helpful reports are available, LAS additional challenges should be weighed against possible long-term advantages over RAA pacing by clinicians.

Declaration of AI use

This Letter to the Editor was prepared in accordance with the TITAN Guidelines 2025 on the declaration and use of artificial intelligence in scholarly communication^[7].

Ethical Approval

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Consent

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Source of funding

No funding was received for this study.

Author contributions

M.H. contributed to methodology, writing – original draft, and data curation. A.H. provided supervision. A.A.K., J.I., and B.S. contributed to writing – review and editing.

Conflicts of interest disclosure

None declared.

Guarantor

Asraf Hussain.

Research Registration Unique Identifying Number (UIN)

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Peer and provenance statement

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Data availability statement

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