Atrial antitachycardia pacing and managed ventricular pacing in bradycardia patients with paroxysmal or persistent atrial tachyarrhythmias: the MINERVA randomized multicentre international trial

Giuseppe Boriani, Raymond Tukkie, Antonis S Manolis, Lluis Mont, Helmut Pürerfellner, Massimo Santini, Giuseppe Inama, Paolo Serra, João de Sousa, Giovanni Luca Botto, Lorenza Mangoni, Andrea Grammatico, Luigi Padeletti, MINERVA Investigators, Giuseppe Boriani, Raymond Tukkie, Antonis S Manolis, Lluis Mont, Helmut Pürerfellner, Massimo Santini, Giuseppe Inama, Paolo Serra, João de Sousa, Giovanni Luca Botto, Lorenza Mangoni, Andrea Grammatico, Luigi Padeletti, MINERVA Investigators

Abstract

Aims: Atrial fibrillation (AF) is a common comorbidity in bradycardia patients. Advanced pacemakers feature atrial preventive pacing and atrial antitachycardia pacing (DDDRP) and managed ventricular pacing (MVP), which minimizes unnecessary right ventricular pacing. We evaluated whether DDDRP and MVP might reduce mortality, morbidity, or progression to permanent AF when compared with standard dual-chamber pacing (Control DDDR).

Methods and results: In a randomized, parallel, single-blind, multi-centre trial we enrolled 1300 patients with bradycardia and previous atrial tachyarrhythmias, in whom a DDDRP pacemaker had recently been implanted. History of permanent AF and third-degree atrioventricular block were exclusion criteria. After a 1-month run-in period, 1166 eligible patients, aged 74 ± 9 years, 50% females, were randomized to Control DDDR, DDDRP + MVP, or MVP. Analysis was intention-to-treat. The primary outcome, i.e. the 2-year incidence of a combined endpoint composed of death, cardiovascular hospitalizations, or permanent AF, occurred in 102/385 (26.5%) Control DDDR patients, in 76/383 (19.8%) DDDRP + MVP patients [hazard ratio (HR) = 0.74, 95% confidence interval 0.55-0.99, P = 0.04 vs. Control DDDR] and in 85/398 (21.4%) MVP patients (HR = 0.89, 95% confidence interval 0.77-1.03, P = 0.125 vs. Control DDDR). When compared with Control DDDR, DDDRP + MVP reduced the risk for AF longer than 1 day (HR = 0.66, 95% CI 0.52-0.85, P < 0.001), AF longer than 7 days (HR = 0.52, 95% CI 0.36-0.73, P < 0.001), and permanent AF (HR = 0.39, 95% CI 0.21-0.75, P = 0.004).

Conclusion: In patients with bradycardia and atrial tachyarrhythmias, DDDRP + MVP is superior to standard dual-chamber pacing. The primary endpoint was significantly lowered through the reduction of the progression of atrial tachyarrhythmias to permanent AF.

Clinicaltrialsgov identifier: NCT00262119.

Keywords: Atrial antitachycardia pacing; Atrial fibrillation; Bradycardia; Managed ventricular pacing; Pacemaker.

© The Author 2014. Published by Oxford University Press on behalf of the European Society of Cardiology.

Figures

Figure 1
Figure 1
Study flow chart. PIC, patient informed consent; MVP, managed ventricular pacing; aATP, atrial antitachycardia pacing; DDDRP, atrial preventive pacing and atrial antitachycardia pacing.
Figure 2
Figure 2
Risk of primary composite endpoint (death, cardiovascular hospitalizations, or permanent AF). MVP, managed ventricular pacing; DDDRP, atrial preventive pacing and atrial antitachycardia pacing.
Figure 3
Figure 3
Risk of AF recurrence longer than 1 day (A), AF recurrence longer than 7 days (B), and permanent AF (C). AF, atrial fibrillation; MVP, managed ventricular pacing; DDDRP, atrial preventive pacing and atrial antitachycardia pacing.

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