The PhysioVP-AF study, a randomized controlled trial to assess the clinical benefit of physiological ventricular pacing vs. managed ventricular pacing for persistent atrial fibrillation prevention in patients with prolonged atrioventricular conduction: design and rationale

• Published in: Europace (London, England) Vol. 25; no. 5
• Main Authors: Pastore, Gianni, Bertini, Matteo, Bonanno, Carlo, Coluccia, Giovanni, Dell'Era, Gabriele, De Mattia, Luca, Grieco, Domenico, Katsouras, Grigorius, Maines, Massimiliano, Marcantoni, Lina, Marinaccio, Leonardo, Paglino, Gabriele, Palmisano, Pietro, Ziacchi, Matteo, Zoppo, Franco, Noventa, Franco
• Format: Journal Article
• Language: English
• Published: US Oxford University Press 19.05.2023
• Subjects: Atrial Fibrillation - complications; Atrial Fibrillation - diagnosis; Atrial Fibrillation - therapy; Atrioventricular Block; Cardiac Pacing, Artificial - adverse effects; Cardiac Pacing, Artificial - methods; Humans; Pacemaker, Artificial; Prospective Studies; Sick Sinus Syndrome - complications; Sick Sinus Syndrome - diagnosis; Sick Sinus Syndrome - therapy; Single-Blind Method; Trial Design; Ventricular pacing avoidance; His bundle pacing; Managed ventricular pacing; Left bundle branch area pacing; Atrial fibrillation
• ISSN: 1099-5129; 1532-2092
• DOI: 10.1093/europace/euad082

Abstract Aims In patients with prolonged atrioventricular (AV) conduction and pacemaker (PM) indication due to sinus node disease (SND) or intermittent AV-block who do not need continuous ventricular pacing (VP), it may be difficult to determine which strategy to adopt. Currently, the standard of care is to minimize unnecessary VP by specific VP avoidance (VPA) algorithms. The superiority of this strategy over standard DDD or DDD rate-responsive (DDD/DDDR) in improving clinical outcomes is controversial, probably owing to the prolongation of the atrialventricular conduction (PR interval) caused by the algorithms. Conduction system pacing (CSP) may offer the most physiological-VP approach, providing appropriate AV conduction and preventing pacing-induced dyssynchrony. Methods and results PhysioVP-AF is a prospective, controlled, randomized, single-blind trial designed to determine whether atrial-synchronized conduction system pacing (DDD-CSP) is superior to standard DDD-VPA pacing in terms of 3-year reduction of persistent-AF occurrence. Cardiovascular hospitalization, quality-of-life, and safety will be evaluated. Patients with indication for permanent DDD pacing for SND or intermittent AV-block and prolonged AV conduction (PR interval > 180 ms) will be randomized (1:1 ratio) to DDD-VPA (VPA-algorithms ON, septal/apex position) or to DDD-CSP (His bundle or left bundle branch area pacing, AV-delay setting to control PR interval, VPA-algorithms OFF). Approximately 400 patients will be randomized in 24 months in 13 Italian centres. Conclusion The PhysioVP-AF study will provide an essential contribution to patient management with prolonged AV conduction and PM indication for sinus nodal disease or paroxysmal 2nd-degree AV-block by determining whether CSP combined with a controlled PR interval is superior to standard management that minimizes unnecessary VP in terms of reducing clinical outcomes. Graphical Abstract Graphical Abstract