Bachmann’s bundle vs conventional right atrial pacing: clinical and arrhythmic outcomes

Background Conventional right atrial (RA) pacing is associated with P-wave prolongation, interatrial conduction delay, and left-sided atrioventricular dyssynchrony, potentially leading to electromechanical dysfunction and increased arrhythmogenesis. Bachmann’s bundle (BB) pacing preserves physiological conduction and has been linked to reduced atrial fibrillation (AF) burden and favourable haemodynamics. Nevertheless, comparative real-world data remains limited. Purpose To compare procedural parameters, atrial thresholds, complication rates, and atrial arrhythmia outcomes between BB and RA pacing. Methods We retrospectively analysed consecutive patients undergoing atrial lead implantation for sinus node dysfunction at a tertiary center between October 2022 and December 2025. Procedural parameters, electrical thresholds, procedure-related complications, and atrial arrhythmia occurrence were evaluated. Results A total of 220 patients were included (mean age 75 years; 45% men), with 175 in the RA and 45 in the BB cohort. Mean follow-up was 160 ± 119 days (BB) and 838 ± 431 days (RA). BB pacing was associated with longer procedure time (81.0 ± 25.1 vs 66.9 ± 30.2 minutes, p = 0.023) and fluoroscopy time (12.3 ± 6.7 vs 5.8 ± 3.8 minutes, p < 0.001). At discharge, atrial capture thresholds were similar (0.56 vs 0.54 V, p = 0.82), while atrial sensing was higher in the RA cohort (3.56 vs 2.56 mV, p = 0.006). During follow-up, atrial undersensing (<0.5 mV) and rise in capture threshold (>1.5 V) were infrequent and comparable between RA and BB groups (6.7% vs 8.1%, p = 0.75; and 4.7% vs 8.9%, p = 0.27). The percentage of atrial pacing was similar (51.9% ± 34.6% RA vs 58.5% ± 34.7% BB), with high pacing burden (>20%) in both groups (74.0% RA vs 79.5% BB). Procedure-related complications were only observed in RA cohort, including three macro-dislodgements and two lead dislodgements. The incidence of atrial arrhythmias was significantly higher in the RA cohort compared with the BB cohort (59.8% vs 33.3%, p = 0.02). Conclusion Bachmann’s bundle pacing is a safe and feasible atrial pacing strategy, demonstrating comparable electrical performance and complication rates to right atrial pacing. Despite differences in follow-up duration between groups, BB pacing was associated with a lower incidence of atrial arrhythmias. These findings suggest a potential benefit of BB pacing in atrial rhythm preservation, warranting further evaluation in studies with balanced follow-up and time-adjusted analyses.