Comparative Effectiveness of Atrial Pacing Sites for Postoperative Atrial Fibrillation

Background: Postoperative atrial fibrillation (POAF) remains the most common arrhythmic complication following cardiac surgery and is associated with increased morbidity, prolonged hospitalization, and higher healthcare costs. Multiple atrial pacing strategies have been evaluated for POAF prevention, but the optimal pacing site remains uncertain. Hypothesis: Atrial pacing strategies that promote more synchronous atrial activation reduce the incidence of POAF compared with conventional right atrial pacing (RAP) or no pacing. Methods: We performed a frequentist random-effects network meta-analysis of randomized clinical trials (RCTs) evaluating temporary atrial pacing for POAF prevention after cardiac surgery using the netmeta package in R (version 4.3.3). Interventions included biatrial pacing (BAP), Bachmann bundle pacing (BBP), left atrial pacing (LAP), RAP, and no pacing (control). The primary outcome was POAF. Treatment effects were estimated using risk ratios (RRs) with 95% confidence intervals (CIs), and interventions were ranked using P-scores. Results: Ten RCTs comprising 1,198 patients were included. Participants had a mean age ranging from 58 to 67 years, with women representing 25% of study population. Most patients underwent CABG, and temporary atrial pacing was maintained for 24 hours to 5 days postoperatively. Compared with no pacing, BAP significantly reduced POAF RR 0.45 (95% CI 0.29-0.70). BBP 0.60 (0.28-1.29), LAP 0.73 (0.42-1.24), and RAP 0.73 (0.49-1.10) showed nonsignificant reductions. Treatment ranking identified BAP as the most effective strategy (P-score 0.916), followed by BBP (0.632), LAP (0.445), RAP (0.437), and control (0.070). Network geometry demonstrated robust connectivity, with most comparisons supported by direct evidence and indirect evidence contributing primarily to BBP-related estimates. Overall network heterogeneity was moderate (I 2 = 48.3%). Conclusions: Biatrial pacing was the highest-ranked and only pacing strategy associated with a statistically significant reduction in POAF following cardiac surgery. Bachmann bundle pacing demonstrated favorable ranking but remains supported by limited evidence. Additional head-to-head trials comparing BAP and BBP are warranted to define the optimal atrial pacing strategy for POAF prevention.