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Lookup NU author(s): Professor Bob Anderson
This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0).
© The Author(s) 2026. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Aims: Unlike ventricular electrical disease, the impact of similar atrial disease on cardiac function has received insufficient importance. We aimed to examine data on atrial anatomy, electrical disease, and pacing to ameliorate abnormalities, offering pointers towards future practice. Methods and results: We used PubMed to explore atrial anatomy, activation, and pacing aiming to improve function. From inception of pacing, causes of deterioration in ventricular systolic function went unrecognized. Their eventual recognition led to fresh pacing strategies, termed conduction system pacing, which have yielded improved and preserved long-term ventricular function: now standard practice. Study of atrial anatomy/conduction implies that similar approaches may improve atrial function and also reduce incidence of atrial fibrillation. Impact of atrial electrical disease on diastolic and subsequent ventricular systolic function has been ignored, despite data showing how pacing alternative atrial sites can abbreviate atrial activation and improve ventricular filling: methods that have not been widely adopted. Comprehension of atrial anatomy/conduction underpins abandonment of right atrial appendage pacing paralleling the move away from right ventricular apical pacing on similar principles. Conclusion: When treating heart failure, atrial resynchronization should be considered along with ventricular resynchronization. Crucially, convenient pacing sites have been outmoded by active-fixation leads that can be placed at stimulation sites approximating normal conduction, including the atria; achievement hinges on understanding atrial anatomy and activation. Atrial resynchronization may significantly improve cardiac function where dyssynchrony relates to atrial disease/conduction delay, but more evidence of benefits must be collected. As resynchronization therapy moves forward, there should be parallel focus on evaluating coordination of atrial activation and timing with respect to the ventricles.
Author(s): Prakash A, Sutton R, Sanchez-Quintana D, Anderson RH
Publication type: Article
Publication status: Published
Journal: Europace
Year: 2026
Volume: 28
Issue: 6
Online publication date: 05/06/2026
Acceptance date: 17/02/2026
Date deposited: 22/06/2026
ISSN (print): 1099-5129
ISSN (electronic): 1532-2092
Publisher: Oxford University Press
URL: https://doi.org/10.1093/europace/euag088
DOI: 10.1093/europace/euag088
Data Access Statement: Data is available upon reasonable request.
PubMed id: 42246754
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