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Santos H, Figueiredo M, Paula SB, Santos M, Osório P, Portugal G, Valente B, Lousinha A, Silva Cunha P, Oliveira M. Apical or Septal Right Ventricular Location in Patients Receiving Defibrillation Leads: A Systematic Review and Meta-Analysis. Cardiol Rev 2023; Publish Ahead of Print:00045415-990000000-00080. [PMID: 36883833 DOI: 10.1097/crd.0000000000000527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
This study reviews the published data comparing the efficacy and safety of apical and septal right ventricle defibrillator lead positioning at 1-year follow-up. Systemic research on Medline (PubMed), ClinicalTrials.gov, and Embase was performed using the keywords "septal defibrillation," "apical defibrillation," "site defibrillation," and "defibrillation lead placement," including implantable cardioverter-defibrillator and cardiac resynchronization therapy devices. Comparisons between apical and septal position were performed regarding R-wave amplitude, pacing threshold at a pulse width of 0.5 ms, pacing and shock lead impedance, suboptimal lead performance, left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter, readmissions due to heart failure and mortality rates. A total of 5 studies comprising 1438 patients were included in the analysis. Mean age was 64.5 years, 76.9% were male, with a median LVEF of 27.8%, ischemic etiology in 51.1%, and a mean follow-up period of 26.5 months. The apical lead placement was performed in 743 patients and septal lead placement in 690 patients. Comparing the 2 placement sites, no significant differences were found regarding R-wave amplitude, lead impedance, suboptimal lead performance, LVEF, left ventricular end-diastolic diameter, and mortality rate at 1-year follow-up. Pacing threshold values favored septal defibrillator lead placement (P = 0.003), as well as shock impedance (P = 0.009) and readmissions due to heart failure (P = 0.02). Among patients receiving a defibrillator lead, only pacing threshold, shock lead impedance, and readmission due to heart failure showed results favoring septal lead placement. Therefore, generally, the right ventricle lead placement does not appear to be of major importance.
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Affiliation(s)
- Helder Santos
- From the Department of Cardiology, Centro Hospitalar de Lisboa Central - Hospital Santa Marta, Lisbon, Portugal
- Department of Cardiology, Centro Hospitalar Barreiro- Montijo, Barreiro, Portugal
| | - Margarida Figueiredo
- Department of Cardiology, Centro Hospitalar Barreiro- Montijo, Barreiro, Portugal
| | - Sofia B Paula
- Department of Cardiology, Centro Hospitalar Barreiro- Montijo, Barreiro, Portugal
| | - Mariana Santos
- Department of Cardiology, Centro Hospitalar Barreiro- Montijo, Barreiro, Portugal
| | - Paulo Osório
- From the Department of Cardiology, Centro Hospitalar de Lisboa Central - Hospital Santa Marta, Lisbon, Portugal
| | - Guilherme Portugal
- From the Department of Cardiology, Centro Hospitalar de Lisboa Central - Hospital Santa Marta, Lisbon, Portugal
| | - Bruno Valente
- From the Department of Cardiology, Centro Hospitalar de Lisboa Central - Hospital Santa Marta, Lisbon, Portugal
| | - Ana Lousinha
- From the Department of Cardiology, Centro Hospitalar de Lisboa Central - Hospital Santa Marta, Lisbon, Portugal
| | - Pedro Silva Cunha
- From the Department of Cardiology, Centro Hospitalar de Lisboa Central - Hospital Santa Marta, Lisbon, Portugal
| | - Mário Oliveira
- From the Department of Cardiology, Centro Hospitalar de Lisboa Central - Hospital Santa Marta, Lisbon, Portugal
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Byeon K, Kim HR, Park SJ, Park YJ, Choi JH, Kim JY, Park KM, On YK, Kim JS. Initial Experience with Left Bundle Branch Area Pacing with Conventional Stylet-Driven Extendable Screw-In Leads and New Pre-Shaped Delivery Sheaths. J Clin Med 2022; 11:jcm11092483. [PMID: 35566608 PMCID: PMC9104478 DOI: 10.3390/jcm11092483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/21/2022] [Accepted: 04/26/2022] [Indexed: 12/04/2022] Open
Abstract
Until recently, left bundle branch area pacing (LBBAp) has mostly been performed using lumen-less fixed screw leads. There are limited data on LBBAp with conventional style-driven extendable screw-in (SDES) leads, particularly data performed by operators with no previous experience with LBBAp procedures. In total, 42 consecutive patients undergoing LBBAp using SDES leads and newly designed delivery sheaths (LBBAp group) were compared with those treated with conventional right ventricular pacing (RVp) for atrioventricular block (RVp group, n = 84) using propensity score matching (1:2 ratio). The LBBAp was successful in 83% (35/42) of patients, with satisfactory pacing thresholds (0.8 ± 0.2 V at 0.4 ms). In the LBBAp group, the mean paced-QRS duration obtained during RV apical pacing (173 ± 18 ms) was significantly reduced by LBBAp (116 ± 14 ms, p < 0.001). Compared with the RVp group, the LBBAp group showed more physiological pacing, suggested by a much narrower paced-QRS duration (116 ± 14 vs. 151 ± 21 ms, p < 0.001). The pacing threshold was comparable in both groups. The LBBAp group revealed stable pacing thresholds for 6.8 ± 4.8 months post-implant and no serious complications including lead dislodgement or septal perforation. The novel approach of LBBAp using SDES leads and the new dedicated pre-shaped delivery sheaths was effectively and safely performed, even by inexperienced operators with LBBAp procedures.
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Affiliation(s)
- Kyeongmin Byeon
- Division of Cardiology, Department of Internal Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong 14353, Korea;
| | - Hye Ree Kim
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju 52727, Korea;
| | - Seung-Jung Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.-H.C.); (J.Y.K.); (K.-M.P.); (Y.K.O.); (J.S.K.)
- Correspondence: ; Tel.: +82-2-3410-7145; Fax: +82-2-3410-3849
| | - Young Jun Park
- Division of Cardiology, Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju 26426, Korea;
| | - Ji-Hoon Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.-H.C.); (J.Y.K.); (K.-M.P.); (Y.K.O.); (J.S.K.)
| | - Ju Youn Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.-H.C.); (J.Y.K.); (K.-M.P.); (Y.K.O.); (J.S.K.)
| | - Kyoung-Min Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.-H.C.); (J.Y.K.); (K.-M.P.); (Y.K.O.); (J.S.K.)
| | - Young Keun On
- Division of Cardiology, Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.-H.C.); (J.Y.K.); (K.-M.P.); (Y.K.O.); (J.S.K.)
| | - June Soo Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.-H.C.); (J.Y.K.); (K.-M.P.); (Y.K.O.); (J.S.K.)
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Sogade OO, Aben RN, Eyituoyo H, Arinze NC, Sogade FO. Feasibility study for echocardiography-guided lead insertion for permanent cardiac implantable electronic devices. Pacing Clin Electrophysiol 2021; 44:1365-1370. [PMID: 34121208 PMCID: PMC8457189 DOI: 10.1111/pace.14296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 04/26/2021] [Accepted: 06/02/2021] [Indexed: 11/29/2022]
Abstract
Background Permanent cardiac implantable electronic devices (CIEDs) are traditionally implanted with the assistance of fluoroscopy. While clinically effective, this technique exposes both patients and providers to radiation which is associated with adverse health effects and represents an occupational hazard. In this study, we investigate the safety and feasibility of permanent CIED placement under the guidance of transthoracic echocardiography (TTE). There is also increasing interest in use of non‐fluoroscopic options for noninvasive cardiac electrophysiologic procedures. Methods Fifteen patients consecutively consented for initial implant of CIEDs, specifically dual chamber pacemakers (DCPM) and dual chamber implantable cardioverter defibrillators (DCICDs). Patients were excluded if they had previous implants, abandoned leads, or anatomic anomalies including congenital and known persistent left superior vena cava (PLSVC). We used TTE to guide and implant atrial and ventricular leads. Results Eleven patients received DCPMs and four patients received DCICDs. The procedure duration was 49.3 min for DCICD and 52.3 min for DCPM, p = .807. The average number of right atrial lead attempts was 1.6 for DCPMs and 1.8 for DCICD, p = .860. The average number of right ventricular lead attempts for DCPMs was 2.2 and 1.0 attempt for DCICDs, p = .044. There were no complications at 90‐day follow‐up. Conclusion We demonstrate the feasibility of TTE‐guided DCPM/DCICD implantation without use of fluoroscopy. We present this method as a safe alternative for permanent CIED placement that may reduce risk of radiation exposure and cost while maintaining safety and efficacy. No operators wore lead aprons during the procedure.
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Affiliation(s)
- Omolade O Sogade
- Washington University School of Medicine, St. Louis, Missouri, USA
| | - Rieta N Aben
- Georgia Arrhythmia Consultants, Macon, Georgia, USA.,Department of Medicine, Mercer University School of Medicine, Macon, Georgia, USA
| | - Harry Eyituoyo
- Georgia Arrhythmia Consultants, Macon, Georgia, USA.,Department of Medicine, Mercer University School of Medicine, Macon, Georgia, USA
| | - Nkechi C Arinze
- Georgia Arrhythmia Consultants, Macon, Georgia, USA.,Department of Medicine, Mercer University School of Medicine, Macon, Georgia, USA
| | - Felix O Sogade
- Georgia Arrhythmia Consultants, Macon, Georgia, USA.,Department of Medicine, Mercer University School of Medicine, Macon, Georgia, USA
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Xin MK, Gao P, Zhang SY. Effects of long-term right ventricular apex pacing on left ventricular dyssynchrony, morphology and systolic function. Int J Cardiol 2021; 331:91-99. [PMID: 33529668 DOI: 10.1016/j.ijcard.2021.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/23/2020] [Accepted: 01/07/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Right ventricular apex (RVA) is still the most common implanted site in the world. There are a large number of RVA pacing population who have been carrying dual-chamber permanent pacemaker (PPM) over decades. Comparison of left ventricular dyssynchrony, morphology and systolic function between RVA pacing population and healthy population is unknown. METHOD This case-control study enrolled 61 patients suffered from complete atrioventricular block (III°AVB) for replacement of dual-chamber PPM. Then, 61 healthy controls matched with PPM patients in gender, age, follow-up duration and complications were included. The lead impedance, pacing threshold and sensing were compared between at implantation and long-term follow-up. Left ventricular (LV) dyssynchrony, morphology and systolic function were compared between RVA pacing population (RVA group) and healthy population (healthy group) at implantation (baseline) and follow-up. And clarify the predictors of LV systolic function in RVA group at follow-up. RESULTS After 112.44 ± 34.94 months of follow-up, comparing with parameters at implantation, atrial lead impedance decreased significantly (690 ± 2397 Ω vs 613 ± 2257 Ω, p = 0.048); atrial pacing threshold has a increased trend and P-wave amplitude has a decreased trend, but there was no statistical differences; while, RVA ventricular lead threshold increased significantly (0.50 ± 0.23 V vs 0.91 ± 0.47 V, p < 0.001), impedance (902 ± 397 Ω vs 680 ± 257 Ω,p < 0.001) and R-wave amplitude (11.71 ± 9.40mv vs 7.00 ± 6.91 mv, p < 0.001) decreased significantly. Compared with healthy group, long-term RVA pacing significantly increased ventricular dyssynchrony (mean QRS duration, 156.21 ± 29.80 ms vs 97.08 ± 15.70 ms, p < 0.001), left atrium diameter (LAD, 40.61 ± 6.15 mm vs 37.49 ± 4.80 mm,p = 0.002), left ventricular end-diastolic diameter (LVEDD, 49.15 ± 5.93 mm vs 46.41 ± 3.80 mm,p = 0.003), left ventricular hypertrophy (LVMI, 121.86 ± 41.52 g/m2 vs 98.41 ± 25.29 g/m2,p < 0.001), significantly deteriorated degree of tricuspid regurgitation (p < 0.001), and significantly decreased left ventricular ejection fraction (LVEF, 61.38 ± 8.10% vs 64.64 ± 5.85%, p = 0.012), but after long-term RVA pacing, the mean LVEF was still more than 50%. Long-term RVA group LVEF was negatively correlated with preimplantation LVMI (B = -0.055,t = -2.244,p = 0.029), LVMI at follow-up (B = -0.081,t = -3.864,p = 0.000) and tricuspid regurgitation at follow-up (B = -3.797,t = -3.599,p = 0.001). CONCLUSION In conclusion, although long-term RVA pacing has significantly effects on left ventricular dyssynchrony, morphology and systolic function in III°AVB patients, the mean LVEF is still >50%. High preimplantation LVMI can predict the decline of LVEF.
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Affiliation(s)
- Man-Kun Xin
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Peng Gao
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Shu-Yang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China.
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Squara F, Scarlatti D, Riccini P, Garret G, Moceri P, Ferrari E. Individualized Left Anterior Oblique Projection: A Highly Reliable Patient-Tailored Fluoroscopy Criterion for Right Ventricular Lead Positioning. Circ Arrhythm Electrophysiol 2019; 11:e006107. [PMID: 29925536 DOI: 10.1161/circep.117.006107] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 04/30/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Classical fluoroscopic criteria for the documentation of septal right ventricular (RV) lead positioning have poor accuracy. We sought to evaluate the individualized left anterior oblique (LAO) projection as a novel fluoroscopy criterion. METHODS Consecutive patients undergoing pacemaker or defibrillator implantation were prospectively included. RV lead positioning was assessed by fluoroscopy using posteroanterior, right anterior oblique 30° to rule out coronary sinus positioning, and LAO 40° in the classical group or individualized LAO in the individualized group. Individualized LAO was defined by the degree of LAO that allowed the perfect superposition of the RV apex (using the tip of the RV lead temporarily placed at the apex) and of the superior vena cava-inferior vena cava axis (materialized by a guidewire), hence providing a true profile view of the interventricular septum. Accuracy of fluoroscopy for RV lead positioning was then assessed by comparison with true RV lead positioning using transthoracic echocardiography. RESULTS We included 100 patients, 50 in each study group. Agreement between RV lead septal/free wall positioning in transthoracic echocardiography and fluoroscopy was excellent in the individualized group (k=0.91), whereas it was poor in the classical group (k=0.35). Septal/free wall RV lead positioning was correctly identified in 48/50 (96%) patients in the individualized group versus 38/50 (76%) in the classical group (P=0.004). For septal lead positioning, fluoroscopy had 100% Se and 89.5% Sp in the individualized group versus 91.4% Se and 40% Sp in the classical group. Complications and procedural data were comparable in both groups. CONCLUSION Individualized LAO is a quick and highly reliable patient-tailored fluoroscopy projection for RV lead positioning.
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Affiliation(s)
- Fabien Squara
- Service de Cardiologie, CHU de Nice, Hôpital Pasteur, France.
| | | | | | - Gauthier Garret
- Service de Cardiologie, CHU de Nice, Hôpital Pasteur, France
| | - Pamela Moceri
- Service de Cardiologie, CHU de Nice, Hôpital Pasteur, France
| | - Emile Ferrari
- Service de Cardiologie, CHU de Nice, Hôpital Pasteur, France
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Bansal R, Parakh N, Gupta A, Juneja R, Naik N, Yadav R, Sharma G, Roy A, Verma SK, Bahl VK. Incidence and predictors of pacemaker-induced cardiomyopathy with comparison between apical and non-apical right ventricular pacing sites. J Interv Card Electrophysiol 2019; 56:63-70. [PMID: 31363943 DOI: 10.1007/s10840-019-00602-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 07/22/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Asynchronous activation of left ventricle (LV) due to chronic right ventricular (RV) pacing has been known to predispose to LV dysfunction. The predictors of LV dysfunction remain to be prospectively studied. This study was designed to follow up patients with RV pacing to look for development of pacing-induced cardiomyopathy (PiCMP), identify its predictors and draw comparison between apical vs non-apical RV pacing sites. METHODS Three hundred sixty-three patients undergoing dual-chamber and single-chamber ventricular implants were enrolled and followed up. Baseline clinical parameters; paced QRS duration and axis; RV lead position by fluoroscopy; LV ejection fraction (LVEF) by Simpson's method on transthoracic echocardiography (TTE); intraventricular dyssynchrony (septal-posterior wall contraction delay) and interventricular dyssynchrony (aortopulmonary ejection delay) on TTE were recorded. The patients were followed up at 6-12 monthly interval with estimation of LVEF and pacemaker interrogation at each visit. Pacemaker-induced cardiomyopathy (PiCMP) was defined as a fall in ejection fraction of 10% as compared to the baseline LVEF. Patients developing PiCMP were compared to other patients to identify predictors. RESULTS The mean age of study population was 59.8 years, 68.3% being males. Fifty-one percent and 49% patients underwent VVIR and DDDR pacemaker implantation, respectively. After attrition, 254 patients were analysed. PiCMP developed in 35 patients (13.8%) over a mean follow-up of 14.5 months. After multivariate analysis, burden of ventricular pacing > 60% [HR 4.26, p = 0.004] and interventricular dyssynchrony (aortopulmonary ejection delay > 40 msec) [HR 3.15, p = 0.002] were identified as predictors for PiCMP in patients undergoing chronic RV pacing. There was no effect of RV pacing site (apical vs non-apical) on incidence of PiCMP [HR 1.44, p = 0.353). CONCLUSIONS Incidence of PiCMP with RV pacing was found to be 13.8% over a mean follow-up of 14.5 months. Burden of right ventricular pacing and interventricular dyssynchrony were identified as the most important predictors for the development of PiCMP. Non-apical RV pacing site did not offer any benefit in terms of incidence of PiCMP over apical lead position.
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Affiliation(s)
- Raghav Bansal
- Department of Cardiology, All India Institute of Medical Sciences, 7th Floor, Cardiothoracic Sciences Centre, New Delhi, 110029, India
| | - Neeraj Parakh
- Department of Cardiology, All India Institute of Medical Sciences, 7th Floor, Cardiothoracic Sciences Centre, New Delhi, 110029, India.
| | - Anunay Gupta
- Department of Cardiology, All India Institute of Medical Sciences, 7th Floor, Cardiothoracic Sciences Centre, New Delhi, 110029, India
| | - Rajnish Juneja
- Department of Cardiology, All India Institute of Medical Sciences, 7th Floor, Cardiothoracic Sciences Centre, New Delhi, 110029, India
| | - Nitish Naik
- Department of Cardiology, All India Institute of Medical Sciences, 7th Floor, Cardiothoracic Sciences Centre, New Delhi, 110029, India
| | - Rakesh Yadav
- Department of Cardiology, All India Institute of Medical Sciences, 7th Floor, Cardiothoracic Sciences Centre, New Delhi, 110029, India
| | - Gautam Sharma
- Department of Cardiology, All India Institute of Medical Sciences, 7th Floor, Cardiothoracic Sciences Centre, New Delhi, 110029, India
| | - Ambuj Roy
- Department of Cardiology, All India Institute of Medical Sciences, 7th Floor, Cardiothoracic Sciences Centre, New Delhi, 110029, India
| | - Sunil Kumar Verma
- Department of Cardiology, All India Institute of Medical Sciences, 7th Floor, Cardiothoracic Sciences Centre, New Delhi, 110029, India
| | - Vinay Kumar Bahl
- Department of Cardiology, All India Institute of Medical Sciences, 7th Floor, Cardiothoracic Sciences Centre, New Delhi, 110029, India
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Chávez-González E, Barja LD, Ortega DF, Pérez-Rodríguez A. Estimulación eléctrica permanente en región septal en pacientes con insuficiencia cardíaca secundaria a estimulación en ápex de ventrículo derecho. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2018; 88:474-482. [DOI: 10.1016/j.acmx.2018.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 05/28/2018] [Accepted: 05/31/2018] [Indexed: 11/26/2022] Open
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Ventricular septal pacing: Optimum method to position the lead. Indian Heart J 2018; 70:713-720. [PMID: 30392512 PMCID: PMC6204444 DOI: 10.1016/j.ihj.2018.01.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 12/18/2017] [Accepted: 01/10/2018] [Indexed: 12/02/2022] Open
Abstract
Adverse hemodynamics of right ventricular (RV) pacing is known for years. Several studies have revealed that adverse outcomes of RV apical pacing are directly linked to cumulative percentage of ventricular pacing. Algorithms to minimize ventricular pacing are only effective if there is good atrioventricular (AV) conduction. A need for an alternate site for ventricular pacing is evident in patients with high presumed ventricular pacing burden. Most studied alternate site for ventricular pacing is ventricular septum (outflow tract septum and mid-septum). Conventionally septal position of the ventricular pacing lead is confirmed by fluoroscopic appearance of the lead and characteristics electrocardiographic (ECG) features. However, several recent studies have challenged these fluoroscopic and ECG features as to be inadequate. So, there is need for a systematic approach for septal positioning of the ventricular lead.
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Krzemień-Wolska K, Tomasik A, Nowalany-Kozielska E, Jacheć W. Prognosis of patients with implanted pacemakers in 4‑year follow-up : Impact of right ventricular pacing site. Herz 2018; 43:315-324. [PMID: 28396904 PMCID: PMC5999135 DOI: 10.1007/s00059-017-4561-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 03/08/2017] [Indexed: 10/26/2022]
Abstract
BACKGROUND Pacing remains the method of choice for treatment of cardiac electrical conduction disorders. This study examined the interrelationship between the site of the right ventricular lead tip and patient prognosis in association with other cardiovascular risk factors over a 4‑year follow-up period. PATIENTS AND METHODS The study comprised 450 consecutive patients (223 women; aged 69.16 ± 9.63 years) who had their first SSI or DDD pacemaker implanted for typical indications. RESULTS During follow-up, 91 (20.2%) patients died. The positive prognostic factors were: female sex (hazard ratio [HR] = 0.426), DDD pacemaker (HR = 0.526), oral anticoagulant use (HR = 0.330; all groups), sodium concentration (HR = 0.926), oral anticoagulant (HR = 0.115) and statin (HR = 0.260) use (female group), and non-apical location of the right ventricular lead tip (HR = 0.549; male group). Risk factors for death were: age (HR = 1.063), diabetes requiring insulin (HR = 2.832), creatinine concentration (HR = 1.005; all groups), age (HR = 1.11; female group), and elevated creatinine level (HR = 1.012; male group). In all patients, the non-apical location of the right ventricular lead tip was associated with an 18.92% reduced mortality rate during the 4‑year follow-up, which was statistically significant for the male group. CONCLUSION The non-apical location of the right ventricular lead tip was a positive prognostic factor and was statistically significant in the male subgroup.
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Affiliation(s)
| | - A Tomasik
- Szpital Specjalistyczny w Zabrzu, Zabrzu, Poland
- Second Department of Cardiology, Medical University of Silesia, ul. Skłodowskiej 10, 41-800, Zabrzu, Poland
| | - E Nowalany-Kozielska
- Szpital Specjalistyczny w Zabrzu, Zabrzu, Poland
- Second Department of Cardiology, Medical University of Silesia, ul. Skłodowskiej 10, 41-800, Zabrzu, Poland
| | - W Jacheć
- Szpital Specjalistyczny w Zabrzu, Zabrzu, Poland.
- Second Department of Cardiology, Medical University of Silesia, ul. Skłodowskiej 10, 41-800, Zabrzu, Poland.
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Worsnick SA, Sharma PS, Vijayaraman P. Right Ventricular Septal Pacing: A Paradigm Shift. J Innov Card Rhythm Manag 2018; 9:3137-3146. [PMID: 32494491 PMCID: PMC7252807 DOI: 10.19102/icrm.2018.090501] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 10/27/2017] [Indexed: 11/06/2022] Open
Abstract
The right ventricular (RV) apex has been considered to be the primary site for ventricular lead implantation since the original descriptions of permanent pacing. However, long-term RV apical pacing has been shown to have negative effects on ventricular function and hemodynamics as a result of ventricular dyssynchrony. Alternative sites of ventricular pacing, particularly the RV septum and His bundle, have been evaluated for patients with a need for long-term ventricular pacing. In this article, we review the available data on the use of these alternative sites for RV pacing.
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Squara F, Scarlatti D, Riccini P, Garret G, Moceri P, Ferrari E. Classical fluoroscopy criteria poorly predict right ventricular lead septal positioning by comparison with echocardiography. J Interv Card Electrophysiol 2018. [PMID: 29536314 DOI: 10.1007/s10840-018-0355-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Fluoroscopic criteria have been described for the documentation of septal right ventricular (RV) lead positioning, but their accuracy remains questioned. METHODS AND RESULTS Consecutive patients undergoing pacemaker or defibrillator implantation were prospectively included. RV lead was positioned using postero-anterior and left anterior oblique 40° incidences, and right anterior oblique 30° to rule out coronary sinus positioning when suspected. RV lead positioning using fluoroscopy was compared to true RV lead positioning as assessed by transthoracic echocardiography (TTE). Precise anatomical localizations were determined with both modalities; then, RV lead positioning was ultimately dichotomized into two simple clinically relevant categories: RV septal or RV free wall. Accuracy of fluoroscopy for RV lead positioning was then assessed by comparison with TTE. We included 100 patients. On TTE, 66/100 had a septal RV lead and 34/100 had a free wall RV lead. Fluoroscopy had moderate agreement with TTE for precise anatomical localization of RV lead (k = 0.53), and poor agreement for septal/free wall localization (k = 0.36). For predicting septal RV lead positioning, classical fluoroscopy criteria had a high sensitivity (95.5%; 63/66 patients having a septal RV lead on TTE were correctly identified by fluoroscopy) but a very low specificity (35.3%; only 12/34 patients having a free wall RV lead on TTE were correctly identified by fluoroscopy). CONCLUSION Classical fluoroscopy criteria have a poor accuracy for identifying RV free wall leads, which are most of the time misclassified as septal. This raises important concerns about the efficacy and safety of RV lead positioning using classical fluoroscopy criteria.
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Affiliation(s)
- Fabien Squara
- CHU de Nice, Hôpital Pasteur, Service de Cardiologie, 30 Avenue de la Voie Romaine, CS 51069, 06001, Nice Cedex 1, France.
| | - Didier Scarlatti
- CHU de Nice, Hôpital Pasteur, Service de Cardiologie, 30 Avenue de la Voie Romaine, CS 51069, 06001, Nice Cedex 1, France
| | - Philippe Riccini
- CHU de Nice, Hôpital Pasteur, Service de Cardiologie, 30 Avenue de la Voie Romaine, CS 51069, 06001, Nice Cedex 1, France
| | - Gauthier Garret
- CHU de Nice, Hôpital Pasteur, Service de Cardiologie, 30 Avenue de la Voie Romaine, CS 51069, 06001, Nice Cedex 1, France
| | - Pamela Moceri
- CHU de Nice, Hôpital Pasteur, Service de Cardiologie, 30 Avenue de la Voie Romaine, CS 51069, 06001, Nice Cedex 1, France
| | - Emile Ferrari
- CHU de Nice, Hôpital Pasteur, Service de Cardiologie, 30 Avenue de la Voie Romaine, CS 51069, 06001, Nice Cedex 1, France
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12
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Kim JH, Kang KW, Chin JY, Kim TS, Park JH, Choi YJ. Major determinant of the occurrence of pacing-induced cardiomyopathy in complete atrioventricular block: a multicentre, retrospective analysis over a 15-year period in South Korea. BMJ Open 2018; 8:e019048. [PMID: 29439074 PMCID: PMC5829811 DOI: 10.1136/bmjopen-2017-019048] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES The predictors of pacing-induced cardiomyopathy (PICM) for complete atrioventricular block (CAVB) have not yet been defined. The aim of this study was to investigate the major determinant of the occurrence of PICM. SETTING This is a multicentre, retrospective analysis of CAVB from tertiary referral centres in Daejeon, South Korea. PARTICIPANTS A cohort of 900 consecutive patients with an implanted pacemaker was collected from December 2001 to August 2015. Of these, a total of 130 patients with CAVB with pacing-dependent rhythm who underwent ECG and echocardiogram before and after implantation were analysed for the occurrence of PICM. OUTCOME MEASURES Cox proportional hazards models evaluated the determinant of PICM by ECG, device parameters and echocardiogram over a mean of 4.5 years. RESULTS PICM was observed in 16.1% (n=21) of all patients with CAVB (age, 64±11 years; male, 36.2%). The preimplant left ventricular (LV) ejection fraction (66%±9% vs 66%±8%) and non-apical pacing (40.4% vs 33.3%) were similar; however, the native QRS duration (124±34 ms vs 149±32 ms) and the paced QRS duration (pQRSd) (139±29 ms vs 167±28 ms) were significantly different between the two groups. The postimplant LV ejection fraction (61%±7% vs 31%±8%) was also significantly different at the end of follow-up. A pQRSd significantly correlated with PICM (HR 1.05, 95% CI 1.02 to 1.09, P=0.001). A pQRSd with a cut-off value of above 140 ms had a sensitivity of 95% while a pQRSd with a cut-off value of above 167 ms had a specificity of 90% for PICM. CONCLUSION In patients with CAVB with pacing-dependent rhythm, regardless of the pacing site, the pQRSd is a major determinant of the occurrence of PICM.
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Affiliation(s)
- Jun Hyung Kim
- Division of Cardiology, Chungnam National University Hospital, Daejeon, Korea
| | - Ki-Woon Kang
- Division of Cardiology, Eulji University Hospital, Daejeon, Korea
| | - Jung Yeon Chin
- Division of Cardiology, Eulji University Hospital, Daejeon, Korea
| | - Tae-Seok Kim
- Division of Cardiology, Catholic Saint Hospital, Daejeon, Korea
| | - Jae-Hyeong Park
- Division of Cardiology, Chungnam National University Hospital, Daejeon, Korea
| | - Yu Jeong Choi
- Division of Cardiology, Eulji University Hospital, Daejeon, Korea
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13
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Kiehl EL, Makki T, Kumar R, Gumber D, Kwon DH, Rickard JW, Kanj M, Wazni OM, Saliba WI, Varma N, Wilkoff BL, Cantillon DJ. Incidence and predictors of right ventricular pacing-induced cardiomyopathy in patients with complete atrioventricular block and preserved left ventricular systolic function. Heart Rhythm 2018; 13:2272-2278. [PMID: 27855853 DOI: 10.1016/j.hrthm.2016.09.027] [Citation(s) in RCA: 253] [Impact Index Per Article: 42.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Right ventricular (RV) pacing may worsen left ventricular cardiomyopathy in patients with reduced left ventricular ejection fraction (LVEF) and advanced atrioventricular block. OBJECTIVE The objectives of this study were to calculate incidence and identify predictors of RV pacing-induced cardiomyopathy (PICM) in complete heart block (CHB) with preserved LVEF and to describe outcomes of subsequent cardiac resynchronization therapy (CRT) upgrade. METHODS An analysis of consecutive patients receiving permanent pacemaker (PPM) from 2000 to 2014 for CHB with LVEF >50% was performed. PICM was defined as CRT upgrade or post-PPM LVEF ≤40%. PICM association was determined via multivariable regression analysis. CRT response was defined by LVEF increase ≥10% or left ventricular end-systolic volume decrease ≥15%. RESULTS Of the 823 study patients, 101 (12.3%) developed PICM over the mean follow-up of 4.3 ± 3.9 years, with post-PPM LVEF being 33.7% ± 7.4% in patients with PICM vs 57.6% ± 6.1% in patients without PICM (P < .001). In multivariable analysis, lower pre-PPM LVEF (hazard ratio [HR] 1.047 per 1% LVEF decrease; 95% confidence interval [CI] 1.002-1.087; P = .042) and RV pacing % both as a continuous (HR 1.011 per 1% RV pacing; 95% CI 1.002-1.02; P = .021) and as a categorical (<20% or ≥20% RV pacing) (HR 6.76; 95% CI 2.08-22.0; P = .002) variable were independently associated with PICM. Only 29 patients with PICM (28.7%) received CRT upgrade despite an 84% responder rate (LVEF increase 18.5% ± 8.1% and left ventricular end-systolic volume decrease 45.1% ± 15.0% in responders). CRT upgrade was associated with greater post-PPM LVEF decrease, lower post-PPM LVEF, and post-PPM LVEF ≤35% (P = .006, P = .004, and P = .004, respectively). CONCLUSION PICM is not uncommon in patients receiving PPM for CHB with preserved LVEF and is strongly associated with RV pacing burden >20%. CRT response rate is high in PICM, but is perhaps underutilized.
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Affiliation(s)
| | - Tarek Makki
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Rahul Kumar
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Divya Gumber
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Deborah H Kwon
- Department of Cardiovascular Medicine, Imaging Section, Cleveland Clinic Foundation, Cleveland, Ohio
| | - John W Rickard
- Department of Cardiovascular Medicine, Electrophysiology Section, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mohamed Kanj
- Department of Cardiovascular Medicine, Electrophysiology Section, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Oussama M Wazni
- Department of Cardiovascular Medicine, Electrophysiology Section, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Walid I Saliba
- Department of Cardiovascular Medicine, Electrophysiology Section, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Niraj Varma
- Department of Cardiovascular Medicine, Electrophysiology Section, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Bruce L Wilkoff
- Department of Cardiovascular Medicine, Electrophysiology Section, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Daniel J Cantillon
- Department of Cardiovascular Medicine, Electrophysiology Section, Cleveland Clinic Foundation, Cleveland, Ohio.
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14
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Abstract
INTRODUCTION Congenital complete heart block affects 1/15,000 live-born infants, predominantly due to atrioventricular nodal injury from maternal antibodies of mothers with systemic lupus erythermatosus or Sjogren's syndrome. The majority of these children will need a pacemaker implanted prior to becoming young adults. This article will review the various patient and technical factors that influence the type of pacemaker implanted, and the current literature on optimal pacing practices. Areas covered: A literature search was performed using PubMed, Embase and Web of Science. Data regarding epicardial versus transvenous implants, pacing-induced ventricular dysfunction, alternative pacing strategies (including biventricular pacing, left ventricular pacing, and His bundle pacing), and complications with pacemakers in the pediatric population were reviewed. Expert commentary: There are numerous pacing strategies available to children with congenital complete heart block. The risks and benefits of the initial implant should be weighed against the long-term issues inherent with a life-time of pacing.
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Affiliation(s)
- Stephanie F Chandler
- a Department of Cardiology , Boston Children's Hospital , Boston , MA , USA.,b Department of Pediatrics , Harvard Medical School , Boston , MA , USA
| | - Francis Fynn-Thompson
- c Department of Cardiovascular Surgery , Boston Children's Hospital , Boston , MA , USA.,d Department of Surgery , Harvard Medical School , Boston , MA , USA
| | - Douglas Y Mah
- a Department of Cardiology , Boston Children's Hospital , Boston , MA , USA.,b Department of Pediatrics , Harvard Medical School , Boston , MA , USA
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15
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Hirayama Y, Kawamura Y, Sato N, Saito T, Tanaka H, Saijo Y, Kikuchi K, Ohori K, Hasebe N. Functional characteristics of left ventricular synchronization via right ventricular outflow-tract pacing detected by two-dimensional strain echocardiography. J Arrhythm 2017; 33:28-34. [PMID: 28217226 PMCID: PMC5300840 DOI: 10.1016/j.joa.2016.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 04/07/2016] [Accepted: 05/02/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Recently, due to the detrimental effects on the ventricular function associated with right ventricular apical (RVA) pacing, right ventricular septal (RVS) pacing has become the preferred pacing method. However, the term RVS pacing refers to both right ventricular outflow-tract (RVOT) and mid-septal (RVMS) pacing, leading to a misinterpretation of the results of clinical studies. The purpose of this study, therefore, was to elucidate the functional differences of RVA, RVOT, and RVMS pacing in patients with atrioventricular block. METHODS We compared the QRS duration, global longitudinal strain (GLS), and left ventricular (LV) synchronization parameters at the three pacing sites in 47 patients. The peak systolic strain (PSS) time delay between the earliest and latest segments among the 18 LV segments and standard deviation (SD) of the time to the PSS were also calculated for the 18 LV segments at each pacing site using two-dimensional (2D) strain echocardiography. RESULTS RVMS pacing was associated with a significantly shorter QRS duration compared with RVA and RVOT pacing (154.4±21.4 vs 186.5±19.9 and 171.1±21.5 ms, P<0.001). In contrast, RVOT pacing revealed a greater GLS (-14.69±4.92 vs -13.12±4.76 and -13.51±4.81%, P<0.001), shorter PSS time delay between the earliest and latest segments (236.0±87.9 vs 271.3±102.9 and 281.9±126.6%, P=0.007), and shorter SD of the time to the PSS (70.8±23.8 vs 82.7±30.8 and 81.5±33.7 ms, P=0.002) compared with RVA and RVMS pacing. CONCLUSIONS These results suggest that the functional characteristics of RVOT pacing may be a more optimal pacing site than RVMS, regardless of the pacing QRS duration, in patients with atrioventricular conduction disorders.
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Affiliation(s)
- Yasutaka Hirayama
- Division of Cardiology, Hokkaido Cardiovascular Hospital, Sapporo, Japan
| | - Yuichiro Kawamura
- Department of Cardiology, Asahikawa Medical University, Asahikawa Medical University, Midorigaoka Higashi 2-1-1, Asahikawa, 078-8510, Japan
| | - Nobuyuki Sato
- Department of Cardiology, Asahikawa Medical University, Asahikawa Medical University, Midorigaoka Higashi 2-1-1, Asahikawa, 078-8510, Japan
| | - Tatsuya Saito
- Division of Cardiovascular Surgery, Hokkaido Cardiovascular Hospital, Sapporo, Japan
| | - Hideichi Tanaka
- Division of Cardiology, Hokkaido Cardiovascular Hospital, Sapporo, Japan
| | - Yasuaki Saijo
- Division of Community Medicine and Epidemiology, Department of Health Science, Asahikawa Medical University, Midorigaoka Higashi 2-1-1, Asahikawa, 078-8510, Japan
| | - Kenjiro Kikuchi
- Division of Cardiology, Hokkaido Cardiovascular Hospital, Sapporo, Japan
| | - Katsumi Ohori
- Division of Cardiovascular Surgery, Hokkaido Cardiovascular Hospital, Sapporo, Japan
| | - Naoyuki Hasebe
- Department of Cardiology, Asahikawa Medical University, Asahikawa Medical University, Midorigaoka Higashi 2-1-1, Asahikawa, 078-8510, Japan
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16
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Fauchier L, Alonso C, Anselme F, Blangy H, Bordachar P, Boveda S, Clementy N, Defaye P, Deharo JC, Friocourt P, Gras D, Halimi F, Klug D, Mansourati J, Obadia B, Pasquié JL, Pavin D, Sadoul N, Taieb J, Piot O, Hanon O. Position paper for management of elderly patients with pacemakers and implantable cardiac defibrillators: Groupe de Rythmologie et Stimulation Cardiaque de la Société Française de Cardiologie and Société Française de Gériatrie et Gérontologie. Arch Cardiovasc Dis 2016; 109:563-585. [PMID: 27595465 DOI: 10.1016/j.acvd.2016.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 04/01/2016] [Indexed: 02/03/2023]
Abstract
Despite the increasingly high rate of implantation of pacemakers (PMs) and implantable cardioverter defibrillators (ICDs) in elderly patients, data supporting their clinical and cost-effectiveness in this age stratum are ambiguous and contradictory. We reviewed the data regarding the applicability, safety and effectiveness of conventional pacing, ICDs and cardiac resynchronization therapy (CRT) in elderly patients. Although periprocedural risk may be slightly higher in the elderly, the implantation procedure for PMs and ICDs is still relatively safe in this age group. In older patients with sinus node disease, the general consensus is that DDD pacing with the programming of an algorithm to minimize ventricular pacing is preferred. In very old patients presenting with intermittent or suspected atrioventricular block, VVI pacing may be appropriate. In terms of correcting potentially life-threatening arrhythmias, the effectiveness of ICD therapy is similar in older and younger individuals. However, the assumption of persistent ICD benefit in the elderly population is questionable, as any advantageous effect of the device on arrhythmic death may be attenuated by higher total non-arrhythmic mortality. While septuagenarians and octogenarians have higher annual all-cause mortality rates, ICD therapy may remain effective in selected patients at high risk of arrhythmic death and with minimum comorbidities despite advanced age. ICD implantation among the elderly, as a group, may not be cost-effective, but the procedure may reach cost-effectiveness in those expected to live more than 5-7years after implantation. Elderly patients usually experience significant functional improvement after CRT, similar to that observed in middle-aged patients. Management of CRT non-responders remains globally the same, while considering a less aggressive approach in terms of reinterventions (revision of left ventricular [LV] lead placement, addition of a right ventricular or LV lead, LV endocardial pacing configuration). Overall, physiological age, general status and comorbidities rather than chronological age per se should be the decisive factors in making a decision about device implantation selection for survival and well-being benefit in elderly patients.
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Affiliation(s)
- Laurent Fauchier
- CHU Trousseau, université François-Rabelais, 37044 Tours, France.
| | | | | | - Hugues Blangy
- Institut Lorrain du Cœur et des Vaisseaux, CHU de Nancy, 54500 Vandœuvre-lès-Nancy, France
| | | | | | - Nicolas Clementy
- CHU Trousseau, université François-Rabelais, 37044 Tours, France
| | | | | | | | - Daniel Gras
- Nouvelles cliniques nantaises, 44202 Nantes, France
| | | | | | | | | | | | | | - Nicolas Sadoul
- Institut Lorrain du Cœur et des Vaisseaux, CHU de Nancy, 54500 Vandœuvre-lès-Nancy, France
| | - Jerome Taieb
- Centre hospitalier, 13616 Aix-en-Provence, France
| | - Olivier Piot
- Centre cardiologique du Nord, 93200 Saint-Denis, France
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17
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Beck H, Curtis AB. Right Ventricular Versus Biventricular Pacing for Heart Failure and Atrioventricular Block. Curr Heart Fail Rep 2016; 13:230-236. [DOI: 10.1007/s11897-016-0299-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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18
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Das A, Kahali D. Physiological cardiac pacing: Current status. Indian Heart J 2016; 68:552-8. [PMID: 27543481 PMCID: PMC4990729 DOI: 10.1016/j.ihj.2016.03.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 03/09/2016] [Accepted: 03/28/2016] [Indexed: 11/16/2022] Open
Abstract
Adverse hemodynamics of right ventricular (RV) pacing is a well-known fact. It was believed to be the result of atrio-ventricular (AV) dyssynchrony and sequential pacing of the atrium and ventricle may solve these problems. However, despite maintenance of AV synchrony, the dual chamber pacemakers in different trials have failed to show its superiority over single chamber RV apical pacing in terms of death, progression of heart failure, and atrial fibrillation (AF). As a consequence, investigators searched for alternate pacing sites with a more physiological activation pattern and better hemodynamics. Direct His bundle pacing and Para-Hisian pacing are the most physiological ventricular pacing sites. But, this is technically difficult. Ventricular septal pacing compared to apical pacing results in a shorter electrical activation delay and consequently less mechanical dyssynchrony. But, the study results are heterogeneous. Selective site atria pacing (atrial septal) is useful for patients with atrial conduction disorders in prevention of AF.
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Affiliation(s)
- Asit Das
- RMO-cum-Clinical Tutor, Department of Cardiology, IPGME&R and SSKM Hospital, Kolkata, India.
| | - Dhiman Kahali
- Senior Interventional Cardiologist, B. M. Birla Heart Research Centre, Kolkata, India
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19
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Mafi-Rad M, Luermans JGLM, Blaauw Y, Janssen M, Crijns HJ, Prinzen FW, Vernooy K. Feasibility and Acute Hemodynamic Effect of Left Ventricular Septal Pacing by Transvenous Approach Through the Interventricular Septum. Circ Arrhythm Electrophysiol 2016; 9:e003344. [PMID: 26888445 DOI: 10.1161/circep.115.003344] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Left ventricular septal (LVS) pacing reduces ventricular dyssynchrony and improves cardiac function relative to right ventricular apex (RVA) pacing in animals. We aimed to establish permanent placement of an LVS pacing lead in patients using a transvenous approach through the interventricular septum. METHODS AND RESULTS Ten patients with sinus node dysfunction scheduled for dual-chamber pacemaker implantation were prospectively enrolled. A custom pacing lead with extended helix was introduced via the left subclavian vein and, after positioning against the right ventricular septum (RVS) using a preshaped guiding catheter, driven through the interventricular septum to the LVS. The acute hemodynamic effect of RVA, RVS, and LVS pacing was evaluated by invasive LVdP/dtmax measurements. The lead was successfully delivered to the LVS in all patients. Procedure time and fluoroscopy time shortened with experience. QRS duration was shorter during LVS pacing (144 ± 20 ms) than during RVA (172 ± 33 ms; P = 0.02 versus LVS) and RVS pacing (165 ± 17 ms; P = 0.004 versus LVS). RVA and RVS pacing reduced LVdP/dtmax compared with baseline atrial pacing (-7.1 ± 4.1% and -6.9 ± 4.3%, respectively), whereas LVS pacing maintained LVdP/dtmax at baseline level (1.0 ± 4.3%; P = 0.001 versus RVA and RVS). R-wave amplitude and pacing threshold were 12.2 ± 6.7 mV and 0.5 ± 0.2 V at implant and remained stable during 6-month follow-up without lead-related complications. CONCLUSIONS Permanent placement of an LVS pacing lead by transvenous approach through the interventricular septum is feasible in patients. LVS pacing preserves acute left ventricular pump function. This new pacing method could serve as an alternative and hemodynamically preferable approach for antibradycardia pacing.
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Affiliation(s)
- Masih Mafi-Rad
- From the Department of Cardiology, Maastricht University Medical Center, The Netherlands (M.M.-R., J.G.L.M.L., Y.B., M.J., H.J.C., K.V.); and Department of Physiology, Maastricht University, Cardiovascular Research Institute Maastricht, The Netherlands (F.W.P.)
| | - Justin G L M Luermans
- From the Department of Cardiology, Maastricht University Medical Center, The Netherlands (M.M.-R., J.G.L.M.L., Y.B., M.J., H.J.C., K.V.); and Department of Physiology, Maastricht University, Cardiovascular Research Institute Maastricht, The Netherlands (F.W.P.)
| | - Yuri Blaauw
- From the Department of Cardiology, Maastricht University Medical Center, The Netherlands (M.M.-R., J.G.L.M.L., Y.B., M.J., H.J.C., K.V.); and Department of Physiology, Maastricht University, Cardiovascular Research Institute Maastricht, The Netherlands (F.W.P.)
| | - Michel Janssen
- From the Department of Cardiology, Maastricht University Medical Center, The Netherlands (M.M.-R., J.G.L.M.L., Y.B., M.J., H.J.C., K.V.); and Department of Physiology, Maastricht University, Cardiovascular Research Institute Maastricht, The Netherlands (F.W.P.)
| | - Harry J Crijns
- From the Department of Cardiology, Maastricht University Medical Center, The Netherlands (M.M.-R., J.G.L.M.L., Y.B., M.J., H.J.C., K.V.); and Department of Physiology, Maastricht University, Cardiovascular Research Institute Maastricht, The Netherlands (F.W.P.)
| | - Frits W Prinzen
- From the Department of Cardiology, Maastricht University Medical Center, The Netherlands (M.M.-R., J.G.L.M.L., Y.B., M.J., H.J.C., K.V.); and Department of Physiology, Maastricht University, Cardiovascular Research Institute Maastricht, The Netherlands (F.W.P.)
| | - Kevin Vernooy
- From the Department of Cardiology, Maastricht University Medical Center, The Netherlands (M.M.-R., J.G.L.M.L., Y.B., M.J., H.J.C., K.V.); and Department of Physiology, Maastricht University, Cardiovascular Research Institute Maastricht, The Netherlands (F.W.P.).
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20
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Yang JH, Kim JY, Kim SH, Oh YS. Reversal of Pacing-Induced Cardiomyopathy by Normal QRS Axis Pacing. Korean Circ J 2016; 46:421-4. [PMID: 27275181 PMCID: PMC4891609 DOI: 10.4070/kcj.2016.46.3.421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 10/08/2015] [Accepted: 10/27/2015] [Indexed: 12/05/2022] Open
Abstract
Right ventricular apical pacing has been a commonly used method for placement of permanent pacemaker, but it is known to be associated with ventricular dyssynchrony and may lead to heart failure. Septal pacing could be an alternative method to improve this complication but the results have been conflicting; hence, other strategies are needed. This case is about a patient with pacing-induced cardiomyopathy who showed much improvement after repositioning the leads to a site different from that of normally paced QRS axis.
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Affiliation(s)
- Ji Hyun Yang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ju Youn Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Hwan Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yong-Seog Oh
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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21
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Cicchitti V, Radico F, Bianco F, Gallina S, Tonti G, De Caterina R. Heart failure due to right ventricular apical pacing: the importance of flow patterns. Europace 2016; 18:1679-1688. [DOI: 10.1093/europace/euw024] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 01/25/2016] [Indexed: 01/12/2023] Open
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22
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Ebrille E, DeSimone CV, Vaidya VR, Chahal AA, Nkomo VT, Asirvatham SJ. Ventricular pacing - Electromechanical consequences and valvular function. Indian Pacing Electrophysiol J 2016; 16:19-30. [PMID: 27485561 PMCID: PMC4936653 DOI: 10.1016/j.ipej.2016.02.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Although great strides have been made in the areas of ventricular pacing, it is still appreciated that dyssynchrony can be malignant, and that appropriately placed pacing leads may ameliorate mechanical dyssynchrony. However, the unknowns at present include: 1. The mechanisms by which ventricular pacing itself can induce dyssynchrony; 2. Whether or not various pacing locations can decrease the deleterious effects caused by ventricular pacing; 3. The impact of novel methods of pacing, such as atrioventricular septal, lead-less, and far-field surface stimulation; 4. The utility of ECG and echocardiography in predicting response to therapy and/or development of dyssynchrony in the setting of cardiac resynchronization therapy (CRT) lead placement; 5. The impact of ventricular pacing-induced dyssynchrony on valvular function, and how lead position correlates to potential improvement. This review examines the existing literature to put these issues into context, to provide a basis for understanding how electrical, mechanical, and functional aspects of the heart can be distorted with ventricular pacing. We highlight the central role of the mitral valve and its function as it relates to pacing strategies, especially in the setting of CRT. We also provide future directions for improved pacing modalities via alternative pacing sites and speculate over mechanisms on how lead position may affect the critical function of the mitral valve and thus overall efficacy of CRT.
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Affiliation(s)
- Elisa Ebrille
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA; Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | | | - Vaibhav R Vaidya
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Anwar A Chahal
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA; Clinical and Translational Science, Mayo Graduate School, Rochester, MN, USA
| | - Vuyisile T Nkomo
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA; Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA.
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Moore P, Coucher J, Ngai S, Stanton T, Wahi S, Gould P, Booth C, Pratap J, Kaye G. Imaging and Right Ventricular Pacing Lead Position: A Comparison of CT, MRI, and Echocardiography. Pacing Clin Electrophysiol 2016; 39:382-92. [PMID: 26769293 DOI: 10.1111/pace.12817] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 01/04/2016] [Accepted: 01/04/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Right ventricular nonapical (RVNA) pacing may reduce the risk of heart failure. Fluoroscopy is the standard approach to determine lead tip position, but is inaccurate. We compared cardiac computed tomography (CT), magnetic resonance imaging (MRI), two-dimensional and three-dimensional transthoracic echocardiography (TTE), and chest x-ray (CXR) to assess which provides the optimal assessment of right ventricular (RV) lead tip position. METHODS Eighteen patients with MRI-conditional pacemakers (10 RVNA and eight apical [RVA] leads) underwent contrast CT, MRI, TTE, and a standard postimplant posteroanterior and lateral CXR. To compare images, the RV was arbitrarily partitioned into three long-axis segments (right ventricular outflow tract, middle, and apex), and two short-axis segments (septal and nonseptal). Agreement between modalities was assessed. RESULTS RV lead tip position was identified in all patients on CT, TTE, and CXR, but was not identified in seven (39%) patients on MRI due to device-related artifact. Of 10 leads deemed to be nonapical/septal during implant, 70% were identified as nonapical on CXR, 60% on CT, 60% on MRI, and 80% on TTE. On CT imaging only 10% were truly septal, 20% on MRI, 30% on CXR, and 80% on TTE. Agreement was better between modalities when assessing position of the designated RVA leads. CONCLUSION During implant leads intended for the septum are not confirmed as such on subsequent imaging, and marked heterogeneity is apparent between modalities. MRI is limited by artifact, and discrepancy exists between TTE and CT in identifying septal lead position. CT gave the clearest definition of lead tip position.
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Affiliation(s)
- Peter Moore
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - John Coucher
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Stanley Ngai
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Tony Stanton
- Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Sudhir Wahi
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Paul Gould
- Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Cameron Booth
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Jit Pratap
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Gerald Kaye
- Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
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24
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Gould PA, Ng K, Chacko Y, Doneva S, Claughton A, Korczyk D, Dimeski G. Characterisation and Comparison of Acute Haemodynamic, Cardiac Biochemical and Hormonal Response to Different Ventricular Pacing Sites in the Normal Heart. Heart Lung Circ 2016; 25:140-7. [DOI: 10.1016/j.hlc.2015.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 06/01/2015] [Accepted: 07/19/2015] [Indexed: 11/25/2022]
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25
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Singh H, Patel CD, Sharma G, Naik N. Comparison of left ventricular systolic function and mechanical dyssynchrony using equilibrium radionuclide angiography in patients with right ventricular outflow tract versus right ventricular apical pacing: A prospective single-center study. J Nucl Cardiol 2015; 22:903-11. [PMID: 25609582 DOI: 10.1007/s12350-014-0033-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 11/03/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Chronic ventricular pacing is known to adversely affect left ventricular (LV) function. Studies comparing right ventricular outflow tract (RVOT) pacing with RV apical (RVA) pacing have shown heterogeneous outcomes. Our aim was to objectively assess LV function and mechanical dyssynchrony in patients with RVOT and RVA pacing using equilibrium radionuclide angiography (ERNA). METHODS Fifty-one patients who underwent permanent pacemaker implantation and had normal LV function were prospectively included. Twenty-nine patients had pacemaker lead implanted in the RVOT and 22 at the RVA site. All patients underwent ERNA within 5 days post-pacemaker implantation and follow-up studies at 6 and 12 months. Standard deviation of LV mean phase angle (SD LV mPA) expressed in degrees, which was derived by Fourier first harmonic analysis of phase images, was used to quantify left intraventricular dyssynchrony. RESULTS No significant difference was observed between the two groups with respect to indication (P = .894), Type/mode (P = .985), and percentage of ventricular pacing (P = .352). Paced QRS duration was significantly longer in RVA group than RVOT group (P = .05). There was no statistically significant difference between the RVA and RVOT groups at baseline with respect to LVEF (P = .596) and SD LV mPA (P = .327). Within the RVA group, a significant decline in LVEF was observed over 12-month follow-up (from 57.3% ± 5.32% to 55.6% ± 6.25%; P = .012). In the RVOT group, the change in LVEF was not statistically significant (from 56.7% ± 4.08% to 54.3% ± 6.63%; P = .159). No significant change in SD LV mPA was observed over 12-month follow-up within the RVA group (from 10.5 ± 2.58° to 10.4 ± 3.54°; P = 1.000) as well as in the RVOT group (from 9.7 ± 3.28° to 9.4 ± 2.85°; P = .769). However, between the RVA and RVOT groups, no significant difference was observed at 12-month follow-up in terms of LVEF and dyssynchrony (LVEF P = .488; SD LV mPA P = .296). CONCLUSION No significant difference was observed between RVOT and RVA groups with regard to LV function and synchrony over a 12-month follow-up. RVOT pacing offers may lead to better preservation of LV function on longer follow-up.
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Affiliation(s)
- Harmandeep Singh
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Chetan D Patel
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Gautam Sharma
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Nitish Naik
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, 110029, India
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Kaye G. Pacing site in pacemaker dependency: is right ventricular septal lead position the answer? Expert Rev Cardiovasc Ther 2015; 12:1407-17. [PMID: 25418757 DOI: 10.1586/14779072.2014.979791] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The right ventricular apex has been the traditional site for lead placement in patients with atrioventricular block. Pacing at the right ventricular apex may have long-term deleterious effects on left ventricular (LV) function, promoting heart failure and increasing mortality. Pacing at the right ventricular septum has been proposed to minimize deterioration in LV function. Although experimental data suggest that septal pacing protects LV function, clinical studies have provided conflicting results. A recent large study in patients with heart block did not show a protective effect with septal pacing. Other pacing approaches are becoming increasingly relevant; however, prediction of what method should be employed in which patient is not currently possible. Other factors such as baseline LV function and associated co-morbidities impact LV function, irrespective of pacing site. Continued monitoring of cardiac function post-implant is therefore critical to ongoing care. An algorithm for managing patients with atrioventricular block is proposed.
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Affiliation(s)
- Gerry Kaye
- Department of Cardiology, Princess Alexandra Hospital, Woolloongabba and University of Queensland, Brisbane 4102, Australia
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HUSSAIN MOHAMMADAKHTAR, FURUYA-KANAMORI LUIS, KAYE GERALD, CLARK JUSTIN, DOI SUHAILA. The Effect of Right Ventricular Apical and Nonapical Pacing on the Short- and Long-Term Changes in Left Ventricular Ejection Fraction: A Systematic Review and Meta-Analysis of Randomized-Controlled Trials. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:1121-36. [DOI: 10.1111/pace.12681] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 06/05/2015] [Accepted: 06/09/2015] [Indexed: 01/26/2023]
Affiliation(s)
- MOHAMMAD AKHTAR HUSSAIN
- From the Division of Epidemiology and Biostatistics; School of Public Health, The University of Queensland; Brisbane Australia
| | - LUIS FURUYA-KANAMORI
- Research School of Population Health; The Australian National University; Canberra Australia
| | - GERALD KAYE
- Department of Cardiology; Princess Alexandra Hospital; Brisbane Australia
- University of Queensland Medical School; Brisbane Australia
| | - JUSTIN CLARK
- Cochrane Acute Respiratory Infections Group, Faculty of Health Sciences and Medicine, Bond University; Gold Coast Australia
| | - SUHAIL A.R. DOI
- Research School of Population Health; The Australian National University; Canberra Australia
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Zou C, Song J, Li H, Huang X, Liu Y, Zhao C, Shi X, Yang X. Right ventricular outflow tract septal pacing is superior to right ventricular apical pacing. J Am Heart Assoc 2015; 4:jah3942. [PMID: 25896891 PMCID: PMC4579934 DOI: 10.1161/jaha.115.001777] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background The effects of right ventricular apical pacing (RVAP) and right ventricular outflow tract (RVOT) septal pacing on atrial and ventricular electrophysiology have not been thoroughly compared. Methods and Results To identify a more favorable pacing strategy with fewer adverse effects, 80 patients who had complete atrioventricular block with normal cardiac function and who were treated with either RVAP (n=42) or RVOT septal pacing (n=38) were recruited after an average of 2 years of follow‐up. The data from electrocardiography and echocardiography performed before pacemaker implantation and at the end of follow‐up were collected. The patients in the RVOT septal pacing and RVAP groups showed similar demographic and clinical characteristics before pacing treatments. After a mean follow‐up of 2 years, the final maximum P‐wave duration; P‐wave dispersion; Q‐, R‐, and S‐wave complex duration; left atrial volume index; left ventricular end‐systolic diameter; ratio of transmitral early diastolic filling velocity to mitral annular early diastolic velocity; and interventricular mechanical delay in the RVOT septal pacing group were significantly less than those in the RVAP group (P<0.05). The final left ventricular ejection fraction of the RVOT septal pacing group was significantly higher than that of the RVAP group (P<0.05). Conclusions Compared with RVAP, RVOT septal pacing has fewer adverse effects regarding atrial electrical activity and structure in patients with normal cardiac function.
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Affiliation(s)
- Cao Zou
- Department of Cardiology, First Affiliated Hospital of Soochow University, Suzhou, China (C.Z., J.S., H.L., X.Y.)
| | - Jianping Song
- Department of Cardiology, First Affiliated Hospital of Soochow University, Suzhou, China (C.Z., J.S., H.L., X.Y.)
| | - Hui Li
- Department of Cardiology, First Affiliated Hospital of Soochow University, Suzhou, China (C.Z., J.S., H.L., X.Y.)
| | - Xingmei Huang
- Department of Electrocardiography, First Affiliated Hospital of Soochow University, Suzhou, China (X.H., Y.L.)
| | - Yuping Liu
- Department of Electrocardiography, First Affiliated Hospital of Soochow University, Suzhou, China (X.H., Y.L.)
| | - Caiming Zhao
- Department of Echocardiography, First Affiliated Hospital of Soochow University, Suzhou, China (C.Z., X.S.)
| | - Xin Shi
- Department of Echocardiography, First Affiliated Hospital of Soochow University, Suzhou, China (C.Z., X.S.)
| | - Xiangjun Yang
- Department of Cardiology, First Affiliated Hospital of Soochow University, Suzhou, China (C.Z., J.S., H.L., X.Y.)
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Honing in on optimal ventricular pacing sites: an argument for his bundle pacing. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:372. [PMID: 25778424 DOI: 10.1007/s11936-015-0372-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OPINION STATEMENT Frequent ventricular pacing is often or completely unavoidable in patients with high-grade or complete heart block. Over time, patients with high-burden RV pacing are at risk for developing symptomatic cardiomyopathy due to pacing-induced ventricular dyssynchrony. Growing awareness of this concern has generated interest in alternative pacing sites like the septum and outflow tract, the thinking being that these sites will more closely mimic His-Purkinje-mediated ventricular activation. Numerous studies have met with mixed results likely due to the fact that-to quote Marvin Gaye-there ain't nothing like the real thing. Herein lies the advantage of His bundle pacing (HBP), as it is the only pacing modality capable of physiological ventricular activation. HBP has been demonstrated to be safe and reliable in various forms of AV block with minimal drawbacks, namely modestly higher pacing thresholds when compared with other RV sites. Additionally, HBP is a truly physiologic alternative to biventricular pacing to effect cardiac resynchronization therapy (CRT), a concept supported by small observational and prospective studies. In our view, His bundle pacing should be considered in nearly all patients requiring ventricular pacing.
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30
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Chen K, Mao Y, Liu SH, Wu Q, Luo QZ, Pan WQ, Jin Q, Zhang N, Ling TY, Chen Y, Gu G, Shen WF, Wu LQ. Is right ventricular mid-septal pacing superior to apical pacing in patients with high degree atrio-ventricular block and moderately depressed left ventricular function? J Zhejiang Univ Sci B 2015; 15:507-14. [PMID: 24903987 DOI: 10.1631/jzus.b1400034] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE We are aimed to investigate whether right ventricular mid-septal pacing (RVMSP) is superior to conventional right ventricular apical pacing (RVAP) in improving clinical functional capacity and left ventricular ejection fraction (LVEF) for patients with high-degree atrio-ventricular block and moderately depressed left ventricle (LV) function. METHODS Ninety-two patients with high-degree atrio-ventricular block and moderately reduced LVEF (ranging from 35% to 50%) were randomly allocated to RVMSP (n=45) and RVAP (n=47). New York Heart Association (NYHA) functional class, echocardiographic LVEF, and distance during a 6-min walk test (6MWT) were determined at 18 months after pacemaker implantation. Serum levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) were measured using an enzyme-linked immunosorbent assay (ELISA) kit. RESULTS Compared with baseline, NYHA functional class remained unchanged at 18 months, distance during 6MWT (485 m vs. 517 m) and LVEF (36.7% vs. 41.8%) were increased, but BNP levels were reduced (2352 pg/ml vs. 710 pg/ml) in the RVMSP group compared with those in the RVAP group, especially in patients with LVEF 35%-40% (for all comparisons, P<0.05). However, clinical function capacity and LV function measurements were not significantly changed in patients with RVAP, despite the pacing measurements being similar in both groups, such as R-wave amplitude and capture threshold. CONCLUSIONS RVMSP provides a better clinical utility, compared with RVAP, in patients with high-degree atrioventricular block and moderately depressed LV function whose LVEF levels ranged from 35% to 40%.
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Affiliation(s)
- Kang Chen
- Department of Cardiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; Outpatient Department, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Nicolás-Franco S, Rodríguez-González FJ, Nicolás-Boluda A, Sánchez-Martos A. Importance of ventricular function in the election of electro heart mode. Med Intensiva 2015; 39:172-8. [PMID: 25555308 DOI: 10.1016/j.medin.2014.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 09/17/2014] [Accepted: 09/18/2014] [Indexed: 11/29/2022]
Abstract
The integration of the ventricular function is essential when making decisions over a patient subjected to cardiac electrostimulation in order to understand the structure followed in the new cardiac stimulation and resynchronising therapy guides. To support the importance of ventricular function in cardiac electrostimulation it is important to know: (i)the deleterious effect of stimulation on the right ventricle apex; (ii)the effect over the left ventricular function produced by complete blockage of the left branch, and (iii)left ventricular disfunction as arrythmogenic substrate. When it comes to decide what type of cardiac electrostimualtion to apply we will know: the percentage of ventricular stimulation needed and its ventricular function. A normal ventricular function will enable electrostimulation from the right ventricle apex or alternative site. On the contrary, if this value is lower than 50% the most recommended electrostimulation is cardiac resynchronisation (CRT-P), which will be accompanied by defibrillation (CRT-D) if FEVI is lower than 35%.
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Affiliation(s)
- S Nicolás-Franco
- Unidad de Electroestimulación Cardíaca, Hospital General Universitario Rafael Méndez, Lorca, Murcia, España.
| | - F J Rodríguez-González
- Unidad de Electroestimulación Cardíaca, Hospital General Universitario Rafael Méndez, Lorca, Murcia, España
| | - A Nicolás-Boluda
- Biotecnología, Universidad Politécnica de Valencia, Valencia, España
| | - A Sánchez-Martos
- Unidad de Electroestimulación Cardíaca, Hospital General Universitario Rafael Méndez, Lorca, Murcia, España
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Kim SH, Oh YS, Nam GB, Choi KJ, Park JS, Park SW, Park SJ, On YK, Kim JS, Shin WS, Kim JH, Jang SW, Lee MY, Kim YH, Rho TH. Paced QRS axis as a predictor of pacing-induced left ventricular dysfunction. J Interv Card Electrophysiol 2014; 41:223-9. [DOI: 10.1007/s10840-014-9950-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 09/10/2014] [Indexed: 12/01/2022]
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Alhous MHA, Small GR, Hannah A, Hillis GS, Frenneaux M, Broadhurst PA. Right ventricular septal pacing as alternative for failed left ventricular lead implantation in cardiac resynchronization therapy candidates. Europace 2014; 17:94-100. [PMID: 25359384 DOI: 10.1093/europace/euu259] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
AIMS To compare the effects on left ventricular (LV) function of right ventricular (RV) septal pacing vs. cardiac resynchronization therapy (CRT) in patients with an indication for the latter. Cardiac resynchronization therapy is an effective therapy in patients with drug-refractory heart failure. Despite advances in implantation techniques, LV lead placement can be impossible in up to 10% of cases. We, therefore, assessed the effects of RV septal pacing from mid septum (RVmIVS) and outflow tract (RVOT) on cardiac performance, in comparison with CRT. METHODS AND RESULTS Twenty-two patients scheduled for CRT underwent dual-chamber temporary pacing. The ventricular lead was placed at the RV apex (RVA), RVmIVS, and RVOT in random order. Comprehensive echocardiography was performed in a baseline AAI mode and then at each RV position in dual chamber pacemaker function (D pacing, D sensing, D dual responses) mode and repeated on the next day following CRT implantation. Right ventricular apex pacing did not change any of the assessed echocardiography parameters. Both RVmIVS and RVOT pacing increased LV ejection fraction (EF): 29 ± 7% at baseline vs. 32 ± 6% (P = 0.02) and 32 ± 5% (P = 0.04) with RVmIVS and RVOT pacing, respectively. Similarly, the dyssynchrony index (Ts-SD) decreased: 50 ± 19 ms at baseline vs. 39 ± 17 ms (P = 0.04) and 37 ± 17 ms (P = 0.006) with RVmIVS and RVOT pacing, respectively. Cardiac resynchronization therapy further improved LVEF and Ts-SD to 36 ± 7% and 34 ± 15 ms, respectively, however, only LVEF was significantly higher compared with RVmIVS and RVOT pacing (P = 0.03 and P = 0.01 respectively). There were no significant differences in either LVEF or Ts-SD between RVmIVS and RVOT. CONCLUSION Right ventricular septal pacing from mid septum or RVOT pacing improves LVEF and LV synchrony in CRT candidates. Further improvement in LVEF was achieved by CRT, which remains the 'gold standard' therapy in these patients. However, RV septal pacing is worthy of further study as an alternative strategy when LV lead implantation fails.
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Affiliation(s)
- M Hafez A Alhous
- Department of Cardiology, Aberdeen Royal Infirmary/University of Aberdeen, Aberdeen AB25 2ZN, UK
| | - Gary R Small
- Department of Cardiology, Aberdeen Royal Infirmary/University of Aberdeen, Aberdeen AB25 2ZN, UK
| | - Andrew Hannah
- Department of Cardiology, Aberdeen Royal Infirmary/University of Aberdeen, Aberdeen AB25 2ZN, UK
| | - Graham S Hillis
- The George Institute for Global Health, University of Sydney, Australia
| | - Michael Frenneaux
- Department of Cardiology, Aberdeen Royal Infirmary/University of Aberdeen, Aberdeen AB25 2ZN, UK
| | - Paul A Broadhurst
- Department of Cardiology, Aberdeen Royal Infirmary/University of Aberdeen, Aberdeen AB25 2ZN, UK
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Zhang H, Hou X, Wang Y, Xue S, Cao K, Chen J, Zou J. The acute and chronic effects of different right ventricular site pacing on left ventricular mechanical synchrony as assessed by phase analysis of SPECT myocardial perfusion imaging. J Nucl Cardiol 2014; 21:958-66. [PMID: 24872255 DOI: 10.1007/s12350-014-9912-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 03/10/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study aimed to assess acute and chronic effects of right ventricular mid-septum (RVS) versus right ventricular apex (RVA) pacing on left ventricular (LV) mechanical dyssynchrony using phase analysis of gated single photon emission computed tomography myocardial perfusion imaging (MPI). METHODS Thirty-nine patients with complete atrioventricular (AV) block, who were indicated for permanent pacing, were recruited and randomized to receive RVA (n = 20) or RVS (n = 19) pacing. All patients underwent MPI at 1 week and 6 months after pacemaker implantation. LV dyssynchrony and cardiac function were assessed by MPI and compared between the two groups. RESULTS There were no significant differences in baseline characteristics between the RVS and RVA groups. The paced QRS duration was significantly longer in the RVA group than in the RVS group. LV dyssynchrony parameters were not significantly different between the groups at the 1-week follow-up, but they were significantly smaller in the RVS group than in the RVA group at the 6-month follow-up. LV dyssynchrony parameters significantly decreased in the RVS group from the 1-week follow-up to the 6-month follow-up, but were unchanged in the RVA group. No differences in LV function parameters were observed between the groups at the 1-week and 6-month follow-ups. CONCLUSIONS RVS pacing produces better electrical and mechanical synchrony than RVA pacing for patients with complete AV block.
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Affiliation(s)
- Hongxiang Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China,
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Kaye GC, Linker NJ, Marwick TH, Pollock L, Graham L, Pouliot E, Poloniecki J, Gammage M. Effect of right ventricular pacing lead site on left ventricular function in patients with high-grade atrioventricular block: results of the Protect-Pace study. Eur Heart J 2014; 36:856-62. [PMID: 25189602 DOI: 10.1093/eurheartj/ehu304] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 06/02/2014] [Indexed: 11/14/2022] Open
Abstract
AIM Chronic right ventricle (RV) apical (RVA) pacing is standard treatment for an atrioventricular (AV) block but may be deleterious to left ventricle (LV) systolic function. Previous clinical studies of non-apical pacing have produced conflicting results. The aim of this randomized, prospective, international, multicentre trial was to compare change in LV ejection fraction (LVEF) between right ventricular apical and high septal (RVHS) pacing over a 2-year study period. METHODS AND RESULTS We randomized 240 patients (age 74 ± 11 years, 67% male) with a high-grade AV block requiring >90% ventricular pacing and preserved baseline LVEF >50%, to receive pacing at the RVA (n = 120) or RVHS (n = 120). At 2 years, LVEF decreased in both the RVA (57 ± 9 to 55 ± 9%, P = 0.047) and the RVHS groups (56 ± 10 to 54 ± 10%, P = 0.0003). However, there was no significant difference in intra-patient change in LVEF between confirmed RVA (n = 85) and RVHS (n = 83) lead position (P = 0.43). There were no significant differences in heart failure hospitalization, mortality, the burden of atrial fibrillation, or plasma brain natriutetic peptide levels between the two groups. A significantly greater time was required to place the lead in the RVHS position (70 ± 25 vs. 56 ± 24 min, P < 0.0001) with longer fluoroscopy times (11 ± 7 vs. 5 ± 4 min, P < 0.0001). CONCLUSION In patients with a high-grade AV block and preserved LV function requiring a high percentage of ventricular pacing, RVHS pacing does not provide a protective effect on left ventricular function over RVA pacing in the first 2 years. PROTECT-PACE ClinicalTrials.gov number NCT00461734.
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Affiliation(s)
- Gerald C Kaye
- Department of Cardiology, The University of Queensland and Princess Alexandra Hospital, Ipswich Road, Wolloongabba, Brisbane 4102, Queensland, Australia
| | | | | | | | | | | | | | - Michael Gammage
- The Medical School, University of Birmingham, Birmingham, UK
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Akerström F, Pachón M, Puchol A, Jiménez-López J, Segovia D, Rodríguez-Padial L, Arias MA. Chronic right ventricular apical pacing: adverse effects and current therapeutic strategies to minimize them. Int J Cardiol 2014; 173:351-60. [PMID: 24721486 DOI: 10.1016/j.ijcard.2014.03.079] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 01/27/2014] [Accepted: 03/12/2014] [Indexed: 02/07/2023]
Abstract
The permanent cardiac pacemaker is the only effective therapy for patients with symptomatic bradycardia and hundreds of millions are implanted worldwide every year. Despite its undisputed clinical benefits, the last two decades have drawn much attention to the negative effects associated with long-term pacing of the right ventricle (RV). Experimental and clinical studies have shown that RV pacing produces ventricular dyssynchrony, similar to that of left bundle branch block, with consequent detrimental effects on cardiac structure and function, with adverse clinical outcomes such as atrial fibrillation, heart failure and death. Although clinical evidence largely comes from subanalyses of pacemaker and implantable cardiac defibrillator studies, there is strong evidence that patients with reduced left ventricular function are at high risk of suffering from the detrimental effects of long-term RV pacing. Biventricular pacing in cardiac resynchronization therapy devices can prevent ventricular dyssynchrony and has emerged as an attractive option in this patient group with promising results and more clinical studies underway. Moreover, there is evidence that specific pacemaker algorithms that minimize RV pacing can reduce the negative effects of RV stimulation on cardiac function and may also prevent clinical deterioration. The extent of the long-term clinical effects of RV pacing in patients with normal ventricular function and how to prevent this are less clear and subject to future investigation.
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Affiliation(s)
- Finn Akerström
- Cardiac Arrhythmia and Electrophysiology Unit, Department of Cardiology, Hospital Virgen de la Salud, Toledo, Spain
| | - Marta Pachón
- Cardiac Arrhythmia and Electrophysiology Unit, Department of Cardiology, Hospital Virgen de la Salud, Toledo, Spain
| | - Alberto Puchol
- Cardiac Arrhythmia and Electrophysiology Unit, Department of Cardiology, Hospital Virgen de la Salud, Toledo, Spain
| | - Jesús Jiménez-López
- Cardiac Arrhythmia and Electrophysiology Unit, Department of Cardiology, Hospital Virgen de la Salud, Toledo, Spain
| | - Diana Segovia
- Cardiac Arrhythmia and Electrophysiology Unit, Department of Cardiology, Hospital Virgen de la Salud, Toledo, Spain
| | - Luis Rodríguez-Padial
- Cardiac Arrhythmia and Electrophysiology Unit, Department of Cardiology, Hospital Virgen de la Salud, Toledo, Spain
| | - Miguel A Arias
- Cardiac Arrhythmia and Electrophysiology Unit, Department of Cardiology, Hospital Virgen de la Salud, Toledo, Spain.
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Abstract
Biventricular pacing has been an exciting recent advance in the management of drug-refractory heart failure. This new therapy has evolved as much from necessity as scientific observation, since benefits derived from pharmacotherapy currently appear to have reached their peak. Clinical trials of biventricular pacing are establishing morbidity and mortality benefits in heart failure. New challenges in the use of these pacemakers are now arising. These include the accurate diagnosis of ventricular dyssynchrony and, hence, potential responders to the refinement of implantation of the left ventricular lead to the appropriate dyssynchronous ventricular area and optimization of pacemaker programming. This review gives a general overview of the principles and the current evidence for the use of biventricular pacemakers in the treatment of heart failure. In addition, a discussion of current research and future projects is included.
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Affiliation(s)
- Paul A Gould
- Wynn Department of Metabolic Cardiology, Baker Heart Research Institute, PO Box 6492, Melbourne, Victoria 8008, Australia.
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Da Costa A, Gabriel L, Romeyer-Bouchard C, Géraldine B, Gate-Martinet A, Laurence B, Levallois M, Isaaz K. Focus on right ventricular outflow tract septal pacing. Arch Cardiovasc Dis 2013; 106:394-403. [PMID: 23850059 DOI: 10.1016/j.acvd.2012.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 08/04/2012] [Accepted: 08/08/2012] [Indexed: 10/26/2022]
Abstract
Experimental and clinical studies have shown that right ventricular apical pacing may result in long-term deleterious effects on account of its negative impact on left ventricular remodeling through desynchronization. This risk appears more pronounced in patients with even moderate left ventricular dysfunction and generally occurs after at least 1 year of pacing. As right ventricular apical pacing may be associated with the development of organic mitral insufficiency, other sites that allow for more physiological stimulation, such as right ventricular outflow tract septal pacing, have been developed, with good feasibility and reproducibility. However, the prospective randomized studies and meta-analyses to date have only demonstrated a modest effect on ejection fraction in the medium term, without any significant effect on quality of life and morbimortality. However, the absence of a favorable effect for right ventricular outflow tract septal pacing compared with right ventricular apical pacing in terms of clinical manifestations and patient prognosis appears to be more associated with the designs of these studies, which were not homogeneous with regard to methodology used, judgment criteria, follow-up and, especially, statistical power. Two randomized prospective multicentre studies are currently ongoing in order to evaluate the favorable effect of infundibular septal pacing, when considering the indirect negative effects of right ventricular apical pacing as reported in the literature.
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Affiliation(s)
- Antoine Da Costa
- Service de Cardiologie, Université Jean Monnet, Hôpital Nord, Centre Hospitalier Universitaire de Saint-Etienne, France.
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Butrous H, Pai SM, Pai RG. Deleterious Effects of Right Ventricular Apical Pacing in Patients with Normal Ejection Fraction: Implications of Potential Expanding Epidemic. Echocardiography 2013; 30:995-6. [DOI: 10.1111/echo.12324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Hoda Butrous
- Department of Cardiology; Loma Linda University Medical Center; Loma Linda; California
| | - Sudha M. Pai
- Department of Cardiology; Loma Linda University Medical Center; Loma Linda; California
| | - Ramdas G. Pai
- Department of Cardiology; Loma Linda University Medical Center; Loma Linda; California
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Left ventricular volumes and systolic function after long-term right ventricular pacing may be predicted by paced QRS duration, but not pacing site. Heart Lung Circ 2013; 23:43-8. [PMID: 23806197 DOI: 10.1016/j.hlc.2013.04.122] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 04/23/2013] [Accepted: 04/27/2013] [Indexed: 01/20/2023]
Abstract
BACKGROUND Long-term right ventricular apical (RVA) pacing causes adverse left ventricular (LV) remodelling and clinical outcomes. METHODS Forty-one patients (19 men, mean age 70.9±14.2, 23 right ventricular septal and 18 RVA pacing) underwent pacemaker implantation for atrioventricular block. LV volumes and left ventricular ejection fraction (LVEF) were assessed by echocardiography 39.3±17.2 months after implantation. Predictors of left ventricular systolic volume (LVESV), left ventricular diastolic volume (LVEDV) and LVEF were analysed. RESULTS No difference was found between RVA pacing and right ventricular septal pacing groups in LVESV (40.6±22.6 vs 33±14.4ml; p=0.199), LVEDV (88.2±31.2 vs 73.7±23.9ml; p=0.102) and LVEF (56.1±8.6 vs 56±6.6%; p=0.996). With multivariate stepwise regression, only pQRSd and renal impairment independently predicted LVESV (β=0.522, 95% CI: 0.242-0.802; p=0.001 and β=40.3, 95% CI: 17.6-62.9; p=0.001 respectively), LVEDV (β=0.786, 95% CI: 0.338-1.235; p=0.001 and β=42.8, 95% CI: 6.6-79; p=0.022 respectively) and LVEF (β=-0.161, 95% CI: -0.283 to -0.04; p=0.011 and β=-14.8, 95% CI: -24.6 to -5.0; p=0.004 respectively). CONCLUSIONS pQRSd and renal impairment, but not pacing site or baseline LVEF, may be predictors for LV volumes and systolic function after long-term RV pacing. pQRSd may be target for pacing site optimisation.
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Curtis AB, Worley SJ, Adamson PB, Chung ES, Niazi I, Sherfesee L, Shinn T, Sutton MSJ. Biventricular pacing for atrioventricular block and systolic dysfunction. N Engl J Med 2013; 368:1585-93. [PMID: 23614585 DOI: 10.1056/nejmoa1210356] [Citation(s) in RCA: 538] [Impact Index Per Article: 48.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Right ventricular pacing restores an adequate heart rate in patients with atrioventricular block, but high percentages of right ventricular apical pacing may promote left ventricular systolic dysfunction. We evaluated whether biventricular pacing might reduce mortality, morbidity, and adverse left ventricular remodeling in such patients. METHODS We enrolled patients who had indications for pacing with atrioventricular block; New York Heart Association (NYHA) class I, II, or III heart failure; and a left ventricular ejection fraction of 50% or less. Patients received a cardiac-resynchronization pacemaker or implantable cardioverter-defibrillator (ICD) (the latter if the patient had an indication for defibrillation therapy) and were randomly assigned to standard right ventricular pacing or biventricular pacing. The primary outcome was the time to death from any cause, an urgent care visit for heart failure that required intravenous therapy, or a 15% or more increase in the left ventricular end-systolic volume index. RESULTS Of 918 patients enrolled, 691 underwent randomization and were followed for an average of 37 months. The primary outcome occurred in 190 of 342 patients (55.6%) in the right-ventricular-pacing group, as compared with 160 of 349 (45.8%) in the biventricular-pacing group. Patients randomly assigned to biventricular pacing had a significantly lower incidence of the primary outcome over time than did those assigned to right ventricular pacing (hazard ratio, 0.74; 95% credible interval, 0.60 to 0.90); results were similar in the pacemaker and ICD groups. Left ventricular lead-related complications occurred in 6.4% of patients. CONCLUSIONS Biventricular pacing was superior to conventional right ventricular pacing in patients with atrioventricular block and left ventricular systolic dysfunction with NYHA class I, II, or III heart failure. (Funded by Medtronic; BLOCK HF ClinicalTrials.gov number, NCT00267098.).
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Affiliation(s)
- Anne B Curtis
- Department of Medicine, University at Buffalo, Buffalo General Medical Center, 100 High St., D2-76, Buffalo, NY 14203, USA.
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Weizong W, Zhongsu W, Yujiao Z, Mei G, Jiangrong W, Yong Z, Xinxing X, Yinglong H. Effects of right ventricular nonapical pacing on cardiac function: a meta-analysis of randomized controlled trials. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2013; 36:1032-51. [PMID: 23438131 DOI: 10.1111/pace.12112] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Revised: 12/18/2012] [Accepted: 01/13/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND A meta-analysis of randomized controlled trials (RCTs) was conducted to compare the effects of right ventricular nonapical (RVNA) and right ventricular apical (RVA) pacing on cardiac function. METHODS A systematic literature search was performed using MEDLINE, EMBASE, and the Cochrane Library to identify RCTs comparing RVNA pacing with RVA pacing with follow-up ≥2 months. Twenty RCTs involving 1,114 patients were included. RESULTS Compared with RVA pacing, RVNA (mainly right ventricular septum [RVS]) pacing exhibited not only excellent pacing threshold and R-wave amplitude but also higher impedance. RVNA pacing showed a significant increase in left ventricular ejection fraction (LVEF) at the end of follow-up (weighted mean difference = 3.58, 95% confidence interval = 1.80-5.35), and the effects were observed in the following subgroups: 6-month follow-up, ≤12-month follow-up, >12-month follow-up, baseline LVEF ≤45%, and baseline LVEF >45%. RVS and RVA pacing significantly differed in improving LVEF (weighted mean difference = 4.82, 95% confidence interval = 2.78-6.87). In addition, RVNA pacing resulted in a narrower QRS duration, a smaller left ventricular end-systolic volume, and a lower New York Heart Association functional class. CONCLUSIONS This meta-analysis found that RVNA (mainly RVS) pacing exhibited satisfactory long-term lead performance compared with RVA pacing and demonstrated beneficial effects in improving LVEF after the 6-month follow-up. Furthermore, it proved superior to RVA pacing in terms of interventricular synchrony and cardiac function.
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Affiliation(s)
- Wang Weizong
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Jinan City, China
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Domenichini G, Sunthorn H, Fleury E, Foulkes H, Stettler C, Burri H. Pacing of the interventricular septum versus the right ventricular apex: a prospective, randomized study. Eur J Intern Med 2012; 23:621-7. [PMID: 22939807 DOI: 10.1016/j.ejim.2012.03.012] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 03/11/2012] [Accepted: 03/12/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Left ventricular (LV) function may be impaired by right ventricular (RV) apical pacing. The interventricular septum is an alternative pacing site, but randomized data are limited. Our aim was to compare ejection fraction (EF) resulting from pacing the interventricular septum versus the RV apex. METHODS RV lead implantation was randomized to the apex or the mid-septum. LVEF and RVEF were determined at baseline and after 1 and 4 years by radionuclide angiography. RESULTS We enrolled 59 patients, of whom 28 were randomized to the apical group and 31 to the septal group, with follow-up available in 47 patients at 1 year and 33 patients at 4 years. LVEF in the apical and in the septal groups was 55 ± 8% vs. 46 ± 15% (p=0.021) at 1 year and 53 ± 12% vs. 47 ± 15% (p=0.20) at 4 years. Echocardiography confirmed a mid-septal lead position in only 54% of patients in the septal group, with an anterior position in the remaining patients. In the septal group, LVEF decreased significantly in patients with an anterior RV lead (-10.0 ± 7.7%, p=0.003 at 1 year and -8.0 ± 9.5%, p=0.035 at 4 years), but not in patients who had a mid-septal lead. Left intraventricular dyssynchrony was significantly increased in case of an anterior RV lead. RVEF was not significantly impaired by RV pacing, regardless of RV lead position. CONCLUSIONS Pacing at the RV septum confers no advantage in terms of ventricular function compared to the apex. Furthermore, inadvertent placement of the RV lead in an anterior position instead of the mid-septum results in reduced LV function.
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Yusu S, Mera H, Hoshida K, Miyakoshi M, Miwa Y, Tsukada T, Yoshino H, Ikeda T. Selective site pacing from the right ventricular mid-septum. Follow-up of lead performance and procedure technique. Int Heart J 2012; 53:113-6. [PMID: 22688315 DOI: 10.1536/ihj.53.113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Pacing from the right ventricular (RV) apex is associated with adverse effects such as heart failure and atrial fibrillation. We attempted pacing from the RV mid-septum, which is theoretically a more physiological pacing site. A total of 172 consecutive patients with indications for permanent pacemaker implantation were studied. A screw-in lead and a curved stylet were used for lead positioning on the RV mid-septum. Pacemaker indices were evaluated at implantation and one year later. As an electrocardiographic parameter, QRS duration was measured in lead II. These data were compared to those of 66 patients subjected to conventional RV apical pacing. Lead placement was successful in all patients of RV mid-septal pacing. There were no technical problems during or after the procedure. The cumulative percentage of ventricular pacing at one year postimplantation was 85 ± 24 % in the SSP group. Sensing, pacing threshold, and lead impedance in the SSP group remained clinically stable over one year. When these measurements were compared between the SSP and AP groups, the pacing threshold and the lead impedance at one year postimplantation in the SSP group were higher (P < 0.05) and lower (P < 0.01), respectively, than those of the AP group. The mean QRS duration was markedly shorter (123 ± 16 versus 150 ± 18 msec, P < 0.0001). Selective site pacing from the RV mid-septum is feasible and results in less conduction delay compared to conventional RV apical pacing, and its procedure seems to be more physiological in permanent pacemaker implantation.
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Affiliation(s)
- Satoru Yusu
- Second Department of Internal Medicine, Kyorin University School of Medicine, Japan
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Kikuchi M, Tanno K, Miyoshi F, Munetsugu Y, Onuma Y, Ito H, Adachi T, Kawamura M, Asano T, Kobayashi Y. Long-term effectiveness of right septal pacing vs. right apical pacing in patients with atrioventricular block. J Arrhythm 2012. [DOI: 10.1016/j.joa.2012.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Right Ventricular Pacing, Mechanical Dyssynchrony, and Heart Failure. J Cardiovasc Transl Res 2011; 5:219-31. [DOI: 10.1007/s12265-011-9341-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Accepted: 12/11/2011] [Indexed: 11/25/2022]
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Kamenik L, Sedlon P, Hnatek T, Krcova E, Jarkovsky J, Taborsky M. Optimizing the pacing site in the ventricular septum by fluoroscopy and morphology of the paced QRS complex. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2011; 157:56-63. [PMID: 22660211 DOI: 10.5507/bp.2011.063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Accepted: 11/15/2011] [Indexed: 11/23/2022] Open
Abstract
AIMS To analyze the paced QRS duration in various septal positions of the right ventricular leads and with different paced QRS vectors. To use the results to assess parameters suggesting the optimal site for right ventricular pacing. METHODS AND RESULTS A total of 609 patients with leads implanted in the right ventricular septum were classified using fluoroscopy in the lateral view (the primary pacing site), and in the anteroposterior view (the secondary pacing site), according to the QRS vector in leads I and III. Significantly shortened paced QRS was found in the primary pacing site with the true septal compared with the anteroseptal site, with the vector being negative or isoelectric in lead I plus positive in lead III. In secondary pacing sites, no significant difference in pacing QRS duration was found between RVOT-HS, RVOT-LS, mid-septum and inferior-septum. CONCLUSIONS For optimization of the pacing site in the ventricular septum, the following are significant: the primary site based on the lateral view, and the paced QRS vector in leads I and III.
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Affiliation(s)
- Libor Kamenik
- Department od Medicine, First Faculty of Medicine, Charles University in Prague and Central Military Hospital Prague, Czech Republic
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Nikoo MH, Ghaedian MM, Kafi M, Fakhrpour A, Jorat MV, Pakfetrat M, Ostovan M, Emkanjoo Z. Effects of right ventricular septal versus apical pacing on plasma natriuretic peptide levels. J Cardiovasc Dis Res 2011; 2:104-9. [PMID: 21814414 PMCID: PMC3144617 DOI: 10.4103/0975-3583.83036] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: To investigate the contribution of right ventricular (RV) pacing sites to the cardiac function, this study compares plasma B-type natriuretic peptide (BNP) levels during RV septal and apical pacing in patients implanted with a pacemaker. Materials and Methods and Results: Seventy-four consecutive patients with indication for permanent pacing were included. To provide for the possibility of appropriate subgroup analyses, patients were stratified according to their pacing mode into two groups: Those with dual chamber DDD(R)/VDD pacemakers (41 patients, mean age 54.1±18.4 years), and those with single chamber VVI pacemakers (33 patients, mean age 60.6±18.4 years). A prospective single-blinded randomized design was used. Randomization (1:1 way) was between lead placement on the RV septum or RV apex and occurred during the implant in both groups. Compared to baseline, a significant decrease in BNP (429.8±103 pg/ml and 291.7±138 pg/ml, respectively) levels was observed during DDD(R) /VDD pacing after two months. In contrast, during VVI (R) pacing, a significant increase in BNP levels was observed (657.5±104 pg/ml and 889.5±139 pg/ml, respectively). To determine the impact of pacing sites on cardiac function, we assessed the changes in BNP levels in each group separately. Despite the significant difference in the pattern of changes between the two groups (P < 0.02), no significant changes were observed within groups regarding the acute effect of the pacing site (RV apex vs. RV septal) on BNP levels (P=NS). Conclusions: Our main result showed no significant differences between pacing sites and concluded that hemodynamic improvement could be substantially influenced by pacing mode, more than by pacing site.
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Affiliation(s)
- M H Nikoo
- Department of Pacemaker and Electrophysiology, Cardiovascular Research Centre, Shiraz, Iran
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Wang F, Shi H, Sun Y, Wang J, Yan Q, Jin W, Zhang J, Meng W, Zhang F, Chen G, Sun B. Right ventricular outflow pacing induces less regional wall motion abnormalities in the left ventricle compared with apical pacing. Europace 2011; 14:351-7. [PMID: 21946819 DOI: 10.1093/europace/eur309] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS This study aimed to explore if the right ventricular outflow tract (RVOT) pacing is superior to right ventricular apical (RVA) pacing on the overall left ventricular (LV) function and regional wall motion. METHODS AND RESULTS Sixty patients with atrio-ventricular (AV) block and normal ejection fraction undergoing dual-chamber pacemaker implantation were randomized to permanent ventricular stimulation either in the RVOT or the RVA. Left ventricular volume, ejection fraction, and LV regional wall motion were assessed by echocardiography. Right ventricular apical pacing had prolonged QRS duration, compared with RVOT pacing (154.1 ± 26.5 vs. 120.9 ± 22.3, P< 0.05). There were also significant differences in LV pre-ejection interval and interventricular mechanical delay (IVMD) at 12-month follow-up between the two groups, but none in the LV volume, left ventricular ejection fraction, and index of systolic synchrony (Ts-SD). During RVA pacing, the average peak systolic velocity (Sm) of 12 LV segments [3.5, 95% confidence interval (CI) 3.2-3.8 cm/s] had a trend of being lower compared with RVOT pacing (3.9, 95% CI 3.5-4.1 cm/s) (P= 0.09). Further analysis showed that the Sm at the inferior wall and posterior-septum wall was significantly decreased during RVA pacing compared with RVOT pacing. There were no significant differences for other LV segments. CONCLUSION The RVOT pacing in AV block patients over 1 year may be superior to RVA pacing in terms of regional LV performance, LV global electromechanical delay, and IVMD, although intraventricular dyssynchrony and LV volumes do not differ. Larger trials with clinical endpoints are warranted to conclusively define the advantages of RVOT or RV septal pacing.
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Affiliation(s)
- Fang Wang
- Division of Cardiology, Shanghai Jiao Tong University-Affiliated First People's Hospital, Shanghai 200080, China
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50
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Abstract
Cardiac pacing has played a significant role in mitigating morbidity and mortality associated with bradyarrhythmias. Throughout the years, advances made in battery reliability, lead performance, and device portability have rapidly expanded the use of cardiac pacemakers in many different disease states. Despite the benefits, there has been growing awareness of the potential deleterious effects of long-term artificial electrical stimulation including the development of ventricular dyssynchrony and atrial fibrillation. Given their association with an increased risk for heart failure and possibly death, several advances aimed at minimizing them have been made in recent years including changes in atrioventricular pacing algorithms, novel pacing mode modifications, and better identification of hemodynamically optimal pacing sites. This article reviews the advances made and the future direction of innovations in cardiac pacing.
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Affiliation(s)
- Alan Cheng
- Department of Medicine, Division of Cardiology, Section of Cardiac Electrophysiology, Johns Hopkins Medical Institutes, Baltimore, MD, USA.
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