A Comparison of Ventricular Function During High Right Ventricular Septal and Apical Pacing after His‐Bundle Ablation for Refractory Atrial Fibrillation

Abstract

This study compares LV performance during high right ventricular septal (RVS) and apical (RVA) pacing in patients with LV dysfunction who underwent His-bundle ablation for chronic AF. We inserted a passive fixation pacing electrode into the RVA and an active fixation electrode in the RVS. A dual chamber, rate responsive pulse generator stimulated the RVA through the ventricular port and the RVS via the atrial port. Patients were randomized to initial RVA (VVIR) or RVS (AAIR) pacing for 2 months. The pacing site was reversed during the next 2 months. At the 2 and 4 month follow-up visit, each patient underwent a transthoracic echocardiographical study and a rest/exercise first pass radionuclide ventriculogram. We studied nine men and three women (mean age of 68 +/- 7 years) with congestive heart failure functional Class (NYHA Classification): I (3 patients), II (7 patients), and III (2 patients). The QRS duration was shorter during RVS stimulation (158 +/- 10 vs 170 +/- 11 ms, P < 0.001). Chronic capture threshold and lead impedance did not significantly differ. LV fractional shortening improved during RVS pacing (0.31 +/- 0.05 vs 0.26 +/- 0.07, P < 0.01). RVS activation increased the resting first pass LV ejection fraction (0.51 +/- 0.14 vs 0.43 +/- 0.10, P < 0.01). No significant difference was observed during RVS and RVA pacing in the exercise time (5.6 +/- 3.2 vs 5.4 +/- 3.1, P = 0.6) or the exercise first pass LV ejection fraction (0.58 +/- 0.15 vs 0.55 +/- 0.16, P = 0.2). The relative changes in QRS duration and LV ejection fraction at both pacing sites showed a significant correlation (P < 0.01). We conclude that RVS pacing produces shorter QRS duration and better chronic LV function than RVA pacing in patients with mild to moderate LV dysfunction and chronic AF after His-bundle ablation.

Permanent His-Bundle Pacing After Atrioventricular Node Ablation in a Patient With Chronic Atrial Fibrillation and Mitral Regurgitation

“…2 However, hemodynamic deterioration in relation to worsening mitral regurgitation (MR) can occur in a small number of patients following AVN ablation and pacing therapy 5,6 and those with moderate MR prior to the ablation seem prone to this complication. 5,7 High right ventricular (RV) septal pacing produces shorter QRS duration and better chronic LV function than RV apical pacing in patients with mild to moderate LV dysfunction and chronic atrial fibrillation after AVN ablation, [8][9][10][11] but direct His-bundle pacing produces a more physiological ventricular contraction and may result in less worsening of MR in comparison. 12,13 We describe a case of successful permanent His-bundle pacing after AVN ablation in a patient with chronic atrial fibrillation and MR.…”

Permanent Cardiac Pacing in Adults with High Grade Atriovetricular Block and Preserved Left Ventricular Function: Optimal Mode and Site of Pacing

“…Pacing on the right ventricular (RV) septum, at high (septal RVOT pacing) (Giudici et al, 1997;Kolettis et al, 2000;Bourke et al, 2002;Tse et al, 2002;Dabrowska-Kugacka et al, 2009;Gong et al, 2009;Leong et al, 2010;Yoshikawa et al, 2010), mid (Yu et al, 2007;Cano et al, 2010;Muto et al, 2007) or lower (Flevari et al, 2009) septal pacing position has been introduced as a potentially favorable alternative to RVA pacing to preserve a more physiologic ventricular activation. Previous investigations of alternative pacing sites have yielded inconsistent results (Mera et al, 1999;Giudici et al, 1997;Bourke et al, 2002;Victor et al, 2006;Kypta et al, 2008;Dabrowska-Kugacka et al, 2009;Tse et al Europace 2009;Victor et al, 1999) which may be attributable, in part, to the fact that the pacing site was determined on a topological rather than functional basis (Giudici & Karpawich, 1999). Many previous studies (Schwaab et al, 1999;Victor et al, 2006;Yu et al, 2007;Ng et al, 2009;Takemoto et al, 2009;Tse et al, Europace 2009, Gong et al, 2009Leong et al, 2010;Schwaab et al, 2001), have showed that septal pacing induced shorter paced QRS duration than RVA pacing did.…”

“…However, electrocardiographic criteria such as negative deflection of lead I and positive initial R-waves of the paced ventricular complex in leads II and III ( Schwaab et al, 2001;McGavigan et al,2006;Lieberman et al, 2004;Balt et al, 2010) or the narrowest paced QRS complex available during the mapping of the interventricular septum (Tse et al, 2002;Tse et al, 2009a;Tse et al, 2009b;Schwaab et al, 2001), were not used uniformly. Tse et al and Mera et al (Mera et al, 1999) have postulated that the paced QRS duration is a practical indicator for determining the optimal RV pacing site. However, Schwab et al (Schwaab et al, 2001) have found the detailed mapping of the RV with precise measurements of QRS duration has been found to be impractical.…”

“…Right Ventricular Apical permanent pacing could have negative hemodynamic effects. Initially, attention was directed to RV outflow tract/septum pacing and His/para-Hisian pacing in patients with LV dysfunction ( Mera et al, 1999;Schwaab et al, 1999;Buckingham et al, 1997;Buckingham et al, 1998;de Cock et al, 1998) and latter in preserved LV function patients (Giudici et al, 1997;Karpawich & Mital, 1997;Kolettis et al, 2000;Bourke et al, 2002;Tse et al, 2002;Occhetta et al, 2006;Victor et al, 2006;Yu et al, 2007;Kypta et al, 2008;Flevari et al, 2009;Ng et al, 2009;Dabrowska-Kugacka et al, 2009;Takemoto et al, 2009;Gong et al, 2009;Rosso et al, 2010;Verma et al , 2010;106:806-9;Leong et al, 2010;Cano et al,. 2010;Yoshikawa et al, 2010) while subsequently biventricular stimulation began to emerge as an appealing alternative proposal (Yu et al, 2009;Simantirakis et al, 2009;Doshi et al, 2005).…”

Tricuspid Valve Regurgitation After Antiarrhythmic Device Implantation

“…След-ствием апикальной стимуляции является запоз-далое сокращение папиллярных мышц ПЖ с формированием ТР [39]. Выбор альтернатив-ной области стимуляции, например области выводного тракта ПЖ, согласно данным ряда авторов [28,[46][47], является одним из приори-тетов. Эксперты считают, что при апикально имплантированных электродах существует больший риск повреждения аппарата ТК, осо-бенно задней створки, в сравнении с электрода-ми, фиксированными в области выводного тракта ПЖ.…”