Comparison of right ventricular septal pacing and right ventricular apical pacing in patients receiving cardiac resynchronization therapy defibrillators: the SEPTAL CRT Study

Abstract

AimsCardiac resynchronization therapy (CRT) is a recommended treatment of heart failure (HF) patients with depressed left ventricular ejection fraction and wide QRS. The optimal right ventricular (RV) lead position being a matter of debate, we sought to examine whether RV septal (RVS) pacing was not inferior to RV apical (RVA) pacing on left ventricular reverse remodelling in patients receiving a CRT-defibrillator.Methods and resultsPatients (n = 263, age = 63.4 ± 9.5 years) were randomly assigned in a 1:1 ratio to RVS (n = 131) vs. RVA (n = 132) pacing. Left ventricular end-systolic volume (LVESV) reduction between baseline and 6 months was not different between the two groups (−25.3 ± 39.4 mL in RVS group vs. −29.3 ± 44.5 mL in RVA group, P = 0.79). Right ventricular septal pacing was not non-inferior (primary endpoint) to RVA pacing with regard to LVESV reduction (average difference = −4.06 mL; P = 0.006 with a −20 mL non-inferiority margin). The percentage of ‘echo-responders’ defined by LVESV reduction >15% between baseline and 6 months was similar in both groups (50%) with no difference in the time to first HF hospitalization or death (P = 0.532). Procedural or device-related serious adverse events occurred in 68 patients (RVS = 37) with no difference between the two groups (P = 0.401).ConclusionThis study demonstrates that septal RV pacing in CRT is non-inferior to apical RV pacing for LV reverse remodelling at 6 months with no difference in the clinical outcome. No recommendation for optimal RV lead position can hence be drawn from this study.ClinicalTrials. gov numberNCT 00833352.

Clinical and echocardiographic response of apical vs nonapical right ventricular lead position in CRT: A meta‐analysis

“…We retrieved 82 citations from electronic database and manual searches as shown in Figure . We reviewed 16 citations for full‐text articles; 7 full‐text articles were included in the final analysis . Four of the included studies were post hoc analyses of the RCTs and one was randomized crossover trial .…”

“…We reviewed 16 citations for fulltext articles; 7 full-text articles were included in the final analysis. [17][18][19][20][21][22][23] Four of the included studies were post hoc analyses of the RCTs [19][20][21][22] and one was randomized crossover trial. 21 All the included studies were published between 2011 and 2016.…”

Long‐Term Outcomes of Cardiac Resynchronization Therapy Using Apical Versus Nonapical Left Ventricular Pacing

“…In the REVERSE trial, no differences in a composite clinical score were observed between RV apical and nonapical lead positions 3. In the SEPTAL‐CRT (SEPTAL‐cardiac resynchronization therapy) study,19 the LV reverse remodeling response as well as total mortality or HF hospitalization were similar with RV apical and nonapical lead positions. The present study adds further evidence for a lack of influence on outcomes of RV pacing site (apical or septal) in CRT.…”

Optimal site selection and image fusion guidance technology to facilitate cardiac resynchronization therapy

“…Early work evaluating non-apical RV pacing conducted by Khan et al [117] showed that LV remodeling rates were unaffected by RV lead position, while Kutyifa et al [118] also highlighted a higher risk of ventricular arrhythmias. The SEPTAL CRT study randomly assigned patients to receive either a septal or apical RV lead and demonstrated no significant difference in clinical outcome [119]. …”