Functional abnormalities in patients with permanent right ventricular pacing

Abstract

This study demonstrates that preserved synchronous ventricular activation with RVOT pacing prevents the long-term deleterious effects of RVA pacing on myocardial perfusion and function in patients implanted with a permanent pacemaker.

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

“…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).…”

“…Indeed from experience, it is very hard to manipulate leads with fluoroscopy at 40° either from the left or right sided approach. 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.…”

“…The hemodynamic superiority of LV apex and LV septum pacing may be explained by a relatively physiological sequence of electrical activation when pacing from these sites (Mills et al, 2009;Peschar et al, 2003). Some investigators have proposed the idea of a hemodynamic "sweet spot," where each patient has a particular optimal pacing site (Karpawich & Mital, 1997;Tse et al, 2002;Tse et al, 2009 b). The ideal ventricular pacing site should resemble the normal activation and synchronicity of ventricular activation observed with an undamaged conduction system.…”

“…A pacing site that is in closer proximity with the proximal portion of His bundle at the RV septum should lead to a narrower QRS which in turn might reflect a lesser degree of activation delay compared with RVA pacing (Mera et al, 199;Schwaab et al, 1999;Tse et al, 2002) and less dyssynchrony, as demonstrated by multiple echocardiographic techniques (Tse et, 2002;Flevari et al, 2009;Takemoto et al, 2009;Gong et al, 2009;Leong et al, 2010;Cano et al, 2010). 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).…”

“…Results from acute and chronic studies are summarized in table 1 and show mixed results with a tendency toward better hemodynamic outcome when pacing at these alternative sites (Giudici et al, 1997;Kolettis et al, 2000;Tse et al, 2002;Yu et al, 2007;Flevari et al, 2009;Takemoto et al, 2009;Yoshikawa et al, 2010;Yu et al, 2009;de Cock et al, 2003). AF: atrial fibrillation; AV : atrioventricular; AVNA: AV node ablation; AVB: atrioventricular block; DDD: dual chamber pacing; HRA: high right atrium ; NA: not available; PSP: Peak systolic pressure; RVS: right ventricle septum; RVOT: right ventricle outflow tract; RVA: right ventricle apex; SSS: sick sinus syndrome; VA: ventricular asynchrony; VRR : ventricular rate regularization; VVI: single chamber ventricular pacing; * the study population included only children; § LVEF ≤45% in 12 patients; ¥ LVEF <40% in 14% of patients; ¤ LVEF<40% in 1 patient.…”