Pacing-associated left ventricular dysfunction? Think reprogramming first!

Abstract

Programming standard pacemakers to avoid RV pacing is safe, does not adversely affect patients' symptoms or quality of life and is associated with improved LV function, related to the reductions in RV pacing percentage.

The desire for physiological pacing: Are we there yet?

“…In the Mode Selection Trial (MOST), which randomized 2010 patients to single or dual chamber pacing, a 10% increased burden of RVp translated into a 20% risk of hospitalization for heart failure . These studies and others emphasize the avoidance of unnecessary RV pacing …”

“…21 These studies and others emphasize the avoidance of unnecessary RV pacing. 22 The combination of experimental studies, particularly those showing adverse left ventricular cellular effects, together with clinical studies strongly suggest that RV pacing increases the risk of unfavourable clinical outcomes. Over the past 30 years, such concerns have driven interest in pacing from sites other than the RVA.…”

Heart failure and right ventricular pacing – how to avoid the need for cardiac resynchronization therapy

“…We have previously described that in an unselected cohort of in 66 patients with a longterm pacemaker (8-12 years) a pre-specified protocol (Figure 2) [9] including reducing the day-time base rate to 50 beats per minute, with a nocturnal, sleep or hys teresis rate to 40 beats per minute, deactivating rate-adaptive pacing, extending the AV delays or activating an algorithm to reduce unnecessary RV pacing, led to a reduction in mean RV pacing percentage by 49 (95% CI: 41-57)%, (p<0.001) [57]. This was associated with an improvement in LVEF of 6 (95% CI: 4-8)% (p<0.001) with no adverse effect on quality of life as measured using the validated EQ-5D questionnaire designed by the EuroQol group in order to standardize the measures.…”

“…However, long term right ventricular (RV) pacing has been linked to adverse left ventricular (LV) remodeling, [4,5] such that the most common long-term complication of standard pacemaker therapy is pacemaker-associated chronic heart failure (CHF) due to left ventricular systolic dysfunction (LVSD) [6,7,8]. Whilst up to 2-3% of the general population have CHF, the condition is much more common in pacemaker patients with a prevalence up to 50% [7,9] and 12% of people admitted with acute decompensated heart failure (HF) (4% with a de novo admission for heart failure) have a pacemaker [10].…”

The deleterious effects of RV pacing: applicable to all patients?

“…In their paper Gierula et al ,1 present results from a small prospective series of 66 consecutive patients who, at the time of pulse generator replacement, underwent programming changes to minimise unnecessary pacing of the RV. While substantial data exists from randomised trials to suggest RV pacing is detrimental in patients with heart failure, whether long-term RV pacing is safe in patients with normal or mildly impaired cardiac function remains an unanswered question.…”