Upgrading Pacemaker Patients with Right Ventricular Apical Pacing to Right Ventricular Septal Pacing Improves Left Ventricular Performance and Functional Capacity

Tse, Hung‐Fat; Wong, Kwong-Kuen; Siu, Chung‐Wah; Zhang, Xuehua; Ho, Wai Yin; Lau, Chu‐Pak

doi:10.1111/j.1540-8167.2009.01470.x

Cited by 32 publications

(15 citation statements)

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“…Right ventricular (RV) septal pacing is thought to be better than RV apical pacing for shortening the QRS duration and for preserving left ventricular (LV) function [4,5]. However, there are no apparent data suggesting that RV septal pacing is better than RV apical pacing for patients’ prognosis.…”

Section: Introductionmentioning

confidence: 99%

Separated right and left ventricular excitation during right ventricular septal pacing in a patient with narrow QRS wave: a case report

et al. 2014

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IntroductionRight ventricular septal pacing is thought to be better than right ventricular apical pacing for shortening the QRS duration and for preserving left ventricular function. However, right ventricular septal pacing may not be effective in all cases. In this case report, we present a rare case in which right ventricular septal pacing induced thoroughly separated right and left ventricular excitation despite the presence of a relatively narrow QRS wave during atrium-only pacing.Case presentationWe report a case of 63-year-old Japanese man with cardiomyopathy with an implantable cardioverter defibrillator placement for ventricular tachycardia. Three years after implantation, he developed second-degree atrio-ventricular block. Therefore, atrio-ventricular sequential pacing was started; then his heart failure was much worsened. His electrocardiogram showed a dissociated biphasic QRS wave during right ventricular high-septal pacing, despite the presence of a non-fragmented QRS morphology during atrium-only pacing. An activation map during right ventricular high-septal pacing showed that right ventricular conduction started at the pacing site and ended at the right ventricular basal inferior site. Subsequently after a 10ms interval, left ventricular conduction started at the left ventricular posteroseptum and ended at the left ventricular lateral wall. These data indicate that during right ventricular high-septal pacing, the first component of the QRS wave supposedly reflects only right ventricular excitation and the second component only left ventricular excitation. Also due to the intracardiac electrograms, it was assumed that this phenomenon was caused by transversely limited severe transseptal conduction disturbance.ConclusionIt should be noted that even ventricular septal pacing could evoke harmful interventricular dyssynchrony due to transversely limited severe septal conduction disturbance, despite the presence of a relatively narrow QRS wave.

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Section: Introductionmentioning

confidence: 99%

Separated right and left ventricular excitation during right ventricular septal pacing in a patient with narrow QRS wave: a case report

et al. 2014

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“…Right ventricular septal (RVS) pacing has been introduced to avoid this apparent and unpredictable complication of RVA pacing, because this pacing site appears to deliver a more physiological electrical activation of both ventricles, visible with a shorter paced QRS complex, than with RVA pacing [4,5]. …”

Section: Introductionmentioning

confidence: 99%

Acute left ventricular dysfunction secondary to right ventricular septal pacing in a woman with initial preserved contractility: a case report

et al. 2011

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IntroductionRight ventricular apical pacing-related heart failure is reported in some patients after long-term pacing. The exact mechanism is not yet clear but may be related to left ventricular dyssynchrony induced by right ventricular apical pacing. Right ventricular septal pacing is thought to deteriorate left ventricular function less frequently because of a more normal left ventricular activation pattern.Case presentationWe report the case of a 55-year-old Tunisian woman with preserved ventricular function, implanted with a dual-chamber pacemaker for complete atrioventricular block. Right ventricular septal pacing induced a major ventricular dyssynchrony, severe left ventricular ejection fraction deterioration and symptoms of congestive heart failure. Upgrading to a biventricular device was associated with a decrease in the symptoms and the ventricular dyssynchrony, and an increase of left ventricular ejection fraction.ConclusionRight ventricular septal pacing can induce reversible left ventricular dysfunction and heart failure secondary to left ventricular dyssynchrony. This complication remains an unpredictable complication of right ventricular septal pacing.

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“…Studies comparing RV outflow tract (RVOT) with RV apical pacing have been available for more than a decade and include descriptive techniques for RVOT lead positioning 20 . Both acute 21–31 and chronic 32–42 human studies have been undertaken utilizing a variety of alternate RV sites, including the mid RV and RVOT regions as well as patients with or without atrial fibrillation and LV dysfunction. Despite the paucity of robust data from these acute and chronic heterogeneous studies due to inconsistent experimental methods, the results, however, demonstrate a number of important findings.…”

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confidence: 99%

“…There have been 11 published chronic studies since 1999. Five were conducted for up to 6 months 32,33,35–37 with only one positive, 33 whereas those conducted for 12–18 months were generally positive 34,38,40–42 with only one study showing no physiologic benefit with alternate site pacing 39 . In particular, the study by Tse et al 34 did not show significant physiologic differences between the two groups until 18‐month postimplant.…”

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confidence: 99%

Pacing the Right Ventricular Septum: Time to Abandon Apical Pacing

Mond

Vlay

2010

Pacing and Clinical Electrophysiology

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Since the dawn of transvenous cardiac pacing, almost 50 years ago, 1 the right ventricular (RV) apex has been the default site for endocardial transvenous ventricular lead implantation due to the ease of placement, stability, and lead design. However, prolonged pacing from the RV apex has recently been shown to result in progressive left ventricular (LV) dysfunction, 2-6 due to a remodeling process consequent to abnormal ventricular activation and contraction. [7][8][9][10][11][12][13][14][15][16] This deleterious effect has prompted an interest in alternate ventricular pacing sites with a more favorable hemodynamic profile. Among the different sites for RV pacing, the septal areas are theoretically associated with a more physiological ventricular activation resembling that of normal atrio-ventricular (AV) conduction from base to apex. 17 True RV septal pacing has until recently been difficult to consistently achieve. Some of these difficulties relate to the lack of suitable lead technology, the nonstandardized nomenclature, and the inability to consistently and accurately position the pacing leads onto the septum because of its posterior orientation within the RV chamber. 18 We now have a much clearer understanding of the relationship between the anatomy of the RV chamber and the fluoroscopic appearances and electrocardiographic patterns, which in turn has allowed successful development of tools to reliably direct active-fixation leads onto the true RV septum. 19 Why then has RV septal pacing not been universally adopted in preference to RV apical pacing? The most quoted reason is that there is no unequivocal proof that RV septal pacing Disclosures: HM has designed a commercially available right ventricular septal stylet (St. Jude Medical, Sylmar, CA, USA), but has no financial interest in the product.Address for reprints: Assoc. Prof. Harry G.is physiologically superior to RV apical pacing. Studies comparing RV outflow tract (RVOT) with RV apical pacing have been available for more than a decade and include descriptive techniques for RVOT lead positioning. 20 Both acute 21-31 and chronic 32-42 human studies have been undertaken utilizing a variety of alternate RV sites, including the mid RV and RVOT regions as well as patients with or without atrial fibrillation and LV dysfunction. Despite the paucity of robust data from these acute and chronic heterogeneous studies due to inconsistent experimental methods, the results, however, demonstrate a number of important findings.No studies suggest that RV alternate pacing sites are physiologically inferior to the RV apex. Although a number of the studies refer to pacing site as RV septal, there has been to date little instruction on how to either position leads or confirm septal sites. Consequently, most studies, and in particular the earlier reports, are potentially flawed in that the leads were positioned in the mid RV or RVOT, but not necessarily septal. In a report of RVOT pacing using a simple curved stylet, probably similar to the tool used in many of the studies...

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Upgrading Pacemaker Patients with Right Ventricular Apical Pacing to Right Ventricular Septal Pacing Improves Left Ventricular Performance and Functional Capacity

Cited by 32 publications

References 30 publications

Separated right and left ventricular excitation during right ventricular septal pacing in a patient with narrow QRS wave: a case report

Separated right and left ventricular excitation during right ventricular septal pacing in a patient with narrow QRS wave: a case report

Acute left ventricular dysfunction secondary to right ventricular septal pacing in a woman with initial preserved contractility: a case report

Pacing the Right Ventricular Septum: Time to Abandon Apical Pacing

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