Beneficial effects of right ventricular non-apical vs. apical pacing: a systematic review and meta-analysis of randomized-controlled trials

Shimony, Avi; Eisenberg, Mark J.; Filion, Kristian B.; Amit, Guy

doi:10.1093/europace/eur240

Cited by 192 publications

(160 citation statements)

References 38 publications

(49 reference statements)

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“…Meta-analysis by Shimony et al concluded that non-RVAP generally was not inferior to RVAP and that the longer the study period, at least more than 1 year, the more likely the result would favor non-RVAP. A review of individual studies shows that other sources of variation are also important, including duration of follow-up, lead position, percentage pacing, and baseline LV function [4].…”

Section: Discussionmentioning

confidence: 99%

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Changes in left ventricular global and regional longitudinal strain during right ventricular pacing

Algazzar¹,

Katta²,

Ahmed³

et al. 2016

ica

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Background:Our study aimed to demonstrate the short-term impacts of right ventricular apical pacing (RVAP) and right ventricular septal pacing (RVSP) on left ventricular (LV) regional longitudinal strain (RLS) and global longitudinal strain (GLS) in patients with preserved ejection fraction (EF). LV strain and functions may be altered by RVAP. RVSP might be a better alternative. The detrimental effect of right ventricular (RV) pacing may be mediated by regional LV impairment.

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Section: Discussionmentioning

confidence: 99%

“…In a review of 14 randomized studies, Shimony et al found that right ventricular mid-septal pacing (RVMSP) is associated with a better left ventricular ejection fraction (LVEF) during follow-up, compared with right ventricular apical pacing (RVAP) [4].…”

Section: Introductionmentioning

confidence: 99%

Changes in left ventricular global and regional longitudinal strain during right ventricular pacing

Algazzar¹,

Katta²,

Ahmed³

et al. 2016

ica

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“…23 Fourteen randomized controlled trials including 754 patients from 1999 to 2010 were reviewed. It was noted that those patients randomized to RVNA pacing at 12 months' follow-up had greater LV function (95% CI: 2.79-12.27).…”

Section: Studies Evaluating Right Ventricular Outflow Tract and Rightmentioning

confidence: 99%

“…Additionally, the small sample size and limited data on exercise capacity, New York Heart Association functional class, QOL, and survival yielded inconclusive results within these trials. 23 However, the Protection of LV Function During RV Pacing (PROTECT-PACE) trial, a randomized prospective multicenter study that compared change in LVEF between RVA pacing and high-septal RV pacing over a two-year period, had contrasting findings. The primary endpoint was intrapatient change in LVEF as assessed by transthoracic echocardiography (TTE).…”

Section: Studies Evaluating Right Ventricular Outflow Tract and Rightmentioning

confidence: 99%

Right Ventricular Septal Pacing: A Paradigm Shift

Worsnick

Sharma

Vijayaraman

2018

J Innov Cardiac Rhythm Manage

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Several studies conducted in the past 10 years have demonstrated the adverse effects of conventional RVA pacing. The Mode Selection Trial (MOST) study included a total of 2,010 patients with sick sinus syndrome who underwent dual-chamber pacemaker implants that were programmed to either a DDD or VVI mode. At three years following implantation, HF hospitalizations were found to have occurred in 12.3% of the VVI group and 10.3% of the DDD group. Of these, 50% were due to new-onset HF. Patients with a greater than 40% ventricular pacing rate in the DDD group and those with a more than 80% pacing rate in the VVI group had a twofold risk of heart failure events [DDD adjusted hazard ratio (HR): 2.60, 95% confidence interval (CI): 1.05-6.47; p < 0.05 and VVI HR: 2.50, 95% CI: 1.44-4.36; p < 0.05]. The similar increase in HF events in patients with both DDD and VVI pacing modes suggests that RVA pacing was independently associated with higher HF events, regardless of atrioventricular (AV) synchrony. 5 A substudy of the MOST trial further demonstrated that the

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“…A recent cross-sectional multicenter study demonstrated that for pacing in RV, there is no better alternative to apex [5]. The systematic review and metaanalysis of all randomized controlled studies in DDD patients compared to RValternative sites pacing versus apical provided inconclusive results with respect to exercise capacity, functional class, quality of life, and survival [6]. Additionally, the conclusion of the recently published PROTECT-PACE study demonstrated that in patients with AV block and preserved LV function requiring a high percentage of RVP, septal pacing does not provide a protective effect on LV function over RV apical pacing and a significantly greater time was required to I. E. Ovsyshcher Cardiology, Faculty of Health Sciences, Ben-Gurion University, Beersheva, Israel place the lead in the septal position [7].…”

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confidence: 99%

Common sense or evidence: an optimal place for right and left ventricular leads?

Ovsyshcher

2015

J Interv Card Electrophysiol

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BAll true knowledge contradicts common sense.M andell Creighton, Cambridge professor of British history and a Bishop of the Church of England.Increased understanding and recognition of the chronic adverse effects of right ventricular (RV) pacing (mainly apical) in the last decade has stimulated interest in strategies for its attenuation. These effects, left ventricular (LV) remodeling, progressive LV systolic dysfunction, and increased risk in heart failure (HF), may be due to dyssynchronous myocardial electrical activation that bypasses the native cardiac conduction, manifesting itself on the surface ECG as QRS widening. Accordingly, a number of different pacing algorithms have been developed that reduce the degree of RV pacing. Despite expectations regarding the physiological rationale of DDD pacing with algorithms minimizing RV pacing, the results of the ANSWER study [1] as well as three other previous large randomized trials (DANPACE, PreFERMVP, and MINE RVA) fail to demonstrate an overwhelming advantage of pacing minimization approaches over conventional pacing [1]. This lack of significant clinical effect is contrary to expectations and common sense. Explanations for this obvious contradiction have been discussed [1].An additional approach to reducing damage of RV pacing (RVP) was the selection of a new or alternative site such as His bundle/para Hisian tissues or various Bseptal^positions. The most interesting and feasible location is the upper part of the septum because of its proximity to the His bundle which renders it the earliest zone in heart depolarization [2]. Consequently, the QRS here is narrower than from the apex. Moreover, this part of the septum is trabeculated and suitable for active fixation leads. Speculations that pacing from this rather than from other areas would achieve better heart contraction, especially from the apex, is a feasible solution for many implanters and they routinely use this approach hoping to decrease the future risks of pacing-induced HF [2]. Furthermore, some enthusiasts recommend RV septal pacing as a substitute for CRT. Subsequently, the recent EHRA/HRS expert consensus noted regarding RV lead location: Bseptal pacing may be preferred in conventional pacemakers^ [3]. However, experimental and clinical studies demonstrated that various RV pacing sites did not recruit the His-Purkinje system [2,4]. The majority of LV activation instead occurred via slow and dyssynchronous direct myocardial to myocardial cell conduction and that in terms of mechanical dyssynchrony, hemodynamic and electrical parameters septal pacing was not superior to RVapical pacing [2,4]. A recent cross-sectional multicenter study demonstrated that for pacing in RV, there is no better alternative to apex [5]. The systematic review and metaanalysis of all randomized controlled studies in DDD patients compared to RValternative sites pacing versus apical provided inconclusive results with respect to exercise capacity, functional class, quality of life, and survival [6]. Additionally, the conclusion o...

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Beneficial effects of right ventricular non-apical vs. apical pacing: a systematic review and meta-analysis of randomized-controlled trials

Abstract: While RCTs suggest that LVEF is higher with RVNA than with RVA pacing, there remains a need for large RCTs to compare the safety and efficacy of RVNA and RVA pacing.

Cited by 192 publications

References 38 publications

Changes in left ventricular global and regional longitudinal strain during right ventricular pacing

Changes in left ventricular global and regional longitudinal strain during right ventricular pacing

Right Ventricular Septal Pacing: A Paradigm Shift

Common sense or evidence: an optimal place for right and left ventricular leads?

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