Long-term outcomes in patients with atrioventricular block undergoing septal ventricular lead implantation compared with standard apical pacing

Abstract

With regard to different parameters of congestive heart failure, a septal stimulation site is not superior to conventional apical pacing in unselected patients undergoing pacemaker implantation for AV-block.

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

“…The RV septal pacing also resulted in shorter isovolumic relaxation than RV apical pacing (Yu et al, 2007), implicating better diastolic function that has been invasively demonstrated by Kolettis et al (Kolettis et al, 2000) at the cardiac catheterization laboratory. In fact despite the beneficial features of reducing electrical and mechanical dyssynchrony , different studies failed to demonstrate a positive effect on indices of LV structure and 85 function and did not confirm the above mentioned clinical outcomes, at least during the 3-18 months after implantation (Bourke et al, 2002;Victor et al, 2006;Kypta et al, 2008;Dabrowska-Kugacka et al, 2009;Gong et al, 2009;Cano et al, 2010) Kypta et al (Kypta et al, 2008) randomized 98 patients with atrioventricular block (AVblock) undergoing pacemaker implantation to positioning the ventricular lead in the high or mid septum (n =53) or in the apex (n = 45) of the right ventricle. The Changes of N-terminal pro-brain natriuetic peptide (BNP) levels, LVEF, and exercise capacity from baseline to 18 months were statistically not different between septal and apical stimulation.…”

“…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).…”

“…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). Many previous studies (Schwaab et al, 1999;Victor et al, 2006;Yu et al, 2007;Ng et al, 2009;Takemoto et al, 2009;Tse et al, Europace 2009, Gong et al, 2009Leong et al, 2010;Schwaab et al, 2001), have showed that septal pacing induced shorter paced QRS duration than RVA pacing did.…”

“…The clinical occurrence or deterioration of overt heart failure was similar in both treatment arms. Kypta et al (Kypta et al, 2008) concluded that septal stimulation site is not superior to conventional apical pacing in unselected patients undergoing pacemaker implantation for AVB. Gong et al (Gong et al, 2009) demonstrated that RVOT pacing did not benefit over RVA pacing in the aspect of preventing cardiac remodeling and protecting LV systolic function after 12 months of pacing in patients with normal cardiac function although it caused more synchronous LV contraction compared with RVA pacing.…”

“…With active fixation technology, lead placement and stability in the RVS are no longer a problem. Moreover, recently commercially approved stylets (Models 4140, 4150; St. Jude Medical, Sylmar,CA, USA) are available for septal positioning of ventricular leads, which resembles the manually shaped stylet described by the senior author in previous publications (Kypta et al, 2008;Rosso et al, 2010;McGavigan et al, 2006). In a large study, including 460 patients, Vlay et al (Vlay et al, 2006) reported on a 9 year experience of right ventricular outflow tract pacing, an excellent success rate and stable lead measurements over time, without an increased risk for acute or chronic complications compared with RVA pacing.…”