Right Ventricular Outflow Versus Apical Pacing in Pacemaker Patients with Congestive Heart Failure and Atrial Fibrillation

Stambler, Bruce S.; Ellenbogen, Kenneth A.; Zhang, Xiaozheng; Porter, Thomas R.; Xie, Feng; Malik, Rajesh; Small, Roy S.; Burke, Martin C.; Kaplan, Andrew; Nair, Lawrence; Belz, Michael; Fuenzalida, Charles E.; Gold, Michael R.; Love, Charles J.; Sharma, Arjun D.; Silverman, Russell; Sogade, Felix; Natta, Bruce W. Van; Wilkoff, Bruce L.

doi:10.1046/j.1540-8167.2003.03216.x

Cited by 193 publications

(160 citation statements)

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“…18) Additionally, the anatomical accuracy for RV outflow tract is poor and several reports have used inconsistent pacing sites: RV outflow tract free wall or septum. [14][15][16] This has led to procedural difficulties and a risk of complications such as pericardial fluid. 19) The SSP procedure that we introduce in this study enabled safe and accurate positioning of a lead in the RV mid-septum without complications that require a surgical procedure.…”

Section: Discussionmentioning

confidence: 99%

“…[9][10][11] In SSP, His-bundle or para-His pacing 12,13) and a procedure where a ventricular lead is positioned in the RV outflow tract have been used. [14][15][16] The former involves technical difficulties, whereas the latter has produced unsatisfactory longterm effects and also poses a high risk of complications such as pericardial effusion. 17) In this study, we evaluated the efficacy and safety of SSP in patients in whom RV leads were positioned in the middle of the RV septum (mid-septum) and compared it with conventional RV apex pacing.…”

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confidence: 99%

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Selective Site Pacing From the Right Ventricular Mid-Septum

et al. 2012

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SummaryPacing from the right ventricular (RV) apex is associated with adverse effects such as heart failure and atrial fibrillation. We attempted pacing from the RV mid-septum, which is theoretically a more physiological pacing site. A total of 172 consecutive patients with indications for permanent pacemaker implantation were studied. A screw-in lead and a curved stylet were used for lead positioning on the RV mid-septum. Pacemaker indices were evaluated at implantation and one year later. As an electrocardiographic parameter, QRS duration was measured in lead II. These data were compared to those of 66 patients subjected to conventional RV apical pacing. Lead placement was successful in all patients of RV mid-septal pacing. There were no technical problems during or after the procedure. The cumulative percentage of ventricular pacing at one year postimplantation was 85 ± 24 % in the SSP group. Sensing, pacing threshold, and lead impedance in the SSP group remained clinically stable over one year. When these measurements were compared between the SSP and AP groups, the pacing threshold and the lead impedance at one year postimplantation in the SSP group were higher (P < 0.05) and lower (P < 0.01), respectively, than those of the AP group. The mean QRS duration was markedly shorter (123 ± 16 versus 150 ± 18 msec, P < 0.0001). Selective site pacing from the RV mid-septum is feasible and results in less conduction delay compared to conventional RV apical pacing, and its procedure seems to be more physiological in permanent pacemaker implantation. (Int Heart J 2012; 53: 113-116) Key words: Pacing procedure, Selective site pacing, Physiological pacing, Right ventricular mid-septal pacing, Pacemaker implantation T he mainstream of pacing treatment for bradyarrhythmia has been pacing from the right ventricular (RV) apex, which has been regarded as physiological pacing, to maintain atrioventricular synchrony. However, with conventional RV apex pacing, the impulse is conducted from the apex to the base of the heart and from the right to the left ventricles, and therefore the time for impulse conduction in the ventricles is significantly prolonged.1,2) This procedure is reported to cause ventricular dyssynchrony, 3,4) resulting in an increased risk for occurrence of heart failure 5-7) or atrial fibrillation. 7,8) Recently, selective site pacing (SSP), where alternate sites for ventricular pacing are used, has come into use to improve ventricular dyssynchrony. 9-11)In SSP, His-bundle or para-His pacing 12,13) and a procedure where a ventricular lead is positioned in the RV outflow tract have been used.14-16) The former involves technical difficulties, whereas the latter has produced unsatisfactory longterm effects and also poses a high risk of complications such as pericardial effusion. 17)In this study, we evaluated the efficacy and safety of SSP in patients in whom RV leads were positioned in the middle of the RV septum (mid-septum) and compared it with conventional RV apex pacing. We also examined points to obtain f...

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Selective Site Pacing From the Right Ventricular Mid-Septum

et al. 2012

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“…In addition, it does not require special skills in vascular intervention and/or electrophysiology unlike implantation of the LV lead to the CS tributary. The position of the RVOT lead can easily be fluoroscopically controlled and when using screw-in leads it was proven to be stable and with excellent pacing and sensing parameters during long-term follow-up 11,12 . This potential advantage makes bifocal pacing plausible in patients with LV implantation failure who refuse surgical LV lead placement or in whom such a procedure appears to be too risky.…”

Section: Discussionmentioning

confidence: 99%

Bifocal pacing - A novel cardiac resynchronization therapy? Results of bifocal pacing study and review of the current literature

Bulava¹,

Lukl²

2006

BIOMED PAP

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Background: Bifocal pacing (BFP) has been proposed as a more feasible alternative of cardiac resynchronization therapy (CRT).Aim: To evaluate BFP in patients with severe congestive heart failure and significant intraventricular conduction delay and to compare it with biventricular pacing (BVP).Methods: Both echocardiographic examination including tissue Doppler imaging and invasive measurements of cardiac hemodynamics was performed under basal conditions and during BFP and BVP.Results: 50 patients were included: 29 patients with ischemic heart disease (IHD), 21 patients with idiopathic dilated cardiomyopathy (IDCM). Left ventricular (LV) pressure gradient (dp/dt max ) increased during BFP compared to the baseline (13.4 %, 95 % CI 9.2-17.6 %, p < 0.0001) and a further increase was achieved during BVP (29.5 %, 95 % CI 23.7-35.4 %, p < 0.0001). A significant correlation was found between the distance of the right ventricular apical and outflow tract leads and percentage of dp/dt max increase in IDCM patients (r = 0.72, p < 0.001), but not in IHD patients. Interventricular mechanical delay (IVMD) decreased in BFP compared to baseline (43 ± 22 ms vs. 53 ± 31 ms, p = 0.006). BVP produced even shorter IVMD (22 ± 19 ms, p < 0.0001). In all patients, the regional systolic contraction times were significantly shortened, corresponding with prolongation of the respective regional diastolic filling times during both BFP (p < 0.05 for all segments) and BVP (p < 0.001 for all segments). The effect of BVP on regional systole shortening was more pronounced.Conclusions: BFP improves LV hemodynamics by decreasing the inter-and intraventricular conduction delays. The leads in the right ventricle should be placed at the longest achievable distance. BVP is superior to BFP.

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“…RVOT and dual-site RV pacing shortened QRS duration but, after three months, did not consistently improve QOL or other clinical outcomes as compared with RVA pacing. 22 Zou et al assessed RVOT septal pacing in their retrospective analysis of 80 patients with complete AV block and normal cardiac function. 2 Patients who received either RVA pacing (n = 42) or RVOT septal pacing (n = 38) were included.…”

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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Right Ventricular Outflow Versus Apical Pacing in Pacemaker Patients with Congestive Heart Failure and Atrial Fibrillation

Abstract: In patients with CHF, LV dysfunction, and chronic AF, RVOT and dual-site RV pacing shorten QRS duration but after 3 months do not consistently improve QOL or other clinical outcomes compared with RVA pacing.

Cited by 193 publications

References 21 publications

Selective Site Pacing From the Right Ventricular Mid-Septum

Selective Site Pacing From the Right Ventricular Mid-Septum

Bifocal pacing - A novel cardiac resynchronization therapy? Results of bifocal pacing study and review of the current literature

Right Ventricular Septal Pacing: A Paradigm Shift

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