Selective Site Pacing:

Abstract

Selective site right ventricular pacing has been suggested as an approach to reduce the incidence of ventricular dysfunction and hopefully influence the morbidity resulting from traditional right ventricular apical pacing. Pacing from the right ventricular apex allows a stable ventricular rate, and together with atrial pacing and sensing, helps maintain atrioventricular synchrony but does not allow physiological activation of the left ventricle. Traditional atrial pacing sites like the right atrial appendage may encourage atrial tachyarrhythmias, whereas lead placement in right atrial septal sites may reduce the frequency of symptomatic atrial tachyarrhythmia episodes, especially when combined with prevention algorithms. Researchers attempting to pace the heart from these selective sites have been hindered by the lack of uniform definitions of where these sites actually lie and the inadequacy of tools to consistently reach these locations and verify correct placement. This lack of definition consensus may have contributed to the apparent conflict of data, particularly in the right ventricle. There is an urgent need for a standardization of terms and identifying measures for selective pacing sites.

Selective Site Pacing From the Right Ventricular Mid-Septum

“…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.…”

“…[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.…”

Optimizing the pacing site in the ventricular septum by fluoroscopy and morphology of the paced QRS complex

“…For the second classification, an anteroposterior view and methods modified by Lieberman were used 20 . The RV septum was divided into four areas.…”

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

“…However, Schwab et al (Schwaab et al, 2001) have found the detailed mapping of the RV with precise measurements of QRS duration has been found to be impractical. This lack of uniform definitions of where the alternate RV sites actually lie and the inadequacy of tools to consistently reach these locations and verify correct placement may account for the variability in lead positioning within the RVS and may have contributed to the mixed results regarding the long-term hemodynamic benefits of RVS pacing (Lieberman et al, 2004;Balt et al, 2010;Iaizzo et al, 2004). In a recent study, Balt et al (Balt et al, 2010) have concluded that in 143 patients in whom lead implantation in the RVOT was performed, a septal position was achieved in only one-third of patients.…”

“…Indeed from experience, it is very hard to manipulate leads with fluoroscopy at 40° either from the left or right sided approach. However, electrocardiographic criteria such as negative deflection of lead I and positive initial R-waves of the paced ventricular complex in leads II and III ( Schwaab et al, 2001;McGavigan et al,2006;Lieberman et al, 2004;Balt et al, 2010) or the narrowest paced QRS complex available during the mapping of the interventricular septum (Tse et al, 2002;Tse et al, 2009a;Tse et al, 2009b;Schwaab et al, 2001), were not used uniformly. Tse et al and Mera et al (Mera et al, 1999) have postulated that the paced QRS duration is a practical indicator for determining the optimal RV pacing site.…”