The Effects of Right Ventricular Apical Pacing on Ventricular Function and Dyssynchrony

Abstract

Cardiac pacing is the only effective treatment for patients with sick sinus syndrome and atrioventricular conduction disorders. In cardiac pacing, the endocardial pacing lead is typically positioned at the right ventricular (RV) apex. At the same time, there is increasing indirect evidence, derived from large pacing mode selection trials and observational studies, that conventional RV apical pacing may have detrimental effects on cardiac structure and left ventricular function, which are associated with the development of heart failure. These detrimental effects may be related to the abnormal electrical and mechanical activation pattern of the ventricles (or ventricular dyssynchrony) caused by RV apical pacing. Still, it remains uncertain if the deterioration of left ventricular function as noted in a proportion of patients receiving RV apical pacing is directly related to acutely induced left ventricular dyssynchrony. The upgrade from RV pacing to cardiac resynchronization therapy may partially reverse the deleterious effects of RV pacing. It has even been suggested that selected patients with a conventional pacemaker indication should receive cardiac resynchronization therapy to avoid the deleterious effects. This review will provide a contemporary overview of the available evidence on the detrimental effects of RV apical pacing. Furthermore, the available alternatives for patients with a standard pacemaker indication will be discussed. In particular, the role of cardiac resynchronization therapy and alternative RV pacing sites in these patients will be reviewed.

One-year cardiac morphological and functional evolution following permanent pacemaker implantation in right ventricular septal position in chagasic patients

“…Three radiological incidents were used: postero anterior (PA), 10° exist in the literature and the place of choice for implanting the right ventricular electrode has yet to be defined 35 . Moreover, the impact of alternative sites for endocardial pacing has not been prospectively evaluated in Chagas cardiomyopathy.…”

“…For nearly 40 years since the advent of cardiac pacing, the right ventricular apex has been considered the preferred site for ventricular electrode implantation in conventional pacemakers. The assessment of damage caused by iatrogenic left bundle branch block produced by right ventricle unifocal pacing in cardiac pacemakers is a relatively recent concern 35,[38][39][40][41][42] . The main harmful effects are as follows: increased iatrogenic intraventricular conduction delay; left ventricular electrical and mechanical dyssynchrony; left ventricular remodeling; myocardial histopathological changes; left ventricular dysfunction (systolic and diastolic); congestive heart failure; myocardial perfusion defects and changes in segmental mobility; functional mitral regurgitation; increased risk of atrial fibrillation, sinus node dysfunction and normal baseline QRS; left atrial enlargement; ventricular arrhythmias; and activation of the sympathetic nervous system.…”

Right Ventricular Septal Pacing: A Paradigm Shift

“…3 In the last decade (2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010), more data have emerged on the association of RVA pacing and left ventricular (LV) systolic dysfunction, heart failure (HF), ventricular remodeling, atrial fibrillation (AF), and increased mortality. 4 Alternative sites of ventricular pacing, particularly the RV septum and His bundle, have been evaluated for use in patients with a need for long-term ventricular pacing. In this article, we risk of hospitalization for HF increased by 20% for every 10% increase in RV pacing rate.…”

Current possibilities of permanent pacing for prevention of atrial fibrillation and heart failure progression

“…Стимуляция из верхушки ПЖ нарушает электрическую и механиче-скую систолу желудочков вследствие изменения не толь-ко нормальной последовательности, но и скорости про-ведения импульса, так как распространение волны воз-буждения через миокард происходит гораздо медленнее, чем через систему Гиса-Пуркинье [21]. Данные измене-ния схожи с патологическими процессами, которые раз-виваются при блокаде левой ножки пучка Гиса [26].Желудочковая диссинхрония может привести к изме-нениям метаболизма и перфузии миокарда, ремоделиро-ванию, а также к нарушению гемодинамики и сократи-тельной функции левого желудочка (ЛЖ) [11,23].В нескольких исследованиях было показано, что по-стоянная правожелудочковая апикальная стимуляция мо-жет ухудшить региональную перфузию миокарда [13,24,25]. Так, дефекты перфузии ЛЖ имелись у 65% пациентов, у большинства из которых по данным ангиографии были выявлены неизмененные коронарные артерии.…”

“…Желудочковая диссинхрония может привести к изме-нениям метаболизма и перфузии миокарда, ремоделиро-ванию, а также к нарушению гемодинамики и сократи-тельной функции левого желудочка (ЛЖ) [11,23].…”