The importance of avoiding unnecessary right ventricular pacing in clinical practice

Abstract

Symptomatic bradycardia is effectively treated with the implantation of a cardiac pacemaker. Although a highly successful therapy, during recent years there has been a focus on the negative effects associated with long-term pacing of the apex of the right ventricle (RV). It has been shown in both experimental and clinical studies that RV pacing leads to ventricular dyssynchrony, similar to that of left bundle branch block, with subsequent detrimental effects on cardiac structure and function, and in some cases adverse clinical outcomes such as atrial fibrillation, heart failure and death. There is substantial evidence that patients with reduced left ventricular function (LVEF) are at particular high risk of suffering the detrimental clinical effects of long-term RV pacing. The evidence is, however, incomplete, coming largely from subanalyses of pacemaker and implantable cardiac defibrillator studies. In this group of patients with reduced LVEF and an expected high amount of RV pacing, biventricular pacing (cardiac resynchronization therapy) devices can prevent the negative effects of RV pacing and reduce ventricular dyssynchrony. Therefore, cardiac resynchronization therapy has emerged as an attractive option with promising results and more clinical studies are underway. Furthermore, specific pacemaker algorithms, which minimize RV pacing, can also reduce the negative effects of RV stimulation on cardiac function and may prevent clinical deterioration.

Badanie EKG metodą Holtera u chorego z urządzeniem wszczepialnym — przykłady algorytmów ograniczających stymulację prawej komory

“…Ogólną ideę algorytmów zmieniających tryb stymulacji przedstawiono na rycinie 4. Urządzenie zaprogramowane z aktywnym algorytmem MVP, w przypadku braku przewodzenia AV pracuje w trybie DDD(R) -stymulacji komorowej w odpowiedzi na pobudzenia własne przedsionkowe lub sekwencyjnej stymulacji AV z zaprogramowanym W badaniach wykazano, że wyższy odsetek stymulacji prawokomorowej zwiększał ryzyko hospitalizacji z powodu niewydolności serca i przetrwałego lub utrwalonego migotania przedsionków, choć w niektórych pracach nie obserwowano takich zależności względem zgonów, hospitalizacji z przyczyn sercowo-naczyniowych, epizodów migotania przedsionków czy konieczności wykonania kardiowersji [4,5]. W badaniu MOST (MOde Stelection Trail) u chorych z niewydolnością węzła zatokowego wykazano, że odsetek stymulacji prawej komory ponad 40% wiązał się z 3-krotnym wzrostem ryzyka hospitalizacji z powodu niewydolności serca, a z każdym zwiększeniem odsetka stymulacji prawej komory o 25% ryzyko migotania przedsionków zwiększało się o ponad 30%.…”

Cardiac Pacing Induced Cardiomyopathy: Mith or Reality Sustained by Evidence?

“…As of today, there is no unanimous definition of the best system, mode of operation or anatomic site for ACP [ 19 ] . Among the vulnerable individuals, the unfavorable evolution for the appearance of heart disease because of ACP could be linked to the interaction of at least 3 factors: (1) patient-substrate: normal heart versus pre-existing heart disease and systolic dysfunction (LVEF ≤ 45 %) [ 13 , 15 , 18 , 27 , 31 , 48 , 49 ] ; (2) ACP time and dose (%CVP): worse if >40% of time [ 32 , 35 , 46 , 50 ] ; and (3) degree of dyssynchrony generated (ventricular lead site [ 48 49 , 51 , 52 ] , diQRS generated [ 53 ] and artificial LBBB [ 54 ] ).…”

“…The interposition of RV pacing in individuals with pre-existing systolic dysfunction (variable proportion of those who receive a conventional PPM, but a significant group within those who implant ICDs) [ 21 ] accelerates the onset of heart disease by ACP and it is probably in this group that ACP of the RV should be minimized or even eliminated, when possible [ 52 , 55 ] . In search of a better clinical outcome, we grouped the ways of using ACP in two sets:…”

Avaliação de dessincronia atrioventricular em portadores de marca-passo bicameral devido à doença do nó sinusal e bloqueio atrioventricular de primeiro grau

“…Para a DNS, se recomenda, à parte do tratamento da bradiarritmia e do apoio cronotrópico, o amplo manuseio do iAV para privilegiar a contração ventricular pelas vias fisiológicas 4,6,[13][14][15][16][17][18][19] . O gerenciamento por "minimização da estimulação artificial do ventrículo direito (VD)" é uma estratégia de busca intensiva do QRS intrínseco.…”

“…No cenário da ECA moderna, a comprovação de que a ativação artificial do VD proporciona piores desfechos clínicos associada ao QRS largo 1, 6,7,13,16,18,113,[146][147][148] , tem pautado estratégias que, na busca de minimizála, em muitos casos, promovem iPR longos também artificialmente provocados. Esses, pela sua vez, também trariam efeitos adversos 2,20 como a dessincronia AV comprovada neste estudo.…”