Ventricular Pacing Can Induce Hemodynamically Significant Mitral Valve Regurgitation

Mark, Jonathan B.; Chetham, Paul M.

doi:10.1097/00000542-199102000-00030

Cited by 31 publications

(19 citation statements)

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“…Hemodynamic deterioration due to MR after AVJ ablation and RVA pacing has been documented in small studies 12–14,42 . Some previously reported cases were so severe and refractory to medical therapy that mitral valve replacement was necessary 43 .…”

Section: Discussionmentioning

confidence: 99%

“…Patients who undergo AVJ ablation are pacemaker dependent and receive continuous right ventricular pacing. In some patients, right ventricular pacing has been associated with poor clinical outcomes such as congestive heart failure (CHF) 10,11 and mitral regurgitation (MR) 12–14 . The mean annual event rate for CHF in patients with high‐grade atrioventricular block and who are pacemaker‐dependent is 3.3% 15 .…”

Section: Introductionmentioning

confidence: 99%

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Preserved Left Ventricular Ejection Fraction Following Atrioventricular Junction Ablation and Pacing for Atrial Fibrillation

Chen

Hodge

Jahangir

et al. 2007

Cardiovasc electrophysiol

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Methods/Results: We studied 286 patients with AF who underwent AVJ ablation and RVA pacing at our institution between 1990 and 2002. Patients were stratified into a short-term follow-up group (LVEF reassessed by echocardiography within a year after AVJ ablation, n = 134) and a long-term group (LVEF reassessed after a year, n = 152). Among all 286 patients (mean follow-up 20 months), we observed no change in mean LVEF after AVJ ablation and RVA pacing (48% before vs. 48% after, P = 0.42). Short-term follow-up patients had a statistically significant improvement in mean LVEF (46% before vs. 49% after, P = 0.03), whereas there was no statistically significant change in mean LVEF in long-term follow-up patients (49% before vs. 48% after, P = 0.37). Only 9% of short-term patients, 15% of long-term patients, and 1% of patients with baseline LVEF ≤ 40% experienced ≥10% absolute decrease in LVEF. Baseline LVEF > 40% was a multivariate predictor of LVEF decline.Conclusions: RVA pacing after AVJ ablation does not compromise LVEF in the short-or long-term for the vast majority of patients. Better predictors are needed to help us select patients for biventricular pacing after AVJ

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Preserved Left Ventricular Ejection Fraction Following Atrioventricular Junction Ablation and Pacing for Atrial Fibrillation

Chen

Hodge

Jahangir

et al. 2007

Cardiovasc electrophysiol

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“…In patients with severely decreased LV function, this asynchronous delayed activation of the ventricular musculature occasionally causes a deterioration in hemodynamics. RV apical pacing may also disturb mitral valve apposition, which has been associated with the development or worsening of MR. [14][15][16] Vanderheyden et al studied 108 patients undergoing 'ablate and pace' therapy, 3 of whom developed severe MR after AVN ablation and required mitral valve replacement to control progressively worsening heart failure. 5 Permanent pacing using a screw-in lead located near the His-bundle or in the high RV septum or RVOT may contribute to better LV performance than does RVA pacing, and may minimize the worsening of MR.…”

Section: Discussionmentioning

confidence: 99%

Permanent His-Bundle Pacing After Atrioventricular Node Ablation in a Patient With Chronic Atrial Fibrillation and Mitral Regurgitation

Yamauchi

Aonuma

Isobe

2005

Circ J

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ciated with moderate MR. After relief of congestive heart failure, 24-h Holter monitoring showed that total ventricular activity was 171,360 beats/day at a mean heart rate of 119 beats/min, even on methyldigoxin and verapamil.Because of the drug-refractory atrial fibrillation, we decided to use AVN ablation and pacing therapy, but because we were worried that there might be post-procedural deterioration of the MR we elected to use direct His-bundle pacing therapy, which is an advanced but still investigational technique, after written informed consent was given. A hexapolar catheter with 2-mm interelectrode spacing was introduced via a femoral vein and advanced near the AV septum superior to the tricuspid valve. Subsequent mapping and localization of the His-bundle was done in biplane fluoroscopic projections. The catheter was positioned to record the largest bipolar His-bundle potential, and an attempt was made to capture and pace the His-bundle. Next, the ablation catheter with a 4-mm distal electrode (EP Technologies Inc, San Jose, CA, USA) was positioned in the compact AVN area. Radiofrequency energy was delivered, starting posteriorly and advancing anteriorly toward the area of the largest His-bundle potential recording site, until complete AV block was obtained ( Fig 2C). After the second radiofrequency application to the compact AVN, complete AV block was produced and junctional escape rhythm emerged at a mean heart rate of 40 beats/min (Fig 2A). The successful ablation site had a large atrial potential, small ventricular potential, and tiny His-bundle potential, which implied compact AVN ablation, not Hisbundle ablation.Acute hemodynamic assessment using a Swan-Ganz catheter and LV cannulation compared the hemodynamic improvement between 3 pacing sites: the RV outflow tract (RVOT), RV apex (RVA), and His-bundle area. Data obtained were as follows. LV end-diastolic pressure (LVEDP) was 14 mmHg before ablation and after AVN ablation, LVEDP decreased to 11 mmHg during RVA pacing, 9 mmHg during RVOT pacing, and 7 mmHg during Hisbundle pacing. Mean pulmonary capillary wedge pressure trioventricular node (AVN) ablation followed by permanent pacemaker implantation has proven very effective in controlling ventricular rates in patients with drug-refractory atrial fibrillation 1-4 and most patients show a marked improvement in cardiac performance and quality of life. This potential benefit seems to be greatest in patients with depressed left ventricular (LV) function prior to the procedure. 2 However, hemodynamic deterioration in relation to worsening mitral regurgitation (MR) can occur in a small number of patients following AVN ablation and pacing therapy 5,6 and those with moderate MR prior to the ablation seem prone to this complication. 5,7 High right ventricular (RV) septal pacing produces shorter QRS duration and better chronic LV function than RV apical pacing in patients with mild to moderate LV dysfunction and chronic atrial fibrillation after AVN ablation, [8][9][10][11] but direct His-bundle pacing pro...

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“…This dyssynchrony leads to disturbed LV diastolic filling, reduction of cardiac output, and increase in mitral regurgitation. [10–12] Our analysis showed that decrease in systolic BP accompanied by dyspnea and palpitation (as an index of pacemaker syndrome) is related to loss of AV synchrony rather than site of ventricular pacing (RV, LV or BiV). Farmer et al .…”

Section: Discussionmentioning

confidence: 95%

Hemodynamic effect of atrioventricular and interventricular dyssynchrony in patients with biventricular pacing: Implications for the pacemaker syndrome

Mollazadeh

Mohimi

Zeighami

et al. 2012

Journal of Cardiovascular Disease Research

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Background/Objectives:Pacemaker syndrome was mainly described as the sequel of atrioventricular (AV) dyssynchrony. The role of interventricular (VV) dyssynchrony has not been studied yet. The aims of this study were to noninvasively assess the hemodynamic effects of different ventricular pacing sites with and without AV and VV dyssynchrony and to observe the patients for clinical symptoms of the pacemaker syndrome during the AV sequential and ventricular-only pacing modes.Materials and Methods:Between March 2009 and February 2010, 40 patients (28 men; mean age, 61 ± 15 years) with biventricular (BiV) device were enrolled. Mean systolic and diastolic blood pressures (BP) of 5 beats were measured 5 minutes after each mode change using fingertip plethysmography. The patients were also observed for the occurrence of symptoms suggestive of the pacemaker syndrome, including dyspnea, palpitations, dizziness, presyncope, and syncope.Results:There was no difference in mean systolic BP among different ventricular-only pacing modes (all P = NS). However, mean systolic BP was significantly higher in AV sequential biventricular pacing (DDD-BiV) compared with ventricular-only pacing modes (all P<0.05). In addition, there was no difference in terms of pacemaker syndrome-related symptoms following mode change from DDD-BiV to DDD-RV or DDD-LV (all P>0.05).Conclusions:The present study showed that the non-AV sequential BiV and LV pacing may have no significant benefit compared with RV pacing in terms of systolic blood pressure. However, there was marked hemodynamic improvement following mode change to AV sequential BiV pacing. This study may have important implications for pathogenesis of pacemaker syndrome.

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Ventricular Pacing Can Induce Hemodynamically Significant Mitral Valve Regurgitation

Cited by 31 publications

References 0 publications

Preserved Left Ventricular Ejection Fraction Following Atrioventricular Junction Ablation and Pacing for Atrial Fibrillation

Preserved Left Ventricular Ejection Fraction Following Atrioventricular Junction Ablation and Pacing for Atrial Fibrillation

Permanent His-Bundle Pacing After Atrioventricular Node Ablation in a Patient With Chronic Atrial Fibrillation and Mitral Regurgitation

Hemodynamic effect of atrioventricular and interventricular dyssynchrony in patients with biventricular pacing: Implications for the pacemaker syndrome

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