Advances in Cardiac Pacing Device Implantation

Asia Pacific Cardiology - Volume 1 Issue 1;2007:1(1):60-61


The history of cardiac pacing device implantation began in 1958, when Seymour Furman utilised temporary transvenous pacing as therapy for complete heart block.1 Ake Senning implanted the first pacemaker as an asynchronous ventricular device2 in 1959. The indications for cardiac pacing therapy have been expanding to include patients with different heart rhythm disorders, including sinus node dysfunction, atrial tachyarrhythmias and heart failure with cardiac dyssynchrony.3–5

Deleterious Effects of Right Ventricular Apical Pacing

The right ventricular apex has been the conventional site for pacing lead implantation for reasons of stability and technical ease. Producing an iatrogenic left bundle branch block pattern, right ventricular apical (RVA) pacing is associated with deleterious histological, haemodynamic, mechanical and clinical consequences.6–11 Avoidance of RVA pacing may be accomplished by pacemaker programming techniques or special pacing algorithms in sinus node dysfunction. In patients with intact AV conduction, the percentage of ventricular pacing can be reduced to 19% with a pacing algorithm that allows the AV interval to extend beyond 300ms to promote intrinsic AV conduction.12 Another novel pacing mode-switching algorithm recently became available to further decrease the percentage of ventricular pacing in patients with sinus node dysfunction. During normal operation, the pacing mode remains atrial (AAIR) and the ventricular activity is monitored on a beat-to-beat basis to verify intact AV conduction. With persistent loss of AV conduction, the pacing mode switches temporarily to dual chamber (DDDR). The pacing mode switches back to AAIR as soon as intrinsic AV conduction returns. With this novel pacing algorithm, the cumulative percentage of ventricular pacing can be reduced to 4.1%.13
In AV block (AVB) patients who require a high percentage of RV pacing, avoidance of RVA pacing can be achieved only by pacing alternative ventricular sites. Various sites, including the right ventricular outflow tract (RVOT), right ventricular septum (RVS) and His Bundle and left ventricular and biventricular pacing have been studied, RVOT most extensively. A pooled analysis involving nine prospective studies assessing the haemodynamic effects of RVOT pacing in a total of 217 patients revealed a modest but significant benefit over RVA pacing with an odds ratio of 0.34.14 A study comparing RVA with RVOT pacing in 20 patients with atrial fibrillation and AV-junctional ablation showed that left ventricular systolic function was better preserved by RVOT pacing at 23-week follow-up with radionuclide ventriculogram assessment.15


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