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
- Furman S, Robinson G, The use of an intracardiac pacemaker in the correction of total heart block, Surg Forum, 1958;9:245.
- Senning A, Discussion, J Thoracic Surg, 1959;38:639.
- Gregoratos G, Abrams J, et al., ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmias devices, 2002; available at: http://www.acc.org/clinical/guidelines/pacemaker/incorporated/index.htm
- Fuster V, et al., ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation, JACC, 2006;48:149–246.
- Hunt SA, Abraham WT, Chin MH, et al., ACC/AHA guideline update for the diagnosis and management of chronic heart failure in the adult, JACC, 2005;46:1–82.
- Tanabe A, Mohri T, Ohga M, et al., The effects of pacinginduced left bundle branch block on left ventricular systolic and diastolic performances, Jpn Heart J, 1990;31:1372–7.
- Tantengco MVT, et al., Left ventricular dysfunction after long-term right ventricular apical pacing in the young, JACC, 2001;37:2093.
- Karpawich PP, Rabah R, Haas JE, Altered cardiac histology following apical right ventricular pacing in patients with congenital atrioventricular block, PACE, 1999;22:1372–7.
- Thambo JB, et al., Detrimental ventricular remodelling in patients with congenital complete heart block and chronic right ventricular apical pacing, Circulation, 2004;110:3766–72.
- Tse HF, Yu CM, Wong KK, et al., Functional abnormalities with permanent right ventricular pacing, JACC, 2002;40:1451–8.
- Tse HF, Lau CP, Long-term effect of right ventricular pacing on myocardial perfusion and function, JACC, 1997;29:744–9.
- Melzer C, Sowelam S, Sheldon TJ, et al., Reduction of right ventricular pacing in patients with sinus node dysfunction using an enhanced search AV algorithm, PACE, 2005;28:521–7.
- Sweeney MO, Ellenbogen KA, Casavant D, et al., Multicentre, prospective, randomised safety and efficacy study of a new atrial-based managed ventricular pacing mode (MVP) in dual chamber ICDs, J Cardiovasc Electrophysiol, 2005;16:1–7.
- De Cock CC, Giudici MC, Twisk JW, Comparsion of the haemodynamic effects of right ventricular outflow tract pacing with right ventricular apex pacing: A quantitative review, Europace, 2003;5:275–8.
- Bourke JP, Hawkins T, Keavey P, et al., Evolution of ventricular function during permanent pacing from either right ventricular apex or outflow tract following AV-junctional ablation for atrial fibrillation, Europace, 2002;4:218–19.
- Stambler BS, Ellenbogen KA, Zhang X, et al., Right ventricular outflow versus apical pacing in pacemaker patients with congestive heart failure and atrial fibrillation, J Cardiovasc Electrophysiol, 2003;14:1180–86.
- Carlson MD, Ip J, et al., A new pacemaker algorithm for the treatment of atrial fibrillation-results of the atrial dynamic overdrive pacing trial (ADOPT), JACC, 2003;42:627–33.
- D’Allonnes GR, et al., Long-term effects of biatrial synchronous pacing to prevent drug-refractory atrial tachyarrhythmia : a nineyear experience, J Cardiovasc Electrophysiol, 2000;11:1081–91.
- Lau CP, et al., Dual-site atrial pacing for atrial fibrillation in patients without bradycardia, Am J Cardiol, 2001;88:371–5.
- Manolis AS, Sousani E, Simeonidou E, et al., Alternate sites of permanent cardiac pacing: A randomised study of novel technology, Hellenic J Cardiol, 2004;45:147–51.
- Paeletti L, Pieragnoli P, et al., Randomised cross-over comparison of right atrial appendage pacing versus interatrial septum pacing for prevention of paroxysmal atrial fibrillation in patients with sinus bradycardia, Am Heart J, 2001;142:1047–55.
- Bailin SJ, Adler S, Giudici M, Prevention of chronic atrial fibrillation by pacing in the region of Bachmann’s bundle: results of a multicentre randomised trial, J Cardiovasc Electrophysiol, 2001;12:912–17.
- Abraham WT, et al., Cardiac resynchronisation in chronic heart failure, NEJM, 2002;346:1845–53.
- Bristow MR, et al., The comparison of medical therapy, pacing and defibrillation in heart failure investigators. Cardiac resynchronisation therapy with or without an implantable defibrillator in advanced chronic heart failure, NEJM, 2004;350:2140–50.
- Cleland J, et al., The effect of cardiac resynchronisation on morbidity and mortality in heart failure, NEJM, 2005;352:1539–49.
- Sandhu R, Bahler RC, Prevalence of QRS prolongation in a community hospital cohort of patients with heart failure and its relation to left ventricular systolic dysfunction, Am J Cardiol, 2004;93:244–6.
- Shenkman HJ, et al., Congestive heart failure and QRS duration: establishing prognosis study, Chest, 2002;122:528–34.
- Mohri S, He KL, Dickstein M, et al., Cardiac contractility modulation by electric currents applied during the refractory period, Am J Physiol Heart Circ Physiol, 2002;282:H1642–7.
- Pappone C, Rosanio S, et al., Cardiac contractility modulation by electric currents applied during the refractory period in patients with heart failure secondary to ischaemic or idiopathic dilated cardiomyopathy, Am J Cardiol, 2002;90:1307–13.
- Stix G, Borggrefe M, et al., Chronic electrical stimulation during the absolute refractory period of the myocardium improves severe heart failure, Eur Heart J, 2004;25:650–55.
- Nolan J, Batin PD, Andrews R, et al., Prospective study of heart rate variability and mortality in chronic heart failure. Results of the United Kingdom Heart Failure Evaluation and Assessment of Risk Trial (UK-Heart), Circulation, 1998;98:1510–16.
- Yu CM, et al., Device-based intrathoracic impedance correlates with fluid status and provides automated prediction of CHF hospitalisations, J Cardiac Failure, 2004;10(Suppl. 1):S113.