Abstract
The use of cardiac resynchronization therapy (CRT) is well accepted as an important option for the treatment of patients with systolic heart failure and prolonged QRS duration. CRT for patients with narrow QRS complexes is reserved for patients who are undergoing implantation of new or replacement pacemakers or implantable cardioverter defibrillators with an anticipated significant requirement for ventricular pacing. The Biventricular versus Right Ventricular Pacing in Heart Failure Patients with Atrioventricular Block (BLOCK HF) Trial examined the role of CRT in heart failure patients with atrioventricular block and demonstrated significantly better outcomes with CRT compared to right ventricular pacing. On the other hand, conflicting preliminary data were reported by the Biventricular Pacing for Atrioventricular Block to Prevent Cardiac Desynchronization (BioPace) Trial investigators. In this review, we will discuss the adverse consequences of chronic right ventricular pacing, the options of alternate pacing sites in the right ventricle versus biventricular pacing, and the findings from the BLOCK HF Trial as well as the preliminary data from the BioPace Trial. Our goal is to explore the role of biventricular pacing in patients with atrioventricular block.
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Bristow MR, Saxon LA, Boehmer J, et al. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med. 2004;350:2140–50.
Cleland JGF, Daubert J-C, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352:1539–49.
Tracy CM, Epstein AE, Darbar D, et al. 2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2012;60(14):1297–313.
Wilkoff BL, Cook JR, Epstein AE, et al. Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial. JAMA. 2002;288:3115–23.
Sweeney MO, Hellkamp AS, Ellenbogen KA, et al. Adverse effect of ventricular pacing on heart failure and atrial fibrillation among patients with normal baseline QRS duration in a clinical trial of pacemaker therapy for sinus node dysfunction. Circulation. 2003;107(23):2932–7.
Barsheshet A, Moss AJ, Mcnitt S, et al. Long-term implications of cumulative right ventricular pacing among patients with an implantable cardioverter-defibrillator. Heart Rhythm. 2011;8:212–8.
Tops LF, Schalij MJ, Bax Jj MD. The effects of right ventricular apical pacing on ventricular function and dyssynchrony. J Am Coll Cardiol. 2009;54(9):776.
Akerström F, Pachón M, Puchol A, et al. Chronic right ventricular apical pacing: adverse effects and current therapeutic strategies to minimize them. Int J Cardiol. 2014;173(3):351–60.
Prinzen FW, Peschar M. Relation between the pacing induced sequence of activation and left ventricular pump function in animals. Pacing Clin Electrophysiol. 2002;25:484–98.
Prinzen FW, Hunter WC, Wyman BT, et al. Mapping of regional myocardial strain and work during ventricular pacing: experimental study using magnetic resonance imaging tagging. J Am Coll Cardiol. 1999;33:1735–42.
Badke FR, Boinay P, Covell JW. Effects of ventricular pacing on regional left ventricular performance in the dog. Am J Physiol. 1980;238:H858–67.
Tse HF, Lau CP. Long-term effect of right ventricular pacing on myocardial perfusion and function. J Am Coll Cardiol. 1997;29:744–9.
Skalidis EI, Kochiadakis GE, Koukouraki SI, et al. Myocardial perfusion in patients with permanent ventricular pacing and normal coronary arteries. J Am Coll Cardiol. 2001;37:124–9.
Lieberman R, Padeletti L, Schreuder J, et al. Ventricular pacing lead location alters systemic hemodynamics and left ventricular function in patients with and without reduced ejection fraction. J Am Coll Cardiol. 2006;48:1634–41.
Thambo JB, Bordachar P, Garrigue S, et al. Detrimental ventricular remodeling in patients with congenital complete heart block and chronic right ventricular apical pacing. Circulation. 2004;110:3766–72.
Lupi G, Sassone B, Badano L, et al. Effects of right ventricular pacing on intra-left ventricular electromechanical activation in patients with native narrow QRS. Am J Cardiol. 2006;98:219–22.
Liu WH, Chen MC, Chen YL, et al. Right ventricular apical pacing acutely impairs left ventricular function and induces mechanical dyssynchrony in patients with sick sinus syndrome: a real-time three dimensional echocardiographic study. J Am Soc Echocardiography. 2008;21:224–9.
Albertsen AE, Nielsen JC, Poulsen SH, et al. DDD(R)-pacing, but not AAI(R)-pacing induces left ventricular desynchronization in patients with sick sinus syndrome: tissue-doppler and 3D echocardiographic evaluation in a randomized controlled comparison. Europace. 2008;10:127–33.
Karpawich PP, Rabah R, Haas JE. Altered cardiac histology following apical right ventricular pacing in patients with congenital atrioventricular block. Pacing Clin Electrophysiol. 1999;22:1372–7.
van Oosterhout MF, Prinzen FW, Arts T, et al. Asynchronous electrical activation induces asymmetrical hypertrophy of the left ventricular wall. Circulation. 1998;98:588–95.
Vernooy K, Dijkman B, Cheriex EC, et al. Ventricular remodeling during long-term right ventricular pacing following His bundle ablation. Am J Cardiol. 2006;97:1223–7.
Barold SS, Ovsyshcher IE. Pacemaker-induced mitral regurgitation. Pacing Clin Electrophysiol. 2005;28:357–60.
Maurer G, Torres MA, Corday E, et al. Two-dimensional echocardiographic contrast assessment of pacing induced mitral regurgitation: relation to altered regional left ventricular function. J Am Coll Cardiol. 1984;3:986–91.
Andersen HR, Nielsen JC, Thomsen PE, et al. Long-term follow-up of patients from a randomised trial of atrial versus ventricular pacing for sick-sinus syndrome. Lancet. 1997;350:1210–6.
Gold MR, Brockman R, Peters RW, et al. Acute hemodynamic effects of right ventricular pacing site and pacing mode in patients with congestive heart failure secondary to either ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 2000;85(9):1106–9.
de Cock CC, Meyer A, Kamp O, et al. Hemodynamic benefits of right ventricular outflow tract pacing: comparison with right ventricular apex pacing. Pacing Clin Electrophysiol. 1998;21(3):536–41.
Mera F, Delurgio DB, Patterson RE, et al. A comparison of ventricular function during high right ventricular septal and apical pacing after His-bundle ablation for refractory atrial fibrillation. Pacing Clin Electrophysiol. 1999;22(8):1234–9.
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(3):219–28.
Stambler BS, Ellenbogen K, Zhang X, et al. Right ventricular outflow versus apical pacing in pacemaker patients with congestive heart failure and atrial fibrillation. J Cardiovasc Electrophysiol. 2003;14:1180–6.
Victor F, Leclercq C, Mabo P, et al. Optimal right ventricular pacing site in chronically implanted patients: a prospective randomized crossover comparison of apical and outflow tract pacing. J Am Coll Cardiol. 1999;33:311–6.
Tse HF, Yu C, Wong KK, et al. Functional abnormalities in patients with permanent right ventricular pacing: the effect of sites of electrical stimulation. J Am Coll Cardiol. 2002;40:1451–8.
Tse HF, Wong KK, Siu CW, et al. Upgrading pacemaker patients with right ventricular apical pacing to right ventricular septal pacing improves left ventricular performance and functional capacity. J Cardiovasc Electrophysiol. 2009;20:901–5.
Deshmukh P, Casavant DA, Romanyshyn M, et al. Permanent, direct His-bundle pacing: a novel approach to cardiac pacing in patients with normal His-Purkinje activation. Circulation. 2000;101:869–77.
Zanon F, Svetlich C, Occhetta E, et al. Safety and performance of a system specifically designed for selective site pacing. Pacing Clin Electrophysiol. 2011;34:339–47.
Barba-Pichardo R, Sanchez AM, Fernandez-Gomez JM, et al. Ventricular resynchronization therapy by direct His-bundle pacing using an internal cardioverter defibrillator. Europace. 2013;15:83–8.
Occhetta E, Bortnik M, Magnani A, et al. Prevention of ventricular desynchronization by permanent para-Hisian pacing after atrioventricular node ablation in chronic atrial fibrillation: a crossover, blinded, randomized study versus apical right ventricular pacing. J Am Coll Cardiol. 2006;47:1938–45.
Sharma PS, Dandamudi G, Naperkowski A, et al. Permanent His-bundle pacing is feasible, safe, and superior to right ventricular pacing in routine clinical practice. Heart Rhythm. 2015;12(2):305–12.
Shimony A, Eisenberg MJ, Filion KB, Amit G. Beneficial effects of right ventricular non-apical vs. apical pacing: a systematic review and meta-analysis of randomized-controlled trials. Europace. 2012;14(1):81–91.
Mond HG, Hillock RJ, Stevenson IH, et al. The right ventricular outflow tract: the road to septal pacing. Pacing Clin Electrophysiol. 2007;30:482–91.
Kaye G, Stambler BS, Yee R. Search for the optimal right ventricular pacing site: design and implementation of three randomized multicenter clinical trials. Pacing Clin Electrophysiol. 2009;32:426–33.
Kaye GC, Linker NJ, Marwick TH, et al. Effect of right ventricular pacing lead site on left ventricular function in patients with high-grade atrioventricular block: results of the Protect-Pace study. Eur Heart J. 2015;36:856–62. In this randomized, prospective, international, multicentre trial, right ventricular high septal pacing did not provide a protective effect on left ventricular function over right ventricular apical pacing among patients with a high–grade AV block and preserved LV function requiring a high percentage of ventricular pacing.
Doshi RN, Daoud EG, Fellows C, et al. Left ventricular-based cardiac stimulation post AV nodal ablation evaluation (the PAVE study). J Cardiovasc Electrophysiol. 2005;16:1160–5.
Orlov MV1, Gardin JM, Slawsky M, et al. Biventricular pacing improves cardiac function and prevents further left atrial remodeling in patients with symptomatic atrial fibrillation after atrioventricular node ablation. Am Heart J. 2010;159:264–70.
Brignole M, Botto G, Mont L, et al. Cardiac resynchronization therapy in patients undergoing atrioventricular junction ablation for permanent atrial fibrillation: a randomized trial. Eur Heart J. 2011;32:2420–9.
Stavrakis S, Garabelli P, Reynolds DW. Cardiac resynchronization therapy after atrioventricular junction ablation for symptomatic atrial fibrillation: a meta-analysis. Europace. 2012;14:1490–7.
Brignole M, Gammage M, Puggioni E, et al. Comparative assessment of right, left, and biventricular pacing in patients with permanent atrial fibrillation. Eur Heart J. 2005;26:712–22.
Curtis AB, Worley SJ, Adamson PB, Chung ES, Niazi I, Sherfesee L, et al. Biventricular pacing for atrioventricular block and systolic dysfunction. N Engl J Med. 2013;368:1585–93. Article regarding discussed trial.
Curtis AB, Worley SJ, Chung ES, et al. Improvement in clinical outcomes with biventricular versus right ventricular pacing: the BLOCK HF Study. J Am Coll Cardiol. 2016;67:2148–57.
Ponikowski P, Voors AA, Anker SD, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016. doi:10.1002/ejhf.592. This article discusses European guidelines for heart failure treatment with recommendations on device-based therapy including updated CRT indications.
St John Sutton M, Plappert T, Adamson PB, et al. Left ventricular reverse remodeling with biventricular versus right ventricular pacing in patients with atrioventricular block and heart failure in the BLOCK HF. Trial Circ Heart Fail. 2015;8:510–8.
Blanc JJ, Funck RC, Lunati M et al. http://clinicaltrialresults.org/Slides/TCT%202014/Blanc_Biopace.pdf. This website summarizes preliminary results from BioPace trial.
Funck RC, Mueller HH, Lunati M, et al. Characteristics of a large sample of candidates for permanent ventricular pacing included in the biventricular pacing for atrio-ventricular block to prevent cardiac desynchronization study (BioPace). Europace. 2014;16:354–62. This article describes characteristics of patients enrolled in BioPace study.
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Hiroko Beck has received personal fees from Medtronic, Inc. outside of the submitted work.
Anne B Curtis has received personal fees from Medtronic, Inc., and St. Jude Medical outside of the submitted work.
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This article is part of the Topical Collection on Prevention of Heart Failure
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Beck, H., Curtis, A.B. Right Ventricular Versus Biventricular Pacing for Heart Failure and Atrioventricular Block. Curr Heart Fail Rep 13, 230–236 (2016). https://doi.org/10.1007/s11897-016-0299-3
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DOI: https://doi.org/10.1007/s11897-016-0299-3