Published online before print April 24, 2006, doi: 10.1161/CIRCULATIONAHA.105.608356
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
(Circulation. 2006;113:2082-2088.)
© 2006 American Heart Association, Inc.
Heart Failure |
Heart Failure During Cardiac Pacing
From Brigham and Women’s Hospital and Harvard Medical School (M.O.S.), Boston, Mass, and the Duke Clinical Research Institute and Duke University Medical Center (A.S.H.), Durham, NC.
Correspondence to Michael O. Sweeney, MD, Cardiac Arrhythmia Service, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115. E-mail mosweeney{at}partners.org
Received December 15, 2005; revision received February 4, 2006; accepted February 24, 2006.
Background— Right ventricular apical (RVA) pacing creates abnormal left ventricular contraction, hypertrophy, and reduced pump function. The adverse effects of ventricular desynchronization may explain the association of RVA pacing with an increased risk of heart failure hospitalization (HFH) in clinical trials.
Methods and Results— Baseline and postimplantation variables were used to predict HFH in the Mode Selection Trial, a 2010-patient, 6-year trial of dual-chamber (DDDR) versus ventricular (VVIR) pacing in sinus node dysfunction. A Cox model showed that New York Heart Association (NYHA) class at baseline and follow-up predicted HFH (hazard ratio [HR], 3.99; 95% confidence interval [CI], 2.74–5.79 for NYHA class III/IV and HR, 2.17; 95% CI, 1.54–3.04 for NYHA class II versus class I); other predictors were heart failure (HR, 2.30; 95% CI, 1.70–3.11), atrioventricular (AV) block (HR, 1.48; 95% CI, 1.11–1.97), and myocardial infarction (MI)(HR, 1.37; 95% CI, 1.00–1.86). Postimplantation predictors were VVIR cumulative percent ventricular pacing (Cum%VP) >80 (HR, 3.58; 95% CI, 1.72–7.45), DDDR Cum%VP >40 or VVIR Cum%VP 
80 (HR, 1.81; 95% CI, 0.94–3.50) versus DDDR Cum%VP 40; whether QRS duration (QRSd) was paced or spontaneous (HR, 2.21; 95% CI, 1.39–3.54; spontaneous versus paced); and drugs for atrial fibrillation (HR, 1.60; 95% CI, 1.19–2.15). Low baseline ejection fraction (EF) and postimplantation RVA-paced or spontaneous QRSd predicted HFH; the increased risk with QRSd was steeper for normal versus low EF (HR, 1.18; 95% CI, 1.11–1.27; versus HR, 1.08; 95% CI, 1.01–1.15; for a 10-ms increase); at a QRSd of 
200 ms, normal- and low-EF patients had equivalent risk. HFH risk nearly doubled when VVIR Cum%VP was 80 or DDDR Cum%VP was >40 versus DDDR Cum%VP 40 and was additive with other risk factors.
Conclusions— Differences in HFH risk can be explained by interactions between substrate (atrial fibrillation, AV conduction, heart failure, MI, EF) and pacing promoters (ventricular desynchronization-paced QRSd and Cum%VP, and AV desynchronization-pacing mode). Management of RVA pacing is important for reducing the risk of HFH, particularly among patients with low EF and heart failure.
CLINICAL PERSPECTIVE
This article has been cited by other articles:
 |
|
 |
|
  C.-M. Yu, J. Y.-S. Chan, Q. Zhang, R. Omar, G. W.-K. Yip, A. Hussin, F. Fang, K. H. Lam, H. C.-K. Chan, and J. W.-H. Fung Biventricular Pacing in Patients with Bradycardia and Normal Ejection Fraction N. Engl. J. Med., November 26, 2009; 361(22): 2123 - 2134. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 F. Fang, J. Y.-S. Chan, G. W.-K. Yip, J.-M. Xie, Q. Zhang, J. W.-H. Fung, Y.-Y. Lam, and C.-M. Yu Prevalence and determinants of left ventricular systolic dyssynchrony in patients with normal ejection fraction received right ventricular apical pacing: a real-time three-dimensional echocardiographic study Eur J Echocardiogr, November 20, 2009; (2009) jep171v1. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. O. Sweeney Right ventricular pacing and atrial fibrillation: villain, victim, or just misunderstood? Europace, November 1, 2009; 11(11): 1413 - 1414. [Full Text] [PDF]
|
|
|
|
|
|
Y. Murakami, N. Tsuboi, Y. Inden, Y. Yoshida, T. Murohara, Z. Ihara, and M. Takami Difference in percentage of ventricular pacing between two algorithms for minimizing ventricular pacing: results of the IDEAL RVP (Identify the Best Algorithm for Reducing Unnecessary Right Ventricular Pacing) study Europace, September 16, 2009; (2009) eup252v1. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. F. Tops, M. J. Schalij, and J. J. Bax The effects of right ventricular apical pacing on ventricular function and dyssynchrony implications for therapy. J. Am. Coll. Cardiol., August 25, 2009; 54(9): 764 - 776. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. O. Sweeney and F. W. Prinzen Ventricular Pump Function and Pacing: Physiological and Clinical Integration Circ Arrhythm Electrophysiol, June 1, 2008; 1(2): 127 - 139. [Full Text] [PDF]
|
|
|
|
|
|
A. E. Epstein, J. P. DiMarco, K. A. Ellenbogen, N.A. M. Estes III, R. A. Freedman, L. S. Gettes, A. M. Gillinov, G. Gregoratos, S. C. Hammill, D. L. Hayes, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons J. Am. Coll. Cardiol., May 27, 2008; 51(21): e1 - e62. [Full Text] [PDF]
|
|
|
|
 |
|
 Writing Committee Members, A. E. Epstein, J. P. DiMarco, K. A. Ellenbogen, N.A. M. Estes III, R. A. Freedman, L. S. Gettes, A. M. Gillinov, G. Gregoratos, S. C. Hammill, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons Circulation, May 27, 2008; 117(21): e350 - e408. [Full Text] [PDF]
|
|
|
|
|
|
A. Quesada, G. Botto, A. Erdogan, M. Kozak, P. Lercher, J. C. Nielsen, O. Piot, R. Ricci, C. Weiss, D. Becker, et al. Managed ventricular pacing vs. conventional dual-chamber pacing for elective replacements: the PreFER MVP study: clinical background, rationale, and design Europace, March 1, 2008; 10(3): 321 - 326. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. E. Albertsen, J. C. Nielsen, S. H. Poulsen, P. T. Mortensen, A. K. Pedersen, P. S. Hansen, H. K. Jensen, and H. Egeblad Biventricular pacing preserves left ventricular performance in patients with high-grade atrio-ventricular block: a randomized comparison with DDD(R) pacing in 50 consecutive patients Europace, March 1, 2008; 10(3): 314 - 320. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. M. Kavanagh, I. Belenkie, and H. J. Duff Transmural temporospatial left ventricular activation during pacing from different sites: potential implications for optimal pacing Cardiovasc Res, January 1, 2008; 77(1): 81 - 88. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. I Burgess, C. Jenkins, J. Chan, and T. H Marwick Measurement of left ventricular dyssynchrony in patients with ischaemic cardiomyopathy: a comparison of real-time three-dimensional and tissue Doppler echocardiography Heart, October 1, 2007; 93(10): 1191 - 1196. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. O. Sweeney, A. J. Bank, E. Nsah, M. Koullick, Q. C. Zeng, D. Hettrick, T. Sheldon, G. A. Lamas, and the Search AV Extension and Managed Ventricular Pa Minimizing Ventricular Pacing to Reduce Atrial Fibrillation in Sinus-Node Disease N. Engl. J. Med., September 6, 2007; 357(10): 1000 - 1008. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. O. Sweeney, L. L. Ruetz, P. Belk, T. J. Mullen, J. W. Johnson, and T. Sheldon Bradycardia Pacing-Induced Short-Long-Short Sequences at the Onset of Ventricular Tachyarrhythmias: A Possible Mechanism of Proarrhythmia? J. Am. Coll. Cardiol., August 14, 2007; 50(7): 614 - 622. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. M. Scheinman and E. Keung The Year in Clinical Cardiac Electrophysiology J. Am. Coll. Cardiol., May 22, 2007; 49(20): 2061 - 2069. [Full Text] [PDF]
|
|