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Structural heart disease, not the right ventricular pacing site, determines the QRS duration during right ventricular pacing. Heart Vessels 2021; 36:1870-1878. [PMID: 34047815 DOI: 10.1007/s00380-021-01881-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/21/2021] [Indexed: 10/21/2022]
Abstract
Right ventricular (RV) pacing causes changes in the heart's electrical and mechanical activation patterns. The QRS duration is a useful surrogate marker of electrical dyssynchrony; a longer QRS duration during RV pacing indicates poor prognosis. However, the mechanisms underlying a longer QRS duration during RV pacing remain unclear; hence, we investigated factors predicting QRS prolongation during RV pacing. We enrolled 211 patients who underwent catheter ablation for supraventricular tachyarrhythmia and showed no bundle branch block. Three-dimensional mapping for the QRS duration during RV pacing from the RV outflow to RV apex was performed, and differences in the QRS duration were analyzed. The predisposing factors causing QRS > 160 ms during RV apical pacing were also analyzed. The QRS durations at baseline and during RV pacing from the RV outflow and at the RV apex were 85.0 ± 7.5 ms, 163.7 ± 17.1 ms, and 156.2 ± 16.1 ms, respectively. With respect to the QRS duration, there was a significant correlation between RV outflow and RV apical pacing (r = 0.658, p < 0.001). Difference in the QRS duration between the RV outflow and RV apex in each patient was only 12.5 ± 10.4 ms. Logistic multivariable regression analysis identified baseline QRS duration [odds ratio (OR) 1.24, 95% confidence interval (CI) 1.15-1.33, p < 0.01], interventricular septum thickness (OR 1.20, 95% CI 1.02-1.40, p = 0.025), left atrial diameter (OR 1.08, 95% CI 1.01-1.16, p = 0.024), and E/e' (OR 1.23, 95% CI 1.12-1.35, p < 0.01) as significant predictors of QRS prolongation during RV apical pacing. The QRS duration during RV pacing largely depends not on the pacing site, but on the underlying structural heart diseases.
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Keene D, Shun-Shin MJ, Arnold AD, March K, Qureshi N, Ng FS, Tanner M, Linton N, Lim PB, Lefroy D, Kanagaratnam P, Peters NS, Francis DP, Whinnett ZI. Within-patient comparison of His-bundle pacing, right ventricular pacing, and right ventricular pacing avoidance algorithms in patients with PR prolongation: Acute hemodynamic study. J Cardiovasc Electrophysiol 2020; 31:2964-2974. [PMID: 32976636 DOI: 10.1111/jce.14763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/04/2020] [Accepted: 09/15/2020] [Indexed: 11/28/2022]
Abstract
AIMS A prolonged PR interval may adversely affect ventricular filling and, therefore, cardiac function. AV delay can be corrected using right ventricular pacing (RVP), but this induces ventricular dyssynchrony, itself harmful. Therefore, in intermittent heart block, pacing avoidance algorithms are often implemented. We tested His-bundle pacing (HBP) as an alternative. METHODS Outpatients with a long PR interval (>200 ms) and intermittent need for ventricular pacing were recruited. We measured within-patient differences in high-precision hemodynamics between AV-optimized RVP and HBP, as well as a pacing avoidance algorithm (Managed Ventricular Pacing [MVP]). RESULTS We recruited 18 patients. Mean left ventricular ejection fraction was 44.3 ± 9%. Mean intrinsic PR interval was 266 ± 42 ms and QRS duration was 123 ± 29 ms. RVP lengthened QRS duration (+54 ms, 95% CI 42-67 ms, p < .0001) while HBP delivered a shorter QRS duration than RVP (-56 ms, 95% CI -67 to -46 ms, p < .0001). HBP did not increase QRS duration (-2 ms, 95% CI -8 to 13 ms, p = .6). HBP improved acute systolic blood pressure by mean of 5.0 mmHg (95% CI 2.8-7.1 mmHg, p < .0001) compared to RVP and by 3.5 mmHg (95% CI 1.9-5.0 mmHg, p = .0002) compared to the pacing avoidance algorithm. There was no significant difference in hemodynamics between RVP and ventricular pacing avoidance (p = .055). CONCLUSIONS HBP provides better acute cardiac function than pacing avoidance algorithms and RVP, in patients with prolonged PR intervals. HBP allows normalization of prolonged AV delays (unlike pacing avoidance) and does not cause ventricular dyssynchrony (unlike RVP). Clinical trials may be justified to assess whether these acute improvements translate into longer term clinical benefits in patients with bradycardia indications for pacing.
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Affiliation(s)
- Daniel Keene
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Matthew J Shun-Shin
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, UK
| | - Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, UK
| | - Katherine March
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, UK
| | - Norman Qureshi
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Fu Siong Ng
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, UK
| | - Mark Tanner
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Nicholas Linton
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Phang B Lim
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - David Lefroy
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | | | - Nicholas S Peters
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, UK
| | - Darrel P Francis
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
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Loring Z, Sun AY. Should His Bundle Pacing Be Preferred over Cardiac Resynchronization Therapy Following Atrioventricular Junction Ablation? Cardiol Clin 2019; 37:231-240. [PMID: 30926024 PMCID: PMC6442941 DOI: 10.1016/j.ccl.2019.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Atrial fibrillation (AF) and heart failure (HF) are associated with high morbidity and mortality, which is particularly detrimental when patients develop rapid ventricular rates (RVR). Atrioventricular junction (AVJ) ablation with pacemaker implantation has been used as a method of achieving rate control in patients with incessant AF with RVR. Right ventricular only pacing is known to be harmful in the setting of HF. His bundle pacing (HBP) and biventricular (BiV) pacing both offer durable pacing solutions that offer more physiologic activation. This review describes the benefits and drawbacks of HBP and BiV pacing in HF patients after AVJ ablation.
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Affiliation(s)
- Zak Loring
- Division of Cardiology, Section of Electrophysiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA; Duke Clinical Research Institute, 200 Morris St, Durham, NC 27701, USA.
| | - Albert Y Sun
- Division of Cardiology, Section of Electrophysiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA; Division of Cardiology, Section of Electrophysiology, Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, USA
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Gould J, Sieniewicz B, Porter B, Sidhu B, Rinaldi CA. Chronic Right Ventricular Pacing in the Heart Failure Population. Curr Heart Fail Rep 2018; 15:61-69. [PMID: 29435789 PMCID: PMC5857555 DOI: 10.1007/s11897-018-0376-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Purpose of Review We review the trials that have demonstrated potentially harmful effects from right ventricular (RV) apical pacing as well as reviewing the evidence of alternative RV pacing sites and cardiac resynchronization therapy (CRT) for patients who have heart failure and atrioventricular (AV) block. Recent Findings The role of CRT in patients with AV block and impaired left ventricular function remains an important consideration. The BLOCK HF trial demonstrated better outcomes with CRT pacing over RV pacing in patients with left ventricular systolic dysfunction (LVSD) and AV block who were expected to have a high RV pacing burden, but failed to demonstrate a mortality benefit. Summary CRT seems to have a beneficial effect on left ventricular reverse remodeling, systolic function, and clinical outcomes in patients with New York Heart Association (NYHA) functional class I–III heart failure, moderate to severe LVSD, and AV block compared to RV pacing. However, it is less clear whether there is a similar benefit from CRT in patients with a high percentage of RV pacing who have normal or mild LVSD in the treatment of AV block.
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Affiliation(s)
- Justin Gould
- King's College London, London, UK. .,Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Benjamin Sieniewicz
- King's College London, London, UK.,Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Bradley Porter
- King's College London, London, UK.,Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Baldeep Sidhu
- King's College London, London, UK.,Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Christopher A Rinaldi
- King's College London, London, UK.,Guy's and St Thomas' NHS Foundation Trust, London, UK
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