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Mainwaring E, Patel R, Desai C, Acharya R, Raveshia D, Shah S, Panesar H, Patel N, Singh R. Five historical innovations that have shaped modern cardiothoracic surgery. J Perioper Pract 2023:17504589231212967. [PMID: 38149619 DOI: 10.1177/17504589231212967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
Throughout history, many innovations have contributed to the development of modern cardiothoracic surgery, improving patient outcomes and expanding the range of treatment options available to patients. This article explores five key historical innovations that have shaped modern cardiothoracic surgery: cardiopulmonary bypass, surgical pacemakers, video assisted thoracic surgery, robotic surgery and mechanical circulatory support. We will review the development, impact and significance of each innovation, highlighting their contributions to the field of cardiothoracic surgery and their ongoing relevance in contemporary and perioperative practice.
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Affiliation(s)
- Elizabeth Mainwaring
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge, UK
| | - Ravi Patel
- Department of Trauma and Orthopaedics, Shrewsbury and Telford Trust, The Princess Royal Hospital, Telford, UK
- Department of Trauma and Orthopaedics, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK
| | - Chaitya Desai
- Department of Urology, Walsall Manor Hospital, Walsall Healthcare NHS Trust, Walsall, UK
| | - Radhika Acharya
- Department of Intensive Care, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Dimit Raveshia
- Department of General Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Saumil Shah
- Department of Otolaryngology, The Princess Royal Hospital, Telford, UK
| | - Harrypal Panesar
- Department of Otolaryngology, The Princess Royal Hospital, Telford, UK
| | | | - Rohit Singh
- Department of Trauma and Orthopaedics, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK
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Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay. Heart Rhythm 2019; 16:e128-e226. [DOI: 10.1016/j.hrthm.2018.10.037] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Indexed: 12/13/2022]
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Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2019; 140:e382-e482. [DOI: 10.1161/cir.0000000000000628] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | | | | | | | - Kenneth A. Ellenbogen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information
- ACC/AHA Representative
| | - Michael R. Gold
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information
- HRS Representative
| | | | | | - José A. Joglar
- ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | | | | | | | | | | | | | - Cara N. Pellegrini
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information
- HRS Representative
- Dr. Pellegrini contributed to this article in her personal capacity. The views expressed are her own and do not necessarily represent the views of the US Department of Veterans Affairs or the US government
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Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay. J Am Coll Cardiol 2019; 74:e51-e156. [DOI: 10.1016/j.jacc.2018.10.044] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Santilli RA, Giacomazzi F, Porteiro Vázquez DM, Perego M. Indications for permanent pacing in dogs and cats. J Vet Cardiol 2019; 22:20-39. [PMID: 30709617 PMCID: PMC7185536 DOI: 10.1016/j.jvc.2018.12.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 12/14/2018] [Accepted: 12/14/2018] [Indexed: 12/25/2022]
Abstract
Pacemaker implantation is considered as a standard procedure for treatment of symptomatic bradycardia in both dogs and cats. Advanced second-degree and third-degree atrioventricular blocks, sick sinus syndrome, persistent atrial standstill, and vasovagal syncope are the most common rhythm disturbances that require pacing to either alleviate clinical signs or prolong survival. Most pacemakers are implanted transvenously, using endocardial leads, but rarely epicardial leads may be necessary. To decide whether a patient is a candidate for pacing, as well as which pacing modality should be used, the clinician must have a clear understanding of the etiology, the pathophysiology, and the natural history of the most common bradyarrhythmias, as well as what result can be achieved by pacing patients with different rhythm disturbances. The goal of this review was, therefore, to describe the indications for pacing by evaluating the available evidence in both human and veterinary medicine. We described the etiology of bradyarrhythmias, clinical signs and electrocardiographic abnormalities, and the choice of pacing modality, taking into account how different choices may have different physiological consequences to selected patients. It is expected that this review will assist veterinarians in recognizing arrhythmias that may require permanent pacing and the risk-benefit of each pacing modality and its impact on outcome.
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Affiliation(s)
- R A Santilli
- Clinica Veterinaria Malpensa, Viale Marconi 27, 21017 Samarate, Varese, Italy; Department of Clinical Sciences, Cornell University, Ithaca, NY, USA.
| | - F Giacomazzi
- Clinica Veterinaria Malpensa, Viale Marconi 27, 21017 Samarate, Varese, Italy
| | | | - M Perego
- Clinica Veterinaria Malpensa, Viale Marconi 27, 21017 Samarate, Varese, Italy
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DANDAMUDI GOPI, VIJAYARAMAN PUGAZHENDHI. Trials and Tribulations of Ventricular Pacing. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:1313-1316. [DOI: 10.1111/pace.12921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 07/09/2016] [Accepted: 07/18/2016] [Indexed: 01/31/2023]
Affiliation(s)
- GOPI DANDAMUDI
- Indiana University School of Medicine; Indianapolis Indiana
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Lichtenberger J, Scollan KF, Bulmer BJ, Sisson DD. Long-term outcome of physiologic VDD pacing versus non-physiologic VVI pacing in dogs with high-grade atrioventricular block. J Vet Cardiol 2015; 17:42-53. [DOI: 10.1016/j.jvc.2014.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 12/17/2014] [Accepted: 12/23/2014] [Indexed: 10/24/2022]
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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). ACTA ACUST UNITED AC 2013; 16:354-62. [DOI: 10.1093/europace/eut343] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Renin-angiotensin system blockers are associated with reduced mortality and heart failure hospitalization in patients paced for complete atrioventricular block. Heart Rhythm 2011; 9:505-10. [PMID: 22094075 DOI: 10.1016/j.hrthm.2011.11.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND Right ventricular apical pacing can cause dyssynchronous activation of the ventricles, increase sympathetic activation, cause abnormalities in myocardial perfusion, worsen cardiac output and endothelial function, and may be associated with adverse cardiovascular effects. The use of rennin-angiotensin system blockers (RASBs) may be beneficial in counteracting these potentially harmful effects of right ventricular pacing. OBJECTIVE To explore the impact of RASB use on the outcome in patients with right ventricular pacemakers implanted for complete atrioventricular (AV) block. METHODS Patients implanted with right ventricular pacemakers for complete AV block between 1994 and 2009 were identified from the Tayside Pacing Registry. Cox proportional hazards model was used to assess differences in all-cause mortality and congestive heart failure hospitalizations for those receiving RASB during follow-up, adjusted for confounding variables. We also performed 2 sensitivity analyses--a propensity score-matched analysis and time-dependent analyses--to minimize bias. RESULTS Eight hundred twenty patients (57% men; median age 73 years; range 22-103 years) received pacemakers for complete AV block between 1994 and 2008 (54% dual-chamber pacemaker and 46% ventricular demand pacemaker). Two hundred seventy-eight (34%) patients had received RASBs. Mean follow-up was 4.9 ± 4.6 years, with 540 (65%) deaths. RASB use was independently associated with significantly reduced mortality (adjusted hazard ratio 0.67; 95% confidence interval 0.47-0.94; P = .017) and reduced heart failure hospitalization (adjusted hazard ratio 0.42; 95% confidence interval 0.17-0.92; P <.001). CONCLUSIONS This study suggests that RASBs may confer outcome benefits in patients with right ventricular pacemakers implanted for complete AV block.
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Alhous MHA, Small GR, Hannah A, Hillis GS, Broadhurst P. Impact of temporary right ventricular pacing from different sites on echocardiographic indices of cardiac function. Europace 2011; 13:1738-46. [DOI: 10.1093/europace/eur207] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Rimbas Sisu RC, Cinteza M, Vinereanu D. Interventricular septal or standard apical pacing in pacing dependent patients: still a dilemma? MAEDICA 2010; 5:193-200. [PMID: 21977152 PMCID: PMC3177543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Kalahasty G, Ellenbogen K. The Role of Pacemakers in the Management of Patients with Atrial Fibrillation. Cardiol Clin 2009; 27:137-50, ix. [DOI: 10.1016/j.ccl.2008.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Lee KL, Lau CP, Tse HF, Echt DS, Heaven D, Smith W, Hood M. First human demonstration of cardiac stimulation with transcutaneous ultrasound energy delivery: implications for wireless pacing with implantable devices. J Am Coll Cardiol 2007; 50:877-83. [PMID: 17719475 DOI: 10.1016/j.jacc.2007.04.081] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Revised: 03/22/2007] [Accepted: 04/18/2007] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the feasibility and safety of a novel technology that uses energy transfer from an ultrasound transmitter to achieve cardiac stimulation without the use of a pacing lead in humans. BACKGROUND To overcome the limitations of pacemaker leads, a new technology enabling stimulation without the use of a lead is desirable. METHODS A steerable bipolar electrophysiology catheter incorporating a receiver electrode into the tip and circuitry to convert ultrasound energy to electrical energy was inserted transvenously into the heart. An ultrasound transmitting transducer was placed on the chest wall with ultrasound gel. Ultrasound energy was amplitude-adjusted and transmitted at 313 to 385 kHz. The output waveform of the receiver electrode was monitored while the transmitter was moved on the chest wall to target the receiver. The ultrasound transmission amplitude was limited to a mechanical index of 1.9, the maximum allowed for ultrasound imaging systems. Ultrasound-mediated pacing with minimum voltage but consistent capture was obtained for 12 s. RESULTS Twenty-four patients (48 +/- 12 years) were tested during or after completion of clinical electrophysiology procedures. A total of 80 pacing sites were tested (mean 3.3 sites/patient): 12 right atrial, 35 right ventricular, and 33 left ventricular (31 endocardial) sites. The transmit-to-receive distance was 11.3 +/- 3.2 cm (range 5.3 to 22.5 cm). Ultrasound-mediated pacing was achieved at all 80 test sites, with consistent capture at 77 sites. The mechanical index during pacing was 0.5 +/- 0.3 (range 0.1 to 1.5). The mean ultrasound-mediated capture threshold was 1.01 +/- 0.64 V. There was no adverse event related to ultrasound pacing. No patient experienced discomfort during pacing. CONCLUSIONS The feasibility and safety of pacing usng ultrasound energy has been shown acutely.
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Affiliation(s)
- Kathy L Lee
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong SAR, China.
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Abstract
An increasing number of patients are now treated cardiac pacemakers and implantable cardioverter defibrillators and the technology of these is constantly changing. It is vital to have a good understanding of how they function and what the real risks are. Understanding how the device should work when functioning normally, and the possible effects of electromagnetic interference, is paramount to their safe management in the peri-operative period. Knowing when a device should be disabled or reprogrammed requires careful consideration. Information from the patient's pacemaker clinic should be sought whenever possible and can be invaluable. In addition, the Medicines Healthcare products Regulatory Agency have published the first set of UK guidelines on the management of implantable devices in the presence of surgical diathermy and this will undoubtedly provide a firm foundation on which anaesthetists can base much of their practice.
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Affiliation(s)
- M Allen
- Department of Anaesthesia, Moorfields Eye Hospital NHS Foundation Trust, London EC1V 2PD, UK.
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Abstract
BACKGROUND In the treatment of atrioventricular block, dual-chamber cardiac pacing is thought to confer a clinical benefit as compared with single-chamber ventricular pacing, but the supporting evidence is mainly from retrospective studies. Uncertainty persists regarding the true benefits of dual-chamber pacing, particularly in the elderly, in whom it is used less often than in younger patients. METHODS In a multicenter, randomized, parallel-group trial, 2021 patients 70 years of age or older who were undergoing their first pacemaker implant for high-grade atrioventricular block were randomly assigned to receive a single-chamber ventricular pacemaker (1009 patients) or a dual-chamber pacemaker (1012 patients). In the single-chamber group, patients were randomly assigned to receive either fixed-rate pacing (504 patients) or rate-adaptive pacing (505 patients). The primary outcome was death from all causes. Secondary outcomes included atrial fibrillation, heart failure, and a composite of stroke, transient ischemic attack, or other thromboembolism. RESULTS The median follow-up period was 4.6 years for mortality and 3 years for other cardiovascular events. The mean annual mortality rate was 7.2 percent in the single-chamber group and 7.4 percent in the dual-chamber group (hazard ratio, 0.96; 95 percent confidence interval, 0.83 to 1.11). We found no significant differences between the group with single-chamber pacing and that with dual-chamber pacing in the rates of atrial fibrillation, heart failure, or a composite of stroke, transient ischemic attack, or other thromboembolism. CONCLUSIONS In elderly patients with high-grade atrioventricular block, the pacing mode does not influence the rate of death from all causes during the first five years or the incidence of cardiovascular events during the first three years after implantation of a pacemaker.
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Affiliation(s)
- William D Toff
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, United Kingdom.
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Galtes I, Lamas GA. Cardiac pacing for bradycardia support: Evidence-based approach to pacemaker selection and programming. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2004; 6:385-395. [PMID: 15324614 DOI: 10.1007/s11936-004-0022-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The vast majority of pacemakers implanted in the United States for the treatment of symptomatic bradycardia are dual-chamber systems with a complex array of functions, such as rate responsiveness, dynamic atrioventricular delay, and automatic mode switching. Basic hemodynamic studies have convincingly demonstrated the superiority of maintaining atrioventricular synchrony. However, clinical trials have failed to demonstrate the impressive results expected based on physiologic data. The most recent randomized clinical trials have demonstrated that dual-chamber devices, when compared with single-chamber ventricular pacing, do not prevent mortality or stroke, and lead to an unexpectedly small reduction in heart failure hospitalizations. Although improvements in quality of life have not been consistently found when comparing ventricular-based versus atrial-based pacing, a reduction in the incidence of newly diagnosed atrial fibrillation in dual chamber-paced patients has been reported by most trials. Dual-chamber pacing has been reported to reduce pacemaker syndrome in US trials. The addition of rate modulation, in spite of attempting to replicate the normal response to exercise, has not shown a consistently positive impact on quality of life or treadmill time. The use of pacemakers for the treatment of vasovagal syncope is controversial. Adding dual-chamber sensing ability to current implanted defibrillators considerably reduces the number of inappropriate shocks but may increase mortality if not programmed to minimize ventricular stimulation.
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Affiliation(s)
- Israel Galtes
- Mount Sinai Medical Center, Butler Building, 4300 Alton Road, Miami Beach, FL 33140, USA.
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Kerr CR. Stroke and pacing mode: is pacing mode important?**Editorials published in the Journal of the American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology. J Am Coll Cardiol 2004; 43:1623-4. [PMID: 15120822 DOI: 10.1016/j.jacc.2004.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hayes DL, Furman S. Cardiac Pacing:. How It Started, Where We Are, Where We Are Going. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:693-704. [PMID: 15125737 DOI: 10.1111/j.1540-8159.2004.00515.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- David L Hayes
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Mayo College of Medicine, Rochester, Minnesota 55905, USA.
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Affiliation(s)
- David L Hayes
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Mayo College of Medicine, Rochester, Minnesota 55905, USA.
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Kerr CR, Connolly SJ, Abdollah H, Roberts RS, Gent M, Yusuf S, Gillis AM, Tang ASL, Talajic M, Klein GJ, Newman DM. Canadian Trial of Physiological Pacing. Circulation 2004; 109:357-62. [PMID: 14707022 DOI: 10.1161/01.cir.0000109490.72104.ee] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The Canadian Trial of Physiological Pacing (CTOPP) reported that the risk of stroke or cardiovascular death was similar between patients receiving ventricular versus physiological pacemakers at the end of the original follow-up period of 3 years. However, the occurrence of atrial fibrillation was significantly less frequent with physiological pacemakers. To assess a potential delayed benefit of physiological pacing, follow-up of patients in this study was extended to 6 years.
Methods and Results—
A total of 1474 patients requiring a pacemaker for symptomatic bradycardia were randomized to receive ventricular and 1094 to physiological pacemakers. The primary outcome was stroke or cardiovascular death. The study was completed in July 1998, and follow-up was extended to July 2001. At a mean follow-up of 6.4 years, there was no difference between treatment groups in the primary outcome of cardiovascular death or stroke. There was no significant difference in total mortality or stroke between groups. There was a significantly lower rate of development of atrial fibrillation in the physiological group, with a relative risk reduction of 20.1% (CI, 5.4 to 32.5;
P
=0.009).
Conclusions—
The CTOPP extended study does not show a difference in cardiovascular death or stroke, or in total mortality, or in stroke between patients implanted with ventricular or physiological pacemakers over a mean follow-up of >6 years. However, there is a persistent significant reduction in the development of atrial fibrillation with physiological pacing.
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Affiliation(s)
- Charles R Kerr
- Room 344, Division of Cardiology, St Paul's Hospital, 1081 Burrard St, Vancouver, BC, Canada, V6Z 1Y6.
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Dretzke J, Toff WD, Lip GYH, Raftery J, Fry-Smith A, Taylor R. Dual chamber versus single chamber ventricular pacemakers for sick sinus syndrome and atrioventricular block. Cochrane Database Syst Rev 2004; 2004:CD003710. [PMID: 15106214 PMCID: PMC8095057 DOI: 10.1002/14651858.cd003710.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Dual chamber pacing or single chamber atrial pacing ('physiologic' pacing) is believed to have an advantage over single chamber ventricular pacing in that it resembles cardiac physiology more closely by maintaining atrioventricular (AV) synchrony and dominance of the sinus node, which in turn may reduce cardiovascular morbidity and mortality thus contributing to patient survival and quality of life. However, a significant proportion of pacemakers currently implanted are single chamber ventricular pacemakers. OBJECTIVES The objective of this review was to assess the short- and long-term clinical effectiveness of dual chamber pacemakers compared to single chamber ventricular pacemakers in adults with AV block, sick sinus syndrome or both. An additional objective was to assess separately any potential differences in effectiveness between dual chamber pacing and single chamber atrial pacing. The clinical effectiveness of single chamber atrial pacing versus single chamber ventricular pacing was not examined. SEARCH STRATEGY The Cochrane Controlled Trials Register (The Cochrane Library Issue 3, 2002), MEDLINE (1966 to 2002), EMBASE (1980 to 2002) and the Science Citation Index (1980 to 2002) were searched on 19th August 2002. Citation lists and web sites were checked and researchers in the field contacted. SELECTION CRITERIA Parallel group or crossover randomised controlled trials of at least 48 hours duration comparing dual chamber pacing and single chamber ventricular pacing, and investigating cardiovascular morbidity, mortality, patient related quality of life, exercise capacity and complication rates. DATA COLLECTION AND ANALYSIS Data was extracted onto pre-piloted data extraction forms. Quality assessment was undertaken using a checklist, with a sub-sample of quality data independently extracted by a second reviewer. Where appropriate data was available, meta-analysis was performed. Where meta-analysis was not possible, the number of studies showing a positive, neutral or negative direction of effect and statistical significance were simply counted. MAIN RESULTS Five parallel and 26 crossover randomised controlled trials were identified. The quality of reporting was found to be poor. Pooled data from parallel studies shows a statistically non-significant preference for physiologic pacing (primarily dual chamber pacing) for the prevention of stroke, heart failure and mortality, and a statistically significant beneficial effect regarding the prevention of atrial fibrillation (odds ratio (OR) 0.79, 95% CI 0.68 to 0.93). Both parallel and crossover studies favour dual chamber pacing with regard to pacemaker syndrome (parallel: Peto OR 0.11, 95% CI 0.08 to 0.14; crossover: standardised mean difference (SMD) -0.74, 95% CI - 0.95 to -0.52). Pooled data from crossover studies shows a statistically significant trend towards dual chamber pacing being more favourable in terms of exercise capacity (SMD -0.24, 95% CI -0.03 to -0.45). No individual studies reported a significantly more favourable outcome with single chamber ventricular pacing. REVIEWERS' CONCLUSIONS This review shows a trend towards greater effectiveness with dual chamber pacing compared to single chamber ventricular pacing, which supports the current British Pacing and Electrophysiology Group's Guidelines regarding atrioventricular block. Additional randomised controlled trial evidence from ongoing trials in this area will further inform the debate.
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Affiliation(s)
- J Dretzke
- Department of Public Health & Epidemiology, University of Birmingham, Edgbaston, Birmingham, UK, B15 2TT
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Camm AJ. Translation of clinical trials into clinical practice: use of results in formulating guidelines. J Cardiovasc Electrophysiol 2003; 14:S9-14. [PMID: 12950511 DOI: 10.1046/j.1540-8167.14.s9.6.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The "evidence base" for arrhythmology is enormous and highly variable in quality and relevance. Every day, more information becomes available from basic science, bedside research, randomized trials, structured registries, and clinical experience. It has become critically important to develop methods for collating and synthesizing all of these strands of evidence into a useful and applicable format. The guideline is an increasingly valuable tool for this purpose. Guidelines are constructed in a formal and approved manner such that the evidence is graded and combined to produce appropriately classified practical recommendations. Arrhythmology guidelines now must be funded, implemented, value tested, and regularly revised.
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Affiliation(s)
- A John Camm
- Department of Cardiological Sciences, St George's Hospital Medical School, London, United Kingdom.
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Abstract
The evidence base for pacing, specifically with regards to outcome-based randomized trials, is only beginning to emerge. At present, the guidelines for pacing in sinus node dysfunction (SND), atrioventricular block (AVB), and vasovagal syncope are largely based on observational, not randomized studies. The findings from observational studies that physiological pacing was associated with reduced mortality, fewer strokes, less heart failure, and less AF when compared with ventricular pacing, were not uniformly supported by the early randomized trials of a relatively small sample size. Thus, it has become increasingly clear that large scale randomized trials are necessary to measure reliably the benefit, if any, of progressively more expensive and complex pacemakers. To provide reliable answers to these important questions, three large multicenter randomized trials in Canada, the United Kingdom, and the United States have been designed and conducted. The present review analyzed the results of completed randomized trials on pacemaker mode selection. To date, > 6,000 patients requiring permanent pacing to prevent bradycardia have been randomized; among these, dual chamber pacing did not prevent stroke or improve survival when compared with ventricular pacing. However, dual chamber pacing led to a moderate reduction of incident and chronic AF, reduced symptoms of heart failure in patients with SND, prevented pacemaker syndrome, and modestly improved quality-of-life. Further, a 5-10% reduction in mortality by atrial-based pacing cannot be excluded based on the results of the analyzed trials. The availability of data from ongoing randomized trials and their meta analysis should complete the totality of evidence during the next several years.
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Affiliation(s)
- Alicia Montanez
- Division of Cardiology, Mount Sinai Medical Center, Miami Beach, Florida 33140, USA
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Abstract
There is a high prevalence of cardiovascular disorders among elderly patients with recurrent falls or syncope, and cardiovascular causes are implicated in a significant proportion of three cases. Common cardiovascular causes of falls and syncope include carotid sinus syndrome, vasovagal episodes, sick sinus syndrome, and atrioventricular block. A comprehensive history and physical examination supplemented by electrocardiographic monitoring, carotid sinus massage, and tilt-table testing in appropriately selected patients form the basis of the diagnostic evaluation to exclude a significant cardiovascular disorder. Patients with documented symptomatic bradycardia often benefit from pacemaker implantation, as evidenced by a reduction in recurrent events and improved quality of life. Although dual-chamber pacemakers, particularly those with rate responsiveness, provide more physiologic pacing than single-chamber ventricular devices, the superiority of dual-chamber pacemakers in reducing major clinical events has not been demonstrated. The efficacy of an aggressive evaluation and patient-management strategy that includes pacemaker implantation for elderly patients with recurrent falls has been validated only by one prospective clinical trial; however, available data are compelling. For a variety of cardiovascular conditions, permanent pacemaker implantation has a demonstrated efficacy to prevent symptoms that arise from transient hypotension and decreased cerebral perfusion. The implication of these data is that many falls may be preventable through permanent pacemaker implantation in appropriately selected patients.
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Affiliation(s)
- Mitchell N Faddis
- Clinical Cardiac Electrophysiology Unit, Washington University School of Medicine, Cardiology, Box 8086, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
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27
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Bourke JP. Atrioventricular block and problems with atrioventricular conduction. Clin Geriatr Med 2002; 18:229-51. [PMID: 12180245 DOI: 10.1016/s0749-0690(02)00007-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This chapter has summarized briefly the current state of our knowledge on the incidence, etiology, presentation, investigation, and management of patients with AV block. The scope of the material covered has been widened intentionally to include a plethora of AV-conduction abnormalities because of the increases in the understanding of their clinical importance and contribution to left ventricular dysfunction. Under this heading, the critical importance of heart rate, maintenance of AV synchrony, and the sequence of ventricular activation and relaxation have been introduced and summarized briefly. The authors make a strong plea that, in the future, the reader consider AV-conduction abnormalities to be the parent topic, with the more-traditional, narrower subject of AV block forming a subunit thereof.
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Affiliation(s)
- John P Bourke
- Department of Cardiology, University of Newcastle upon Type, Freeman Hospital, Freeman Road, Newcastle upon Tyne, UK.
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28
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Abstract
Retrospective studies and observational clinical data on pacemaker mode selection indicate that physiologic pacing is associated with better clinical outcomes and reduced mortality when compared with single-chamber ventricular pacing. Methodologic flaws in such studies, especially in respect of selection bias, have cast doubt upon the validity of the results and have mandated the performance of randomized, prospective studies of pacemaker-mode prescription. Evidence available to date suggests that atrial-based pacing may confer improved quality of life and a reduction in the incidence of chronic atrial fibrillation and thromboembolic events in sinus node disease. Physiologic pacing modes have, to date, not demonstrated benefit with congestive heart failure or patient longevity. The results of ongoing, large prospective trials of mode prescription in patients with AV block and sinus node disease are needed before any change from current guidelines can be recommended.
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Affiliation(s)
- R G Charles
- Cardiothoracic Centre, Liverpool, United Kingdom
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29
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Ellenbogen KA, Stambler BS, Orav EJ, Sgarbossa EB, Tullo NG, Love CA, Wood MA, Goldman L, Lamas GA. Clinical characteristics of patients intolerant to VVIR pacing. Am J Cardiol 2000; 86:59-63. [PMID: 10867093 DOI: 10.1016/s0002-9149(00)00828-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The incidence and clinical predictors of the development of intolerance to VVIR pacing have not been extensively studied in prospective long-term randomized trials comparing different pacing modes. The frequency and clinical factors predicting intolerance to ventricular pacing are controversial. The Pacemaker Selection in the Elderly (PASE) Trial enrolled 407 patients aged >/=65 years in a 30-month, single-blind, randomized, controlled comparison of quality of life and clinical outcomes with ventricular pacing and dual-chamber pacing in patients undergoing dual-chamber pacemaker implantation for standard clinically accepted indications. We reviewed the clinical, hemodynamic, and electrophysiologic variables at the time of pacemaker implantation in 204 patients enrolled in the PASE trial and randomized to the VVIR mode, some of whom subsequently required crossover (reprogramming) to DDDR pacing. During a median follow-up of 555 days, 53 patients (26%) crossed over from VVIR to DDDR pacing. A decrease in systolic blood pressure during ventricular pacing at the time of pacemaker implantation (p = 0.001), use of beta blockers at the time of randomization (p = 0.01), and nonischemic cardiomyopathy (p = 0.04) were the only variables that predicted crossover in the Cox multivariate regression model. After reprogramming to the dual-chamber mode, patients showed improvement in all aspects of quality of life, with significant improvements in physical and emotional role. The high incidence of crossover from VVIR to DDDR pacing along with significant improvements in quality of life after crossover to DDDR pacing strongly favors dual-chamber pacing compared with single-chamber ventricular pacing in elderly patients requiring permanent pacing.
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Affiliation(s)
- K A Ellenbogen
- Division of Cardiology, Medical College of Virginia/Virginia Commonwealth University, Richmond, Virginia 23298-0053, USA.
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30
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Abstract
Current recommendations in favor of dual-chamber over single-chamber ventricular pacing for patients with sinus node dysfunction or AV conduction disorders were made largely based on observational data and expert opinions. The first randomized pacing mode selection study was relatively small and suggested survival advantage with physiologic pacing only after an extended follow-up duration of 5.5 years. Preliminary results of the first large-scale multicenter randomized pacing mode selection trial revealed only modest reduction in atrial fibrillation without survival advantage after 3 years of physiologic pacing. Two other large-scale multicenter randomized trials comparing physiologic versus ventricular pacing are currently ongoing. They may provide further scientific evidence based on which more objective recommendations can be made with respect to pacing mode selection.
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Affiliation(s)
- C Y Tang
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minnesota, USA.
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31
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Abstract
Retrospective studies have suggested that, in patients with sick sinus syndrome, it has been recognized that atrial, dual-chamber, or other so-called physiologic modes of pacing are associated with a lower incidence of atrial fibrillation, stroke, heart failure, and death than is single-chamber ventricular pacing. Retrospective data in patients with atrioventricular block are less robust, but still suggest lower mortality and morbidity with dual-chamber pacing compared with ventricular pacing alone. Overall, the reduction in risk of atrial fibrillation with dual-chamber compared with ventricular pacing has been calculated at 62%, and for death 36%. Retrospective studies are, of course, potentially subject to bias, and there may be a tendency to implant cheaper, simpler pacemakers in older, sicker patients, which could explain the apparent difference in outcome. Prospective studies are, therefore, required; results from 3 such studies, in which pacing mode was randomly allocated, have been recently published. These, in general, support the apparent benefit of dual-chamber pacing in patients with sick sinus syndrome, but give equivocal results in patients with heart block. Other trials are in progress, and their results are awaited. Like all good trials, they will, in addition to providing some answers, generate further questions. They should provide the evidence on which cost-effective pacing policies may be based.
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Affiliation(s)
- J M McComb
- Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom
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33
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Hildick-Smith DJ, Lowe MD, Newell SA, Schofield PM, Shapiro LM, Stone DL, Grace AA, Petch MC. Ventricular pacemaker upgrade: experience, complications and recommendations. Heart 1998; 79:383-7. [PMID: 9616348 PMCID: PMC1728671 DOI: 10.1136/hrt.79.4.383] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess outcomes of pacemaker upgrade from single chamber ventricular to dual chamber. DESIGN Retrospective analysis of patients undergoing the procedure. SETTING Specialist cardiothoracic unit. PATIENTS 44 patients (15 female, 29 male), mean (SD) age at upgrade 68.2 (12.9) years. INTERVENTIONS Upgrade of single chamber ventricular to dual chamber pacemaker. MAIN OUTCOME MEASURES Procedure duration and complications. RESULTS Principal indications for upgrade were pacemaker syndrome (17), "opportunistic"--that is, at elective generator replacement (8), heart failure (7), non-specific breathlessness/fatigue (7), and neurally mediated syncope (3). Mean (SD) upgrade procedure duration (82.9 (32.6) minutes) significantly exceeded mean VVI implantation duration (42.9 (13.3) minutes) and mean DDD implantation duration (56.6 (22.7) minutes) (both p < 0.01). Complications included pneumothorax (1), ventricular arrhythmia requiring cardioversion (2), protracted procedure (10), atrial lead repositioning within six weeks (8), haematoma evacuation (1), superficial infection (1), and admission to hospital with chest pain (1); 20 patients (45%) suffered one or more complications including four of the eight who underwent opportunistic upgrade. CONCLUSIONS Pacemaker upgrade takes longer and has a higher complication rate than either single or dual chamber pacemaker implantation. This suggests that the procedure should be performed by an experienced operator, and should be undertaken only if a firm indication exists. Patients with atrial activity should not be offered single chamber ventricular systems in the belief that the unit can be upgraded later if necessary at minimal risk.
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Affiliation(s)
- R G Charles
- Cardiothoracic Centre, Liverpool NHS Trust, Liverpool, UK
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