How to prevent unecessary right ventricular pacing Jens Cosedis Nielsen, MD, PhD, DMSci Dept of Cardiology, Aarhus University Hospital, Skejby, Denmark June 27, 2011, Europace Madrid
Conflicts of interest Jens Cosedis Nielsen has received consulting fees/speakers honoraries from Medtronic, St Jude Medical, Biotronik, Astra-Zeneca and Sanofi-aventis.
How to prevent unecessary RV pacing In pacemaker patients SSS AV block In patients with compromised LV function
Disruption of AV synchrony causes AF! Pacing mode and atrial fibrillation, Healey J et al, Circulation 2006
POST-HOC ANALYSIS! DDDR Sweeney et al, Circulation 2003
Sweeney et al., Circulation 2003
9% V-pacing 99% V-pacing Very short AV interval Sweeney et al, NEJM 2007
LAVd 116±12 ms SAVd 32±6 ms J Cardiovasc Electrophysiol 2011, in press
Problems in pacing modes avoiding RV pacing AAIR pacemaker DDDR pacemaker accepting AVB
SSS A-pacing Paced rate 60 bpm Sweeney et al, JCE 2008
The DANPACE trial Initiated and driven by the investigators. Not influenced by company interests. Economic support: Unrestricted grants from Boston Scientific, Ela Medical, Medtronic, St Jude Medical, Pfizer, and the Danish Heart Foundation.
Pacemaker programming Rate adaptive function was active. Lower rate 60 bpm. Upper rate 130 bpm. DDDR: Paced AVI 220 ms. Sensed AVI 200 ms. Rate-adaptive shortening of the AVI.
Programming of AVI DDD 60 bpm. AVI= PR/Astim-QRS + 10% AVI to max AVI 220ms to search for intrinsic AV conduction. If: 220 150 AVI rate adaptive Sensed AVI 20-30ms shorter + AV Hysteresis to paced AVI 220ms
Survival 100 Survival (%) 75 50 25 p=0.53 Single Lead Atrial Pacing Dual Chamber Pacing 0 0 2 4 6 8 10 Years from randomization No. at Risk Single Lead 707 648 466 298 147 25 Dual Chamber 708 629 462 287 136 24
Reoperation 100 Dual Chamber Pacing 75 Single Lead Atrial Pacing 50 25 0 p<0.001 0 2 4 6 8 10 Years from randomization No. at Risk Single Lead 707 527 340 196 33 0 Dual Chamber 708 534 377 198 44 0
Atrial fibrillation 100 75 Dual Chamber Pacing Single Lead Atrial Pacing 50 25 0 p=0.024 0 2 4 6 8 10 Years from randomization No. at Risk Single Lead 707 498 301 157 47 0 Dual Chamber 708 504 330 158 52 0
On-treatment analysis, AF
Cardioversions for AF AAIR DDDR p=0.10
Cheng, S et al. JAMA 2009 PR >/ 200 ms
Patients with SSS No benefit with AAIR pacing compared with DDDR pacing with a moderately prolonged AVI in SSS. AAIR pacing is not appropriate for patients with SSS. DDDR pacing with a moderately prolonged AVI is recommended for SSS.
Patients with AV block and pacemaker
Patients with AV block No studies indicating that minimizing RV pacing is beneficial for these patients! No studies indicating that minimizing RV pacing is safe in these patients! DDD pacing with algorithms allowing AVB to minimize ventricular pacing cannot be recommended for patients with AV block at present time.
Patients with compromised LVEF Patients without /with a need for pacing
DAVID Trial 59% V-pacing DDDR VVIR 3.5% V-pacing The DAVID Trial Investigators, JAMA, 2002
Death or HF hospitalization
Heart Rhythm 2007
Worse outcome with MVP in patients with PR 230ms Sweeney et al, Heart Rhythm, 2010
Compromised LV function and no need for pacing VVI DDD with AV Hysteresis
Alternative RV pacing site
Septal RV pacing: Shorter QRS-width More physiological QRS-axis
Alternative RV pacing site No difference RV septal pacing worse Am J Cardiol 2009 RV septal pacing better JCE 2006
Septal RV pacing Am J Cardiol 2009
Direct His-bundle Pacing: Technically challenging Feasible in a minority of ptt with high grade AVB
Para-His Pacing: Feasible in most ptt with high grade AVB Long-term benefit remains to be investigated
Alternative RV pacing site No pacing site has proven superior to others with respect to clinical outcome in large randomised trials.
PACE 2009
PACE 2009
How to prevent unecessary RV pacing SSS DDDR with a moderately prolonged AVI In patients with short PR: AV block DDDR/AV hysteresis/mvp/aaisafe-r. Avoid very short AVI. Do not use DDD pacing with algorithms allowing AVB to minimize ventricular pacing. Compromised LV function No need for pacing: VVI-ICD Indication for pacing: CRT-P or CRT-D as appropriate.