The importance of avoiding unnecessary right ventricular pacing in clinical practice

Abstract

Symptomatic bradycardia is effectively treated with the implantation of a cardiac pacemaker. Although a highly successful therapy, during recent years there has been a focus on the negative effects associated with long-term pacing of the apex of the right ventricle (RV). It has been shown in both experimental and clinical studies that RV pacing leads to ventricular dyssynchrony, similar to that of left bundle branch block, with subsequent detrimental effects on cardiac structure and function, and in some cases adverse clinical outcomes such as atrial fibrillation, heart failure and death. There is substantial evidence that patients with reduced left ventricular function (LVEF) are at particular high risk of suffering the detrimental clinical effects of long-term RV pacing. The evidence is, however, incomplete, coming largely from subanalyses of pacemaker and implantable cardiac defibrillator studies. In this group of patients with reduced LVEF and an expected high amount of RV pacing, biventricular pacing (cardiac resynchronization therapy) devices can prevent the negative effects of RV pacing and reduce ventricular dyssynchrony. Therefore, cardiac resynchronization therapy has emerged as an attractive option with promising results and more clinical studies are underway. Furthermore, specific pacemaker algorithms, which minimize RV pacing, can also reduce the negative effects of RV stimulation on cardiac function and may prevent clinical deterioration.

Keywords: Cardiac pacing, Right ventricular pacing, Heart failure, Managed ventricular pacing, Cardiac resynchronization therapy, Implantable cardioverter-defibrillator

Core tip: A high amount of long-term right ventricular (RV) pacing produces ventricular dyssynchrony and clinical deterioration in patients with reduced left ventricular ejection fraction (LVEF). In this patient group, cardiac resynchronization therapy has been shown to improve clinical outcomes and should be considered before a conventional pacemaker. In subjects with normal LVEF, the deleterious effects of RV pacing is less clear; however, specific pacemaker algorithms that minimize RV pacing may improve clinical outcomes in selected patients. Future studies will help to better identify those at risk of suffering the negative effects of RV pacing and define the correct use of preventive therapeutic strategies.