Feasibility and Acute Hemodynamic Effect of Left Ventricular Septal Pacing by Transvenous Approach Through the Interventricular Septum

Background—Left ventricular septal (LVS) pacing reduces ventricular dyssynchrony and improves cardiac function relative to right ventricular apex (RVA) pacing in animals. We aimed to establish permanent placement of an LVS pacing lead in patients using a transvenous approach through the interventricular septum. Methods and Results—Ten patients with sinus node dysfunction scheduled for dual-chamber pacemaker implantation were prospectively enrolled. A custom pacing lead with extended helix was introduced via the left subclavian vein and, after positioning against the right ventricular septum (RVS) using a preshaped guiding catheter, driven through the interventricular septum to the LVS. The acute hemodynamic effect of RVA, RVS, and LVS pacing was evaluated by invasive LVdP/dtmax measurements. The lead was successfully delivered to the LVS in all patients. Procedure time and fluoroscopy time shortened with experience. QRS duration was shorter during LVS pacing (144±20 ms) than during RVA (172±33 ms; P=0.02 versus LVS) and RVS pacing (165±17 ms; P=0.004 versus LVS). RVA and RVS pacing reduced LVdP/dtmax compared with baseline atrial pacing (−7.1±4.1% and −6.9±4.3%, respectively), whereas LVS pacing maintained LVdP/dtmax at baseline level (1.0±4.3%; P=0.001 versus RVA and RVS). R-wave amplitude and pacing threshold were 12.2±6.7 mV and 0.5±0.2 V at implant and remained stable during 6-month follow-up without lead-related complications. Conclusions—Permanent placement of an LVS pacing lead by transvenous approach through the interventricular septum is feasible in patients. LVS pacing preserves acute left ventricular pump function. This new pacing method could serve as an alternative and hemodynamically preferable approach for antibradycardia pacing.

[1]  T. Marwick,et al.  Effect of right ventricular pacing lead site on left ventricular function in patients with high-grade atrioventricular block: results of the Protect-Pace study. , 2015, European heart journal.

[2]  J. McMurray,et al.  Cardiovascular risks with azithromycin. , 2013, The New England journal of medicine.

[3]  Anil K. Gehi,et al.  Biventricular pacing for atrioventricular block and systolic dysfunction. , 2013, The New England journal of medicine.

[4]  Anne B Curtis,et al.  Biventricular pacing for atrioventricular block and systolic dysfunction. , 2013, The New England journal of medicine.

[5]  J. Ottervanger,et al.  Upgrading to Biventricular Pacing Guided by Pressure–Volume Loop Analysis During Implantation , 2011, Journal of cardiovascular electrophysiology.

[6]  H. Jensen,et al.  His and para-His pacing in AV block: feasibility and electrocardiographic findings , 2011, Journal of Interventional Cardiac Electrophysiology.

[7]  G. Boriani,et al.  Phrenic stimulation management in CRT patients: are we there yet? , 2011, Current opinion in cardiology.

[8]  E. Heist,et al.  Conventional versus biventricular pacing in heart failure and bradyarrhythmia: the COMBAT study. , 2010, Journal of cardiac failure.

[9]  Frits W Prinzen,et al.  Left Ventricular Septal and Left Ventricular Apical Pacing Chronically Maintain Cardiac Contractile Coordination, Pump Function and Efficiency , 2009, Circulation. Arrhythmia and electrophysiology.

[10]  G. Boriani,et al.  Phrenic Stimulation: A Challenge for Cardiac Resynchronization Therapy , 2009, Circulation. Arrhythmia and electrophysiology.

[11]  Claudia Stöllberger,et al.  Guidelines for device-based therapy of cardiac rhythm abnormalities. , 2009, Heart rhythm.

[12]  Frits W Prinzen,et al.  Echocardiography Is Not Useful Before Cardiac Resynchronization Therapy if QRS Duration Is Available , 2008, Circulation. Cardiovascular imaging.

[13]  Harlan M Krumholz,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 Pacemaker , 2008, Journal of the American College of Cardiology.

[14]  C. Steinwender,et al.  Long-term outcomes in patients with atrioventricular block undergoing septal ventricular lead implantation compared with standard apical pacing. , 2008, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[15]  F. Prinzen,et al.  Direct His bundle pacing preserves coronary perfusion compared with right ventricular apical pacing: a prospective, cross-over mid-term study. , 2008, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[16]  D. Desilvey.  Minimizing ventricular pacing to reduce atrial fibrillation in sinus node disease. , 2008, The American journal of geriatric cardiology.

[17]  G. Lamas,et al.  Minimizing ventricular pacing to reduce atrial fibrillation in sinus-node disease. , 2007, The New England journal of medicine.

[18]  J. Lukl,et al.  Single-centre experience with coronary sinus lead stability and long-term pacing parameters. , 2007, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[19]  J. Daubert,et al.  Upgrading from Single Chamber Right Ventricular to Biventricular Pacing in Permanently Paced Patients with Worsening Heart Failure: The RD‐CHF Study , 2007, Pacing and clinical electrophysiology : PACE.

[20]  C. Cemin,et al.  Permanent direct his bundle pacing does not induce ventricular dyssynchrony unlike conventional right ventricular apical pacing , 2006, Journal of Interventional Cardiac Electrophysiology.

[21]  Jeroen J. Bax,et al.  Right ventricular pacing can induce ventricular dyssynchrony in patients with atrial fibrillation after atrioventricular node ablation. , 2006, Journal of the American College of Cardiology.

[22]  A. Michelucci,et al.  Ventricular pacing lead location alters systemic hemodynamics and left ventricular function in patients with and without reduced ejection fraction. , 2006, Journal of the American College of Cardiology.

[23]  P. Marino,et al.  Prevention of ventricular desynchronization by permanent para-Hisian pacing after atrioventricular node ablation in chronic atrial fibrillation: a crossover, blinded, randomized study versus apical right ventricular pacing. , 2006, Journal of the American College of Cardiology.

[24]  Michael Böhm,et al.  Biventricular versus conventional right ventricular stimulation for patients with standard pacing indication and left ventricular dysfunction: the Homburg Biventricular Pacing Evaluation (HOBIPACE). , 2006, Journal of the American College of Cardiology.

[25]  Arjun D. Sharma,et al.  Percent right ventricular pacing predicts outcomes in the DAVID trial. , 2005, Heart rhythm.

[26]  Paul J. Wang,et al.  The Clinical Implications of Cumulative Right Ventricular Pacing in the Multicenter Automatic Defibrillator Trial II , 2005, Journal of cardiovascular electrophysiology.

[27]  F. Anselme,et al.  A New Dual‐Chamber Pacing Mode to Minimize Ventricular Pacing , 2005, Pacing and clinical electrophysiology : PACE.

[28]  Paul A. Belk,et al.  Randomized pilot study of a new atrial-based minimal ventricular pacing mode in dual-chamber implantable cardioverter-defibrillators. , 2004, Heart rhythm.

[29]  Arjun D. Sharma,et al.  Right Ventricular Outflow Versus Apical Pacing in Pacemaker Patients with Congestive Heart Failure and Atrial Fibrillation , 2003, Journal of cardiovascular electrophysiology.

[30]  J. Twisk,et al.  Comparison of the haemodynamic effects of right ventricular outflow-tract pacing with right ventricular apex pacing: a quantitative review. , 2003, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[31]  G. Lamas,et al.  Adverse Effect of Ventricular Pacing on Heart Failure and Atrial Fibrillation Among Patients With Normal Baseline QRS Duration in a Clinical Trial of Pacemaker Therapy for Sinus Node Dysfunction , 2003, Circulation.

[32]  F. Prinzen,et al.  Left ventricular septal and apex pacing for optimal pump function in canine hearts. , 2003, Journal of the American College of Cardiology.

[33]  David O. Martin,et al.  Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial. , 2002, JAMA.

[34]  C. Lau,et al.  Functional abnormalities in patients with permanent right ventricular pacing: the effect of sites of electrical stimulation. , 2002, Journal of the American College of Cardiology.

[35]  J. Res,et al.  Testing a new mechanism for left interventricular septal pacing: the transseptal route; a feasibility and safety study. , 2002, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[36]  D. Delurgio,et al.  Addition of a Left Ventricular Lead to Conventional Pacing Systems in Patients with Congestive Heart Failure: Feasibility, Safety, and Early Results in 60 Consecutive Patients , 2002, Pacing and clinical electrophysiology : PACE.

[37]  N. Kanuru,et al.  Cardiac resynchronization in patients with congestive heart failure and chronic atrial fibrillation: effect of upgrading to biventricular pacing after chronic right ventricular pacing. , 2002, Journal of the American College of Cardiology.

[38]  D. Casavant,et al.  Permanent, direct His-bundle pacing: a novel approach to cardiac pacing in patients with normal His-Purkinje activation. , 2000, Circulation.

[39]  L. Widman,et al.  Para-Hisian pacing. A new method for differentiating retrograde conduction over an accessory AV pathway from conduction over the AV node. , 1996, Circulation.