Survival analysis in patients with preserved left ventricular function and standard indications for permanent cardiac pacing randomized to right ventricular apical or septal outflow tract pacing.

BACKGROUND: Optimal right ventricular (RV) pacing site in patients referred for permanent cardiac pacing remains controversial. A prospective randomized trial was done to compare long-term effect of permanent RV apex (RVA) vs RV outflow tract (RVOT) pacing on the all-cause and cardiovascular mortality. METHODS AND RESULTS: A total of 122 consecutive patients (70 men, 69 +/-11 years), with standard pacing indications were randomized to RVA (66 patients) or RVOT (56 patients) ventricular lead placement. After the 10-year follow-up period the mortality data were summarized on the basis of an intention-to-treat analysis. During the long-term follow-up, 31 patients from the RVA group died vs 24 patients in the RVOT group (hazard ratio (HR), 0.96; 95% confidence interval (CI), 0.57-1.65; P=0.89). There were 10 cardiovascular deaths in the RVA and 12 in the RVOT group (HR, 1.04; 95%CI, 0.45-2.41; P=0.93). There were no differences in the all-cause or cardiovascular mortality between the pacing sites after adjustment for age, gender, arterial hypertension, atrial fibrillation, New York Heart Association class and left ventricular end-diastolic diameter. CONCLUSIONS: The RVOT provides no additional benefit in terms of long-term survival over RVA pacing.

Echocardiographic evaluation of patients with severe heart failure and impairment of intraventricular conduction following cardiac resynchronisation therapy.

BACKGROUND: Echocardiographic examination is essential for clinical assessment of patients after cardiac resynchronisation therapy (CRT). AIM: To assess the benefit of CRT in patients with end-stage heart failure at long-term follow-up. METHODS: 28 patients with end-stage heart failure, NYHA class >or= III (>or= II in patients with indications for implantable cardioverter defibrillator and echocardiographic signs of ventricular mechanical systolic dyssynchrony), left ventricular ejection fraction (LVEF) <35%, QRS duration >120 ms and left bundle branch block morphology received a biventricular device. Standard colour Doppler echocardiography examination was performed at baseline, and then every 6 months, up to 2 years. Parameters of systolic and diastolic LV function, mitral insufficiency and right ventricular (RV) pressure were evaluated. RESULTS: Following CRT, a statistically significant improvement of LV dimensions (p<0.05), and LVEF (p<0.001) was recorded. CRT also resulted in a mitral regurgitation decrement (p<0.01). Interventricular mechanical delay was shortened (p=0.0005). After 2 years, non-significant worsening of LV dimensions was observed. At long-term follow-up CRT did not result in LV volume, left atrium, RV dimension or RV pressure reduction. CONCLUSIONS: CRT is associated with reverse remodelling of the LV at mid-term follow-up.

Cardiac resynchronisation therapy in patients with end-stage heart failure--long-term follow-up.

BACKGROUND: Cardiac resynchronisation therapy (CRT) has been shown to be effective in the treatment of patients with end-stage heart failure (HF). However, long-term results of CRT have not yet been validated. AIM: To assess the sustained benefit of CRT in patients with end-stage HF at long-term follow-up. In addition, predictors of response to CRT were analysed. METHODS: Twenty-eight patients with end-stage HF, NYHA class >or=III (>or=II in patients with indications for ICD and echocardiographic signs of ventricular mechanical systolic dyssynchrony), left ventricular ejection fraction <35%, QRS duration >120 ms and left bundle branch block morphology received a biventricular device (BiV). In 27 patients LV pacing was achieved via the coronary sinus tributaries and in 1 patient an endocardial LV lead was introduced transseptally. Ten patients received an ICD-CRT device. The control group consisted of 29 patients fulfilling the criteria for ICD-CRT implantation in whom the CRT system was not implanted for various reasons. At baseline, 3 months after implantation, and then every 6 months the following parameters were evaluated: NYHA class, quality of life (QoL) score, QRS duration on surface ECG, and 6-minute walking distance. The need for hospitalisation assessed one year before and one year after implantation was compared. Follow-up was obtained up to 2 years. RESULTS: The NYHA class and 6-minute walking test were significantly improved in the CRT group after 3 months and continued to improve gradually until 24 months of follow-up. The QoL improvement at 6 months was sustained over 2 years. Hospitalisation rate due to worsening of HF decreased. One-year and two-year survival were significantly better in the CRT group than in the control group (94 and 87 vs. 80 and 73% respectively). The only predictor of clinical improvement after CRT implantation was baseline NYHA class. CONCLUSION: Clinical improvements with CRT are progressive and sustained over 2 years of follow-up.

Right ventricular apex versus right ventricular outflow tract pacing: prospective, randomised, long-term clinical and echocardiographic evaluation.

INTRODUCTION: In patients treated with permanent pacing, the electrode is typically placed in the right ventricular apex (RVA). Published data indicate that such electrode placement leads to an unfavourable ventricular depolarization pattern, while right ventricular outflow tract (RVOT) pacing seems to be more physiological. AIM: To compare long-term effects of RVOT versus RVA pacing on clinical status, left ventricular (LV) function, and the degree of atrioventricular valve regurgitation. METHODS: Patients with indications for permanent pacing, admitted to hospital between 1996 and 1997, were randomised to receive RVA or RVOT pacing. In 2004 during a final control visit in 27 patients clinical status, echocardiographic parameters and QRS complex duration as well as NT-proBNP level were measured. Analysed parameters were compared between groups and in the case of data available during the perioperative period also their evolution in time was assessed. RESULTS: Out of 27 patients 14 were randomised to the RVA group and 13 to the RVOT group. No significant differences between groups were observed before the procedure with respect to age, gender, comorbidities or echocardiographic parameters. Mean duration of pacing did not differ significantly between the groups (89+/-9 months in RVA group vs 93+/-6 months in RVOT group, NS). In the RVA group significant LV ejection fraction decrease was observed (from 56+/-11% to 47+/-8%, p <0.05); in the RVOT group LV ejection fraction did not change (54+/-7% and 53+/-9%; NS). Progression of tricuspid valve regurgitation was also observed in the RVA group but not in the RVOT group. During the final visit NT-proBNP level was significantly higher in the RVA group: 1034+/-852 pg/ml vs 429+/-430 pg/ml (p <0.05). CONCLUSIONS: In patients with normal LV function permanent RVA pacing leads to LV systolic and diastolic function deterioration. RVOT pacing can reduce the unfavourable effect and can slow down cardiac remodelling caused by permanent RV pacing. Clinical and echocardiographic benefits observed in the RVOT group after 7 years of pacing are reflected by lower NT-proBNP levels in this group of patients.