Elsevier

The Lancet

Volume 357, Issue 9264, 21 April 2001, Pages 1277-1283
The Lancet

Seminar
Pacing for heart failure

https://doi.org/10.1016/S0140-6736(00)04409-3Get rights and content

Summary

Pacing for patients with severe heart failure without bradyarrhythmia has been proposed as an addition to medical therapy over the past decade. Alteration of the normal electrical activation sequence of the heart modifies its mechanical action, especially when ventricular function is poor. Both the site of ventricular-lead placement and timing with the atria have been manipulated in attempts to alleviate the symptoms of heart failure. Most recently, in addition to the conventional two leads used for pacing, a third lead to pace the left ventricle has been advocated in some patients with heart failure. We review the evidence for pacing in heart failure.

Section snippets

Electromechanical performance in heart failure with pacing

As early as 1925, Wiggers recorded that compared with activation from the atrium, activation from the ventricular epicardium led to lower peak left-ventricular pressure and lower values of its time derivative (dP/dt, rate of change in pressure, which is used to assess changes in contractility). He concluded that the normal sequence of activation and the consequent “orderliness in the mode of contraction” were essential for optimum function.2 However, many patients with severe heart failure have

Temporary pacing studies of multisite pacing for heart failure

Interventricular conduction delay occurs in up to 40% of patients with severe heart failure.3 Simultaneous pacing of the right and left ventricles has been advocated to reverse this delay and thereby improve ventricular function and clinical status. Biventricular pacing in patients in sinus rhythm requires a lead in the right atrium, to sense the sinus-node initiation of the electrical sequence, and leads in the right and left ventricles, which are activated after a programmed atrioventricular

Studies of long-term biventricular pacing

The first two series of permanent biventricular pacemaker implants in seven and five patients, respectively, showed substantial symptomatic benefit in patients who survived the implantation procedure.18, 26 The high mortality was attributed to the selection of patients with end-stage heart failure and the risk of general anaesthesia required for thoracotomy. The approach used in these series and others (PATH-CHF, VENTAK-CHF, VIGOR-CHF),27, 28 has been superseded by the use of the coronary sinus

Planned studies (table 2)

Large studies comparing medical therapy and conventional right-ventricular pacing with alternative-site pacing (left-ventricular or biventricular) are needed. Double-blind controlled studies comparing biventricular pacing with conventional medical therapy are currently recruiting (for example, CARE-HF [Cardiac Resynchronisation for Heart Failure] and MIRACLE [Multisite InSynch Randomised Clinical Evaluation]). The primary endpoint of these trials is total mortality. Each will enrol several

Future developments of left-ventricular-based pacing for heart failure

At present, patients with a baseline QRS duration of more than 150 ms are generally regarded as probable responders to biventricular pacing.23, 39 However, there is anecdotal evidence that patients with normal QRS duration may benefit from this therapy. In patients with dilated cardiomyopathy, ventricular activation is very much more abnormal than is apparent from the surface electrocardiogram. There is evidence of effective bilateral bundle-branch block from signal-averaged

Hazards of biventricular pacing

The implantation procedure of any form of pacing has some risks involved—discomfort to the patient, pneumothorax, system infection, ventricular perforation, and displacement of the lead. Because of the technical difficulties with biventricular pacing, and therefore the much longer duration of the procedure, the hazards may be increased. The pacing technique itself imposes limitations. For example, the patient must be able to lie flat for up to several hours. In patients with a significant

Conclusions

Pacing is not applicable to most patients with heart failure, and it should not be undertaken without specific indication. Conventional dual-chamber pacing should be considered for symptomatic benefit in patients with medically refractory advanced heart failure with a long PR interval, short left-ventricular filling time, and presystolic mitral regurgitation demonstrable on echocardiography. In patients with advanced heart failure and interventricular conduction delay, biventricular pacing is

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