Author + information
- Published online November 6, 2018.
- David J. Slotwiner, MD, FACC, FHRS, Chair, Evidence Review Committee,
- Merritt H. Raitt, MD, FHRS, Vice Chair, Evidence Review Committee,
- Freddy Del-Carpio Munoz, MD, MSc, FHRS, Evidence Review Committee Member,
- Siva K. Mulpuru, MD, Evidence Review Committee Member,
- Naseer Nasser, MD, Evidence Review Committee Member and
- Pamela N. Peterson, MD, MSPH, Evidence Review Committee Member
Background It is unclear whether physiologic pacing by either cardiac biventricular pacing (BiVP) or His-bundle pacing (HisBP) may prevent adverse structural and functional consequences known to occur among some patients who receive right ventricular pacing (RVP).
Aim Our analysis sought to review existing literature to determine if BiVP and/or HisBP might prevent adverse remodeling and be associated with structural, functional, and clinical advantages compared with RVP among patients without severe left ventricular dysfunction (>35%) who required permanent pacing because of heart block.
Methods A literature search was conducted using MEDLINE (through PubMed) and Embase to identify randomized trials and observational studies comparing the effects of BiVP or HisBP versus RVP on measurements of left ventricular dimensions, left ventricular ejection fraction (LVEF), heart failure functional classification, quality of life, 6-minute walk, hospitalizations, and mortality. Data from studies that met the appropriate population, intervention, comparator, and outcomes of interest were abstracted for meta-analysis. Studies that reported pooled outcomes among patients with LVEF both above and below 35% could not be included in the meta-analysis because of strict relationships with industry procedures that preclude retrieval of industry-retained unpublished data on the subset of patients with preserved left ventricular function.
Results Evidence from 8 studies, including a total of 679 patients meeting the prespecified criteria for inclusion, was identified. Results were compared for BiVP versus RVP, HisBP versus RVP, and BiVP+HisBP versus RVP. Among patients who received physiologic pacing with either BiVP or HisBP, the LV end-diastolic and end-systolic volumes were significantly lower (mean duration of follow-up: 1.64 years; –2.77 mL [95% CI –4.37 to –1.1 mL]; p=0.001; and –7.09 mL [95% CI –11.27 to –2.91; p=0.0009) and LVEF remained preserved or increased (mean duration of follow-up: 1.57 years; 5.328% [95% CI: 2.86%–7.8%; p<0.0001). Data on clinical impact such as functional status and quality of life were not definitive. Data on hospitalizations were unavailable. There was no effect on mortality. Several studies stratified results by LVEF and found that patients with LVEF >35% but ≤52% were more likely to receive benefit from physiologic pacing. Patients with chronic atrial fibrillation who underwent atrioventricular node ablation and pacemaker implant demonstrated clear improvement in LVEF with BiVP or HisBP versus RVP.
Conclusion Among patients with LVEF >35%, the LVEF remained preserved or increased with either BiVP or HisBP compared with RVP. However, patient-centered clinical outcome improvement appears to be limited primarily to patients who have chronic atrial fibrillation with rapid ventricular response rates and have undergone atrioventricular node ablation.
A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society
This document was approved by the American College of Cardiology Clinical Policy Approval Committee, the American Heart Association Science Advisory and Coordinating Committee, and the Heart Rhythm Society Board of Trustees in August 2018, and the American Heart Association Executive Committee in October 2018.
The American College of Cardiology requests that this document be cited as follows: Slotwiner DJ, Raitt MH, Del-Carpio Munoz F, Mulpuru SK, Nasser N, Peterson PN. Impact of physiologic versus right ventricular pacing among patients with left ventricular ejection fraction greater than 35%: a systematic review for the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2018;XX:XXX-XXX.
This article has been copublished in Circulation and HeartRhythm.
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- 2018 American College of Cardiology Foundation, the American Heart Association, Inc., and the Heart Rhythm Society