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Biventricular vs. RV Pacing With LVADs
Quick Takes
- Compared with BiV pacing, RV-only pacing in LVAD patients resulted in a 29% higher mean daily step count, 11% higher 6-minute walk test distance, and 7% improved KCCQ-12 score (all p < 0.03).
- This study supports turning off LV lead pacing in LVAD patients with CRT.
Study Questions:
What are the effects of right ventricular (RV) pacing versus biventricular (BiV) pacing on quality of life, functional status, and arrhythmias in patients with a left ventricular assist device (LVAD)?
Methods:
LVAD patients with cardiac resynchronization therapy (CRT) devices were prospectively randomized to pace RV only or BiV for 7–14 days. Ambulatory step count, 6-minute walk test distance, Kansas City Cardiomyopathy Questionnaire (KCCQ) scores, arrhythmia burden, CRT lead function, and echocardiographic data were collected.
Results:
A total of 30 patients were randomized. Compared with BiV pacing, RV-only pacing resulted in a 29% higher mean daily step count, 11% higher 6-minute walk test distance, and 7% improved KCCQ-12 score (all p < 0.03). LV end-diastolic volume was significantly lower with RV pacing (220 vs. 250 ml; p = 0.03). Fewer patients had ventricular tachyarrhythmia episodes during RV pacing (p = 0.03). RV lead impedance was lower with RV pacing (p = 0.047), but no significant differences were observed in impedance across other CRT leads.
Conclusions:
In LVAD patients, RV pacing was associated with significantly improved functional status, quality of life, fewer ventricular tachyarrhythmias, and stable lead impedance compared with BiV pacing. This study supports turning off LV lead pacing in LVAD patients with CRT.
Perspective:
There has not been a consensus about whether patients who have both CRT and LVAD benefit from CRT pacing. CRT pacing at our institution has been deactivated, and the rationale has been improved battery longevity. There have been conflicting retrospective analyses on the impact of CRT pacing in those patients. The present study represents the strongest piece of evidence yet favoring deactivation of BiV pacing in patients who have CRT devices and need ventricular pacing. It is intuitive that correcting electrical dyssynchrony would not provide a substantial benefit to LVAD patients due to their vastly more powerful pump. It is not entirely clear what the mechanism is for BiV pacing causing adverse outcomes in these patients, but it is likely that a peculiar interaction between BiV pacing and suction events exists in LVAD patients. It is striking that the magnitude of the benefits from RV-only pacing over BiV pacing is so large that it required relatively few patients to demonstrate this.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Valvular Heart Disease, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Mechanical Circulatory Support, Echocardiography/Ultrasound
Keywords: Arrhythmias, Cardiac, Cardiac Resynchronization Therapy, Cardiac Resynchronization Therapy Devices, Echocardiography, Electric Impedance, Heart Failure, Heart-Assist Devices, Heart Valve Diseases, Pacemaker, Artificial, Quality of Life, Secondary Prevention, Tachycardia, Ventricular, Vascular Diseases
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