Non-Apical RV Pacing — “Love’s Labor’s Lost or Much Ado About Nothing”

By Sanjay S. Srivatsa, MBBChir, MRCP (UK)


RV septal pacing has been long touted as a more physiologic alternative to right ventricular apical pacing. The data for non-apical and in particular RV septal pacing,  demonstrate  improved LV function, prevention of adverse LV remodeling, and prevention of heart failure. This stands in stark contrast with the plethora of evidence pointing to the deleterious effects of chronic RV apical pacing in patients with normal and especially reduced LV function. The present article reviews the physiologic and clinical evidence for RV septal vs. apical pacing, and presents a novel angiographic technique for efficient attainment of the “optimal” septal pacing site. This article focuses on technically enabling those who would accept septal pacing as a worthwhile goal in NRVP, and wish to achieve it with efficiency, accuracy, and long term success.

The reason for equivocal clinical findings in septal vs. apical pacing studies are also discussed, and a new strategy for non-apical pacing clinical trial design utilizing comparative anatomic assessment of septal pacing site vs. clinical outcome is proposed. Non-apical RV pacing from selective sites such as the septo-parietal trabecular zone of the RV septum, offers a physiologically beneficial, if not safer and superior alternative to RV apical pacing, particularly for those patients with high-grade AV block and significant ventricular pacing dependency, with relatively well preserved LV function (LVEF >40%).

In the near future, the ideal choice for pacing with significant dependency in patients with preserved LV function may be between physiologically optimized biventricular pacing vs. anatomically optimized selective  site RV (mid-septal or RVOT) pacing. The perfection and simplification of leadless pacing and electro-anatomic mapping techniques will go a long way to optimizing selective site RV and LV pacing. Until such time as techniques are perfected, and/or definitive studies accomplished, every pacemaker implanter will have to confront the burning philosophical question in non-apical vs. apical RV pacing: Is it better to do presumptive good (while awaiting definitive data) or pursue a potential path of self-evident harm.


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