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CLINICAL RESEARCH: CLINICAL TRIAL

Prevention of Ventricular Desynchronization by Permanent Para-Hisian Pacing After Atrioventricular Node Ablation in Chronic Atrial Fibrillation

A Crossover, Blinded, Randomized Study Versus Apical Right Ventricular Pacing

Divisione Clinicizzata di Cardiologia, Facoltà di Medicina e Chirurgia di Novara, Università degli Studi del Piemonte Orientale, Novara, Italy.

Manuscript received November 8, 2005; revised manuscript received December 12, 2005, accepted January 2, 2006.

^_* Reprint requests and correspondence: Dr. Eraldo Occhetta, Divisione Clinicizzata di Cardiologia, Azienda Ospedaliera Maggiore della Carità Corso Mazzini 18, 28100 Novara, Italy. (Email: occhetta{at}r-j.it).

OBJECTIVES: The aim of our study was to evaluate the feasibility, the safety, and hemodynamic improvements induced by permanent para-Hisian pacing in patients with chronic atrial fibrillation and narrow QRS who underwent atrioventricular (AV) node ablation.

BACKGROUND: Right ventricular apical pacing, inducing asynchronous ventricular contraction, may impair cardiac function; permanent para-Hisian pacing could preserve interventricular synchrony and improve left ventricular function.

METHODS: After AV node ablation, 16 patients were implanted with a dual-chamber pacemaker connected to a screw-in lead positioned in close proximity to the His bundle and to a right ventricular apical lead. Clinical and echocardiographic data were collected at baseline and after two randomized six-month periods (with para-Hisian and conventional pacing).

RESULTS: During para-Hisian pacing, the interventricular electromechanical delay improved as well (34 ± 18 ms) as during right apical pacing (47 ± 19 ms), p < 0.05. Para-Hisian pacing allowed an improvement in New York Heart Association functional class (1.75 ± 0.4 vs. 2.33 ± 0.6 at baseline and 2.5 ± 0.4 during apical pacing, p < 0.05 for both), in quality-of-life score (16.2 ± 8.7 vs. 32.5 ± 15.0 at baseline, p < 0.05), and in the 6-min walk test (431 ± 73 m vs. 378 ± 60 m at baseline and 360 ± 71 m during apical pacing, p < 0.5 for both). Mitral and tricuspid regurgitation improved during para-Hisian pacing (1.22 ± 0.8 and 1.46 ± 0.5 index, respectively, vs. 1.68 ± 0.6 [p < 0.05] and 1.62 ± 0.7 [p = NS] index at baseline, respectively), with a slight worsening during apical pacing (1.93 ± 1 and 1.93 ± 0.7 index, respectively, p < 0.05 for both).

CONCLUSIONS: Permanent para-Hisian pacing is feasible and safe. Compared with conventional right apical pacing, it allows an improvement in functional and hemodynamic parameters over long-term follow-up.

Abbreviations and Acronyms   AF = atrial fibrillation   AV = atrioventricular   DDDR = dual-chamber rate-responsive pacing-sensing   EF = ejection fraction   ICD = implantable cardioverter-defibrillator   NYHA = New York Heart Association   PM = pacemaker   QoL = quality of life   RF = radiofrequency   VVIR = ventricular rate-responsive pacing-sensing

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