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CLINICAL RESEARCH: PACING AND CARDIAC FUNCTION

Ventricular Pacing Lead Location Alters Systemic Hemodynamics and Left Ventricular Function in Patients With and Without Reduced Ejection Fraction

Randy Lieberman, MD^_*,_*, Luigi Padeletti, MD, Jan Schreuder, MD, Kenneth Jackson, PA^_*, Antonio Michelucci, MD, Andrea Colella, MD, William Eastman, MS, Sergio Valsecchi, BS and Douglas A. Hettrick, PhD

^_* Harper Hospital, Detroit, Michigan
University of Florence, Florence, Italy
San Raffaele University Hospital, Milan, Italy
Medtronic, Inc., Minneapolis, Minnesota

Manuscript received December 26, 2005; revised manuscript received April 17, 2006, accepted April 25, 2006.

^_* Reprint requests and correspondence: Dr. Randy Lieberman, Department of Cardiology, Harper University Hospital, 3990 John R, Detroit, Michigan 48201 (Email: rlieberm{at}dmc.org).

OBJECTIVES: We compared left ventricular (LV) systolic and diastolic function during right ventricular (RV), LV, and biventricular (BiV) pacing in patients with narrow QRS duration with and without LV dysfunction.

BACKGROUND: The optimal RV pacing lead location for patients with a standard indication for ventricular pacing remains controversial.

METHODS: Left ventricular pressure and volume data were determined via conductance catheter during electrophysiology study in 31 patients divided into groups with ejection fraction (EF) 40% (n = 17) or EF <40% (n = 14). QRS duration was 91 ± 18 versus 106 ± 25 ms, respectively (p = NS). Hemodynamic data were recorded during atrial and dual chamber pacing from the RV apex, RV free wall, RV septum, LV free wall, and BiV.

RESULTS: In patients with EF 40%, RV pacing at 1 or more sites, but not LV free wall or BiV pacing, significantly (p < 0.05) impaired cardiac output (CO), stroke work (SW), EF, and LV relaxation compared with atrial overdrive pacing. Right ventricular pacing also impaired hemodynamics and LV function in patients with EF <40%. However, LV and BiV pacing increased CO, SW, EF, and LV +dP/dt_MAX in patients with LV dysfunction. Left ventricular and BiV pacing enhanced an index of global LV cycle efficiency in patients with depressed EF. The detrimental hemodynamic effects of RV pacing were attenuated by selecting the optimal RV pacing site.

CONCLUSIONS: Right ventricular pacing worsens LV function in patients with and without LV dysfunction unless the RV pacing site is optimized. Left ventricular and BiV pacing preserve LV function in patients with EF >40% and improve function in patients with EF <40% despite no clinical indication for BiV pacing.

Abbreviations and Acronyms   AAI = atrial overdrive pacing   AV = atrioventricular   BiV = biventricular   CE = cycle efficiency   DYS = dyssynchrony index   EF = ejection fraction   LV = left ventricular   LVEDP = left ventricular end-diastolic pressure   LVF = left ventricular free wall   LVSP = left ventricular systolic pressure   RCE = regional cycle efficiency   RV = right ventricular   RVA = right ventricular apex   RVF = right ventricular outflow tract free wall   RVOT = right ventricular outflow tract   RVS = right ventricular outflow tract septum   SV = stroke volume   SW = stroke work

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