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Right Ventricular Apical Pacing (RVAP) vs. Right Ventricular Septal Pacing (RVSP): short and intermediate-term effect on echocardiographic indices, left ventricular function and clinical outcome

Santosh Kumar Sinha, Nasar Abdaali, Mukesh Jitendra Jha, Vikas Mishra, Mohammad Asif, Mahmodulla Razi, Ramesh Thakur, Chandra Mohan Varma, Umeshwar Pandey, Vinay Krishna
DOI: 10.5603/FC.a2019.0046

open access

Ahead of print
Original Papers
Published online: 2019-06-17

Abstract

Background- Right ventricular apical pacing (RVAP) has more “desynchronizing effect” than pacing from the interventricular septum (RVSP) and may be translated in worse outcomes in long run. The aim of the present study was to examine the short and intermediate-term effects of RVAP versus RVSP on echocardiographic features, left ventricular function and clinical outcome. Material and method- 467 patients between August 2014 to March 2018 without structural heart disease were prospectively randomized to RVAP (n=226) or RVSP (n=241) and were studied at baseline, 6 months and 12 month by echocardiography, biochemically (NT-proBNP) and clinically (6-minute walk test). LV 2D strain and tissue velocity images were analyzed to measure 18-segment time-to-peak longitudinal systolic strain and 12-segment time-to-peak systolic tissue velocity. Intraventricular dyssynchrony was calculated using Tissue Doppler velocity data by comparing the time to systolic peak velocity between segments in multiple apical views by their respective standard deviations. Interventricular dyssynchrony was measured as the temporal difference of LV pre-ejection period and RV pre-ejection period by pulse-wave Doppler (PWD) images. All the analysis was carried out by using statistical package for social service version 17.0 (SPSS Inc., Chicago, Illinois). The p-value < 0.05 was considered statistically significant. Results- The commonest indication for pacemaker implantation was atrioventricular block (n=311;66.6%), followed by sinus node dysfunction (n=138;29.5%) and chronic bifascicular and trifascicular block (n=18;3.9%), all patients receiving single chamber pacemaker (VVI: n=107;22.9% and VVIR: n=360;77.1%). There were significant difference in NT-proBNP level (410±254 pg/ml vs. 370±168 pg/ml; p=0.02), 6-MWT (442±19 m vs. 482±21 m; p=0.01), mean QRS duration (164±8.3 ms vs. 148±10.6 ms; p=0.02), intraventricular dyssynchrony (septal to lateral wall delay: 88.6±24.2 ms vs. 43.7±11.2ms; p=0.04), interventricular dyssynchrony (31.2±22.8 vs. 19.4±11.2; 0=0.03), end diastolic volume (78.4±15.6 ml vs. 72.8±14.2 ml; p=0.04), end systolic volume (30.2±13.1 ml vs. 25.6±11.7 ml; p=0.05) at the end of 12 months between RVAP and RVSP respectively, though not significantly different at 6 months favouring RVS-paced group. However, no significant difference in ejection fraction (59±5 % vs. 61.5±3.2 %; p=0.39) and NYHA class (1.29±0.3 vs. 1.28±0.4; 0.3) at 6 and 12 months follow up were noted. Conclusion- Right ventricular septal pacing was associated with better outcome in terms of echocardiographic indices, left ventricular function and clinical outcome compared to patients with apical pacing over intermediate-term follow up.

Abstract

Background- Right ventricular apical pacing (RVAP) has more “desynchronizing effect” than pacing from the interventricular septum (RVSP) and may be translated in worse outcomes in long run. The aim of the present study was to examine the short and intermediate-term effects of RVAP versus RVSP on echocardiographic features, left ventricular function and clinical outcome. Material and method- 467 patients between August 2014 to March 2018 without structural heart disease were prospectively randomized to RVAP (n=226) or RVSP (n=241) and were studied at baseline, 6 months and 12 month by echocardiography, biochemically (NT-proBNP) and clinically (6-minute walk test). LV 2D strain and tissue velocity images were analyzed to measure 18-segment time-to-peak longitudinal systolic strain and 12-segment time-to-peak systolic tissue velocity. Intraventricular dyssynchrony was calculated using Tissue Doppler velocity data by comparing the time to systolic peak velocity between segments in multiple apical views by their respective standard deviations. Interventricular dyssynchrony was measured as the temporal difference of LV pre-ejection period and RV pre-ejection period by pulse-wave Doppler (PWD) images. All the analysis was carried out by using statistical package for social service version 17.0 (SPSS Inc., Chicago, Illinois). The p-value < 0.05 was considered statistically significant. Results- The commonest indication for pacemaker implantation was atrioventricular block (n=311;66.6%), followed by sinus node dysfunction (n=138;29.5%) and chronic bifascicular and trifascicular block (n=18;3.9%), all patients receiving single chamber pacemaker (VVI: n=107;22.9% and VVIR: n=360;77.1%). There were significant difference in NT-proBNP level (410±254 pg/ml vs. 370±168 pg/ml; p=0.02), 6-MWT (442±19 m vs. 482±21 m; p=0.01), mean QRS duration (164±8.3 ms vs. 148±10.6 ms; p=0.02), intraventricular dyssynchrony (septal to lateral wall delay: 88.6±24.2 ms vs. 43.7±11.2ms; p=0.04), interventricular dyssynchrony (31.2±22.8 vs. 19.4±11.2; 0=0.03), end diastolic volume (78.4±15.6 ml vs. 72.8±14.2 ml; p=0.04), end systolic volume (30.2±13.1 ml vs. 25.6±11.7 ml; p=0.05) at the end of 12 months between RVAP and RVSP respectively, though not significantly different at 6 months favouring RVS-paced group. However, no significant difference in ejection fraction (59±5 % vs. 61.5±3.2 %; p=0.39) and NYHA class (1.29±0.3 vs. 1.28±0.4; 0.3) at 6 and 12 months follow up were noted. Conclusion- Right ventricular septal pacing was associated with better outcome in terms of echocardiographic indices, left ventricular function and clinical outcome compared to patients with apical pacing over intermediate-term follow up.

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Keywords

Right ventricular apical pacing; Right ventricular septal pacing; NT-proBNP; 6-Minute walk test; Intraventricular dyssynchrony; Interventricular dyssynchrony

About this article
Title

Right Ventricular Apical Pacing (RVAP) vs. Right Ventricular Septal Pacing (RVSP): short and intermediate-term effect on echocardiographic indices, left ventricular function and clinical outcome

Journal

Folia Cardiologica

Issue

Ahead of print

Published online

2019-06-17

DOI

10.5603/FC.a2019.0046

Keywords

Right ventricular apical pacing
Right ventricular septal pacing
NT-proBNP
6-Minute walk test
Intraventricular dyssynchrony
Interventricular dyssynchrony

Authors

Santosh Kumar Sinha
Nasar Abdaali
Mukesh Jitendra Jha
Vikas Mishra
Mohammad Asif
Mahmodulla Razi
Ramesh Thakur
Chandra Mohan Varma
Umeshwar Pandey
Vinay Krishna

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