Manolis Antonis S
First Department of Cardiology, Evagelismos General Hospital of Athens, Athens, Greece.
Pacing Clin Electrophysiol. 2006 Mar;29(3):298-315. doi: 10.1111/j.1540-8159.2006.00338.x.
The purpose of this article is to critically review the data accumulated to date from studies evaluating the hemodynamic and clinical effects of right ventricular apical pacing during conventional permanent cardiac pacing. The data from studies comparing the effects of right ventricular apical pacing and alternate site ventricular pacing are also reviewed.
We conducted a MEDLINE and journal search of English-language reports published in the last decade and searched relevant papers.
Although intraventricular conduction delay in the form of left bundle branch block (LBBB) has traditionally been viewed as an electrophysiologic abnormality, it has now become abundantly clear that it has profound hemodynamic effects due to ventricular dyssynchrony, especially in patients with heart failure. These deleterious effects can be significantly ameliorated by cardiac resynchronization therapy effected by biventricular or left ventricular pacing. However, not only is spontaneous LBBB harmful, but the iatrogenic variety produced by right ventricular apical pacing in patients with permanent pacemakers may be equally deleterious. In this review new evidence from recent studies is presented, which strongly suggests a harmful effect of our long-standing practice of producing an iatrogenic LBBB by conventional right ventricular apical pacing in patients receiving permanent pacemakers. This emerging strong new evidence about the adverse hemodynamic and clinical effects of right ventricular apical pacing would dictate a reassessment of our traditional approach to permanent cardiac pacing and direct our attention to alternate sites of pacing, such as the left ventricle and/or the right ventricular outflow tract or septum, if not for all patients, at least for those with left ventricular dysfunction. Indeed, current convincing data on alternate site ventricular pacing are encouraging and this approach should be actively pursued and further investigated in future studies.
Not only is spontaneous permanent LBBB harmful to our patients, but the iatrogenic variety produced by right ventricular apical pacing during conventional permanent pacing may also be deleterious to some patients. The compelling evidence presented herein cannot be ignored; it may dictate a change of attitude toward right ventricular apical pacing directing our attention to alternate sites of ventricular pacing and avoidance of the right ventricular apex.
本文旨在批判性地回顾迄今为止，从评估传统永久性心脏起搏期间右心室心尖部起搏的血流动力学和临床效果的研究中积累的数据。同时也回顾了比较右心室心尖部起搏和其他部位心室起搏效果的研究数据。
我们对过去十年发表的英文报告进行了MEDLINE和期刊检索，并搜索了相关论文。
虽然以左束支传导阻滞（LBBB）形式存在的室内传导延迟传统上被视为一种电生理异常，但现在已经非常清楚，由于心室不同步，它具有深远的血流动力学影响，尤其是在心力衰竭患者中。双心室或左心室起搏实现的心脏再同步治疗可以显著改善这些有害影响。然而，不仅自发性LBBB有害，永久性起搏器患者中由右心室心尖部起搏产生的医源性LBBB可能同样有害。在本综述中，展示了近期研究的新证据，强烈表明我们长期以来在永久性起搏器患者中通过传统右心室心尖部起搏产生医源性LBBB的做法具有有害影响。关于右心室心尖部起搏不良血流动力学和临床效果的这一新兴有力新证据，将要求我们重新评估传统的永久性心脏起搏方法，并将我们的注意力转向起搏的其他部位，如左心室和/或右心室流出道或间隔，如果不是针对所有患者，至少是针对那些左心室功能不全的患者。事实上，目前关于其他部位心室起搏的令人信服的数据令人鼓舞，这种方法应在未来研究中积极探索并进一步研究。
不仅自发性永久性LBBB对我们的患者有害，而且传统永久性起搏期间右心室心尖部起搏产生的医源性LBBB对一些患者也可能有害。本文提出的令人信服的证据不容忽视；它可能会改变我们对右心室心尖部起搏的态度，将我们的注意力转向心室起搏的其他部位，并避免右心室心尖部。
