Tops Laurens F, Schalij Martin J, Bax Jeroen J
Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
J Am Coll Cardiol. 2009 Aug 25;54(9):764-76. doi: 10.1016/j.jacc.2009.06.006.
Cardiac pacing is the only effective treatment for patients with sick sinus syndrome and atrioventricular conduction disorders. In cardiac pacing, the endocardial pacing lead is typically positioned at the right ventricular (RV) apex. At the same time, there is increasing indirect evidence, derived from large pacing mode selection trials and observational studies, that conventional RV apical pacing may have detrimental effects on cardiac structure and left ventricular function, which are associated with the development of heart failure. These detrimental effects may be related to the abnormal electrical and mechanical activation pattern of the ventricles (or ventricular dyssynchrony) caused by RV apical pacing. Still, it remains uncertain if the deterioration of left ventricular function as noted in a proportion of patients receiving RV apical pacing is directly related to acutely induced left ventricular dyssynchrony. The upgrade from RV pacing to cardiac resynchronization therapy may partially reverse the deleterious effects of RV pacing. It has even been suggested that selected patients with a conventional pacemaker indication should receive cardiac resynchronization therapy to avoid the deleterious effects. This review will provide a contemporary overview of the available evidence on the detrimental effects of RV apical pacing. Furthermore, the available alternatives for patients with a standard pacemaker indication will be discussed. In particular, the role of cardiac resynchronization therapy and alternative RV pacing sites in these patients will be reviewed.
心脏起搏是病态窦房结综合征和房室传导障碍患者的唯一有效治疗方法。在心脏起搏中，心内膜起搏导线通常置于右心室（RV）心尖处。与此同时，来自大型起搏模式选择试验和观察性研究的间接证据越来越多，表明传统的RV心尖起搏可能对心脏结构和左心室功能产生有害影响，而这与心力衰竭的发生有关。这些有害影响可能与RV心尖起搏引起的心室异常电激活和机械激活模式（或心室不同步）有关。然而，在一部分接受RV心尖起搏的患者中观察到的左心室功能恶化是否直接与急性诱发的左心室不同步相关，仍不确定。从RV起搏升级到心脏再同步治疗可能会部分逆转RV起搏的有害影响。甚至有人建议，有传统起搏器适应证的特定患者应接受心脏再同步治疗，以避免有害影响。本综述将对RV心尖起搏有害影响的现有证据进行当代概述。此外，还将讨论有标准起搏器适应证患者的可用替代方案。特别是，将综述心脏再同步治疗和替代RV起搏部位在这些患者中的作用。
