Selective site pacing: the right ventricular approach

Animal data and recent findings in humans have questioned the appropriateness of pacing the heart from the right ventricular apex. Numerous, mostly small sized, studies have evaluated alternative sites within the right ventricle. There is now sufficient evidence that right ventricular apical pacing in patients with left ventricular dysfunction with or without heart failure is detrimental. Pacing from the right side of the heart as an attempt at nonpharmacological therapy for heart failure, turns out to be obsolete. In antibradycardia pacing with the need for continuous ventricular support, the interest in preserving left ventricular function drives the ongoing search for the most favorable pacing site within the right ventricle. Results, so far, are conflicting which may be attributed to the inhomogeneity of patient groups, the small cohorts studied, the differing protocols used, and the lack of accepted definitions of right ventricular lead positions. Larger studies are needed to evaluate intraoperative criteria for optimal lead placement and the potential benefit of nonapical right ventricular pacing.