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Pacemaker selection: time for a rethinking of complex pacing systems?

Nicola Musilli¹, Luigi Padeletti

¹Internal Medicine and Cardiology Institute, University of Florence, V.le Morgagni 85, 50134 Florence, Italy.

European Heart Journal

|October 7, 2005

Summary

Dual-chamber pacing offers modest clinical benefits, with no significant improvements in mortality or stroke compared to single-chamber pacing. Chronic right-ventricular pacing may increase atrial fibrillation and heart failure risks.

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Area of Science:

Cardiology
Biomedical Engineering
Clinical Trials

Background:

Dual-chamber (DDD) pacing is widely used for cardiac rhythm management.
The clinical benefits and cost-effectiveness of DDD pacing require ongoing evaluation.

Purpose of the Study:

To critically assess the evidence regarding the clinical benefits and economic viability of dual-chamber (DDD) pacing.
To compare DDD pacing with single-chamber pacing in terms of mortality, stroke, atrial fibrillation, and heart failure hospitalizations.

Main Methods:

Systematic review and meta-analysis of randomized controlled trials.
Analysis of data on mortality, stroke incidence, atrial fibrillation (AF) development, and heart failure hospitalizations.
Economic evaluation of physiological pacing strategies versus single-chamber pacing.

Main Results:

No significant differences in mortality or stroke were observed between physiological pacing and single-chamber pacing.
Chronic right-ventricular pacing in DDD mode was associated with increased incidence of atrial fibrillation and heart failure hospitalizations.
AF prevention and therapy algorithms demonstrated minimal to absent efficacy.
Widespread use of physiological pacemakers is not economically attractive.

Conclusions:

The clinical benefits of DDD pacing are modest, with potential risks of ventricular desynchronization.
Single-chamber pacing (AAI(R) or VVI(R)) is a cost-effective alternative for most patients with sinus node disease and AV block.
Evidence supports more rational clinical and policy decisions regarding pacemaker selection for improved patient outcomes and cost savings.