Current concepts in pacing 2010-2011: the right and wrong way to pace

Area of Science:

• Cardiology
• Biomedical Engineering

Background:

• Permanent cardiac pacemakers have been used for over 50 years, with evolving technology necessitating clinical practice adaptation.
• Pacing mode choice remains controversial, with significant regional variations in practice.
• Evidence-based medicine scrutinizes the roles and benefits of individual pacemaker technologies.

Purpose of the Study:

• To advocate for the abandonment of single chamber atrial pacing (AAI/R) in favor of dual chamber pacemakers (DDD/R) with advanced algorithms.
• To emphasize the individualized approach to pacemaker selection, particularly for elderly patients with atrioventricular (AV) block.
• To recommend optimal lead placement strategies for right ventricular (RV) pacing and the consideration of cardiac resynchronization therapy (CRT).

Main Methods:

• This opinion statement is based on a critical review of current clinical practices and evidence from randomized clinical trials.
• The authors present their expert opinion on pacing mode selection, lead placement, and the role of CRT.
• The discussion considers patient-specific factors, including age and physiological status.

Main Results:

• Single chamber atrial pacing (AAI/R) is considered an anachronism and should generally be abandoned.
• Dual chamber pacemakers (DDD/R) with algorithms minimizing ventricular pacing are preferred.
• Randomized trials have not shown clear benefits of DDD/R over other modes in elderly AV block patients, but individualized care justifies DDD/R use.
• Right ventricular (RV) septal lead placement is recommended over apical placement.
• Primary cardiac resynchronization therapy (CRT) should be considered for AV block patients with moderate to severely depressed left ventricular systolic function.

Conclusions:

• Dual chamber pacing (DDD/R) with modern algorithms is recommended over single chamber atrial pacing (AAI/R).
• Individualized assessment is crucial for pacemaker selection in all patients, including the elderly with AV block.
• Optimized RV lead placement and consideration of CRT are important for specific patient populations.