Abstract
Since the establishment of cardiac resynchronization therapy in left bundle branch block and mechanical asynchrony, the adverse effects of right ventricular apical pacing have gained increasing scientific interest. The sequelae of “iatrogenic desynchronization” on cardiac structure and function as well as on patients' prognosis could be well documented. “Minimally desynchronizing” stimulation strategies could be an alternative for patients needing ventricular pacing. The search for hemodynamically more advantageous alternative right ventricular pacing sites has failed so far to deliver well validated results, and due to the somewhat higher lead dislodgment rates pure left ventricular pacing cannot be recommended, at least not in pacemaker-dependent patients. Hence there is the question for primary biventricular stimulation in patients with AV block. The results of several biventricular studies with limited numbers of patients have been promising with respect to structural and functional surrogate endpoints. Two major controlled prospective and prognostically orientated studies, the BIOPACE study and the BLOCK-HF study, are currently underway and will report results in the next few years. According to the actual guidelines of the European Society of Cardiology (ESC) the implantation of a biventricular system is recommended in patients with AV block even without left bundle branch block (Class IIa, evidence level C) if they fulfill the remaining criteria that justify the implantation of a biventricular system. According to the guidelines for pacemaker therapy of the German Cardiac Society (GCS) biventricular pacing can be considered in these patients. Both societies do expressly permit the implantation of biventricular systems with ICD backup if indicated.
Zusammenfassung
Seit Etablierung der kardialen Resynchronisationstherapie bei Linksschenkelblock und mechanischer Asynchronie haben die ungünstigen Auswirkungen der apikalen rechtsventrikulären Stimulation bei Patienten mit AV-Block an wissenschaftlichem Interesse gewonnen. Die Folgen der „iatrogenen Desynchronisation“ auf die kardiale Struktur und Funktion sowie auf die Prognose der Patienten konnten gut belegt werden. Für Patienten mit hohem ventrikulären Stimulationsbedarf kommen als Alternative “minimal desynchronisierende” Stimulationsstrategien in Betracht. Die Suche nach hämodynamisch vorteilhafteren alternativen Stimulationsorten im rechten Ventrikel ist bisher ohne ausreichend validierten Erfolg geblieben und eine rein linksventrikuläre Stimulation kann wegen der höheren Sondendislokationsrate zumindest bei schrittmacherabhängigen Patienten nicht empfohlen werden. Somit stellt sich die Frage nach dem Aufwand und Nutzen einer primär biventrikulären Versorgung von Patienten mit AV-Block. Die Ergebnisse verschiedener Studien mit limitierten Patientenzahlen waren bzgl. struktureller und funktioneller Surrogat-Endpunkte bisher viel versprechend. Zwei größere kontrollierte prospektive Studien mit prognostischer Fragestellung, die BIOPACE-Studie und die BLOCK-HF-Studie, sind derzeit im Gang und werden in den nächsten Jahren berichten. In den aktuellen Leitlinien der European Society of Cardiology (ESC) wird bei Patienten mit AV-Block auch ohne Vorliegen eines Linksschenkelblocks die Implantation eines biventrikulären Systems empfohlen (Empfehlungsgrad II a, Evidenzniveau C), wenn sie die übrigen Kriterien erfüllen, die die Implantation eines biventrikulären Systems rechtfertigen. Nach den Leitlinien zur Herzschrittmachertherapie der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung (DGK) kann die biventrikuläre Stimulation bei diesen Patienten erwogen werden. Beide Gesellschaften lassen ausdrücklich bei gegebener Indikation die Versorgung mit einem biventrikulären System mit Defibrillator-Backup zu.
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Funck, R.C., Kölsch, S. & Maisch, B. Biventrikuläre Stimulation bei AV-Block. Herzschr. Elektrophys. 19, 41–47 (2008). https://doi.org/10.1007/s00399-008-0599-8
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DOI: https://doi.org/10.1007/s00399-008-0599-8