Skip to main content
SpringerLink
Log in

Medium- and long-term survival after pacemaker implant: Improved survival with right ventricular outflow tract pacing

  • Published:
Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Introduction

Long-term prognosis after pacemaker implant depends on numerous variables, particularly structural heart disease. There is evidence that apical stimulation could favor the development of heart failure and, therefore, influence mortality. Other right ventricular pacing sites have been studied, for example the outflow tract, but no reports regarding long-term clinical outcome are available.

Objective

Compare all-cause mortality between two different sites of stimulation in the right ventricle.

Methods

We retrospectively analyzed 150 consecutive patients who underwent pacemaker implantation because of complete AV block (spontaneous or after AV node ablation), symptomatic second-degree AV block, and symptomatic atrial fibrillation with slow ventricular response. All patients were implanted at the same institution with the standard technique. Apical stimulation was performed with a passive or active fixation lead and outflow tract pacing with an active fixation lead. Data collection period began in July 1999 and ended on December 2004. All patients included were greater than 70% ventricular paced during pacemaker follow-up. Patients older than 85 years were excluded from the analysis. Age, pacemaker mode, sex, ejection fraction, diabetes, and structural cardiac disease were analyzed. Mean age was 72 ± 7 years (median 74 years, range 27–85 years), 101 (67%) were male, 56 had implanted a VVI PM, and 94 patients a DDD PM. Patients were divided into two groups: outflow tract (55 patients) and apical pacing (95 patients). Mean follow-up was 1,231 ± 642 days (median 1,158 days, range 9 to 2,694 days), which ended on July 2007. Total mortality was examined with the Kaplan–Meier method to construct overall survival curves. Multivariate Cox proportional hazards regression models were performed.

Results

All patients or relatives were contacted personally or by phone. There were no major statistical differences in patient background between the two groups. During follow-up, 18 patients (32%) died in the outflow tract group and 49 (51%) in the apical group (log-rank p = 0.02). Cox regression multivariate analysis showed that outflow tract pacing and a low left ventricular ejection fraction (<40%) were the only independent variables with significant correlation with survival (p = 0.006 and 0.003, respectively).

Conclusions

Outflow tract pacing appears to improve medium- and long-term survival. Prospective randomized trials with a greater amount of patients are necessary to confirm the findings of this study.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Bernstein, V., Rotem, C. E., & Peretz, D. I. (1971). Permanent pacemakers: 8-year follow-up study. Incidence and management of congestive cardiac failure and perforations. Annals of Internal Medicine, 74, 361–369.

    PubMed  CAS  Google Scholar 

  2. Hansen, J. F., & Meibom, J. (1974). The prognosis for patients with complete heart block treated with permanent pacemaker. Acta Medica Scandinavica, 195, 385–389.

    Article  PubMed  CAS  Google Scholar 

  3. Simon, A. B., & Zloto, A. E. (1978). Atrioventricular block: Natural history after permanent ventricular pacing. American Journal of Cardiology, 41, 500–507. DOI 10.1016/0002-9149(78)90006-1.

    Article  PubMed  CAS  Google Scholar 

  4. Alpert, M. A., Curtis, J. J., Sanfelippo, J. F., et al. (1987). Comparative survival following permanent ventricular and dual-chamber pacing for patients with chronic symptomatic sinus node dysfunction with and without congestive heart failure. American Heart Journal, 113, 958–965. DOI 10.1016/0002-8703(87)90057-3.

    Article  PubMed  CAS  Google Scholar 

  5. Rosenqvist, M., & Nordlander, R. (1992). Survival in patients with permanent pacemakers. Cardiology Clinics, 10, 691–703.

    PubMed  CAS  Google Scholar 

  6. Bush, D. E., & Finucane, T. E. (1994). Permanent cardiac pacemakers in the elderly. Journal of the American Geriatrics Society, 42, 326–334.

    PubMed  CAS  Google Scholar 

  7. Shen, W. K., Hammill, S. C., Hayes, D. L., et al. (1994). Long-term survival after pacemaker implantation for heart block in patients > or = 65 years. American Journal of Cardiology, 74, 560–564. DOI 10.1016/0002-9149(94)90744-7.

    Article  PubMed  CAS  Google Scholar 

  8. Lamas, G. A., Pashos, C. L., Normand, S. L., & McNeil, B. (1995). Permanent pacemaker selection and subsequent survival in elderly Medicare pacemaker recipients. Circulation, 91, 1063–1069.

    PubMed  CAS  Google Scholar 

  9. Brunner, M., Olschewski, M., Geibel, A., Bode, C., & Zehender, M. (2004). Long-term survival after pacemaker implantation. Prognostic importance of gender and baseline patient characteristics. European Heart Journal, 25, 88–95. DOI 10.1016/j.ehj.2003.10.022.

    Article  PubMed  Google Scholar 

  10. Pyatt, J. R., Somauroo, J. D., Jackson, M., et al. (2002). Long-term survival after permanent pacemaker implantation: Analysis of predictors for increased mortality. Europace, 4, 113–119. DOI 10.1053/eupc.2002.0233.

    Article  PubMed  CAS  Google Scholar 

  11. Saxon, L. A., Stevenson, W. G., Middlekauff, H. R., & Stevenson, L. W. (1993). Increased risk of progressive hemodynamic deterioration in advanced heart failure patients requiring permanent pacemakers. American Heart Journal, 125, 1306–1310. DOI 10.1016/0002-8703(93)90999-P.

    Article  PubMed  CAS  Google Scholar 

  12. Kusumoto, F. M., & Goldschlager, N. (1997). Cardiac pacing in patients with dilated cardiomyopathy. Journal of Interventional Cardiac Electrophysiology, 1, 103–110. DOI 10.1023/A:1009746930261.

    Article  PubMed  CAS  Google Scholar 

  13. Barin, E. S., Jones, S. M., Ward, D. E., Camm, A. J., & Nathan, A. W. (1991). The right ventricular outflow tract as an alternative permanent pacing site: Long-term follow-up. Pacing and Clinical Electrophysiology, 14, 3–6. DOI 10.1111/j.1540-8159.1991.tb04040.x.

    Article  PubMed  CAS  Google Scholar 

  14. Manolis, A. S. (2006). The deleterious consequences of right ventricular apical pacing: Time to seek alternate site pacing. Pacing and Clinical Electrophysiology, 29, 298–315. DOI 10.1111/j.1540-8159.2006.00338.x.

    Article  PubMed  Google Scholar 

  15. Vlay, S. C. (2006). Right ventricular outflow tract pacing: Practical and beneficial. A 9-year experience of 460 consecutive implants. Pacing and Clinical Electrophysiology, 29, 1055–1062. DOI 10.1111/j.1540-8159.2006.00498.x.

    Article  PubMed  Google Scholar 

  16. Tse, H. F., Yu, C., Wong, K. K., et al. (2002). Functional abnormalities in patients with permanent right ventricular pacing: The effect of sites of electrical stimulation. Journal of the American College of Cardiology, 40, 1451–1458. DOI 10.1016/S0735-1097(02)02169-1.

    Article  PubMed  Google Scholar 

  17. Fondo Nacional De Recursos. Uruguay. Pacemaker Statistics. Retrieved May 20 2007 from http://www.fnr.gub.uy/web2002/estadisticas/PDFs%20registros%20medicos/WEBMARCAPASO.pdf.

  18. Freudenberger, R. S., Wilson, A. C., Lawrence-Nelson, J., Hare, J. M., & Kostis, J. B. (2005). Permanent pacing is a risk factor for the development of heart failure. American Journal of Cardiology, 95, 671–674. DOI 10.1016/j.amjcard.2004.10.049.

    Article  PubMed  Google Scholar 

  19. Deharo, J. C. (2000). Left bundle branch block. Electrocardiographic and prognostic aspects. Archives des maladies du coeur et des vaisseaux, 93, 31–37.

    PubMed  CAS  Google Scholar 

  20. McAnulty, J. H., Rahimtoola, S. H., Murphy, E. S., et al. (1978). Prospective study of sudden death in “high-risk” bundle-branch block. New England Journal of Medicine, 299, 209–215.

    Article  PubMed  CAS  Google Scholar 

  21. Naslafkih, A., & Sestier, F. (2002). Mortality analysis in patients with atrial fibrillation and implantable permanent pacemaker after ablation of the atrioventricular node. Journal of Insurance Medicine, 34, 92–93.

    PubMed  Google Scholar 

  22. Kay, G. N., Ellenbogen, K. A., Giudici, M., et al. (1998). The Ablate and Pace Trial: A prospective study of catheter ablation of the AV conduction system and permanent pacemaker implantation for treatment of atrial fibrillation. APT Investigators. Journal of Interventional Cardiac Electrophysiology, 2, 121–135. DOI 10.1023/A:1009795330454.

    Article  PubMed  CAS  Google Scholar 

  23. Twidale, N., Manda, V., Nave, K., & Seal, A. (1998). Predictors of outcome after radiofrequency catheter ablation of the atrioventricular node for atrial fibrillation and congestive heart failure. American Heart Journal, 136, 647–657. DOI 10.1016/S0002-8703(98)70012-2.

    Article  PubMed  CAS  Google Scholar 

  24. Twidale, N., Manda, V., Holliday, R., et al. (1999). Mitral regurgitation after atrioventricular node catheter ablation for atrial fibrillation and heart failure: Acute hemodynamic features. American Heart Journal, 138, 1166–1175. DOI 10.1016/S0002-8703(99)70084-0.

    Article  PubMed  CAS  Google Scholar 

  25. Vergara, G. (2001). Long-term survival after ablation of atrioventricular node and implantation of a permanent pacemaker in patients with atrial fibrillation. Italian Heart Journal. Supplement, 2, 1243–1245.

    CAS  Google Scholar 

  26. Ozcan, C., Jahangir, A., Friedman, P. A., et al. (2001). Long-term survival after ablation of the atrioventricular node and implantation of a permanent pacemaker in patients with atrial fibrillation. New England Journal of Medicine, 344, 1043–1051. DOI 10.1056/NEJM200104053441403.

    Article  PubMed  CAS  Google Scholar 

  27. Bourke, J. P., Hawkins, T., Keavey, P., et al. (2002). Evolution of ventricular function during permanent pacing from either right ventricular apex or outflow tract following AV-junctional ablation for atrial fibrillation. Europace, 4, 219–228. DOI 10.1053/eupc.2002.0238.

    Article  PubMed  Google Scholar 

  28. Stambler, B. S., Ellenbogen, K., Zhang, X., et al. (2003). ROVA Investigators. Right ventricular outflow versus apical pacing in pacemaker patients with congestive heart failure and atrial fibrillation. Journal of Cardiovascular Electrophysiology, 14, 1180–1186. DOI 10.1046/j.1540-8167.2003.03216.x.

    Article  PubMed  Google Scholar 

  29. Mera, F., DeLurgio, D. B., Patterson, R. E., Merlino, J. D., Wade, M. E., & Leon, A. R. (1999). A comparison of ventricular function during high right ventricular septal and apical pacing after his-bundle ablation for refractory atrial fibrillation. Pacing and Clinical Electrophysiology, 22, 1234–1239. DOI 10.1111/j.1540-8159.1999.tb00606.x.

    Article  PubMed  CAS  Google Scholar 

  30. Muto, C., Luca, O., Canciello, M., et al. (2007). Effect of pacing the right ventricular mid-septum tract in patients with permanent atrial fibrillation and low ejection fraction effect of pacing the RV mid-septum tract. Journal of Cardiovascular Electrophysiology, 18, 1032–1036. DOI 10.1111/j.1540-8167.2007.00914.x.

    Article  PubMed  Google Scholar 

  31. Victor, F., Mabo, P., Manssur, H., et al. (2006). A randomized comparison of permanent septal versus apical right ventricular pacing: Short-term results. Journal of Cardiovascular Electrophysiology, 17, 238–242. DOI 10.1111/j.1540-8167.2006.00358.x.

    Article  PubMed  Google Scholar 

  32. McGavigan, A. D., Roberts-Thomson, K. C., Hillock, R. J., Stevenson, I. H., & Mond, H. G. (2006). Right ventricular outflow tract pacing: Radiographic and electrocardiographyc correlates of lead position. Pacing and Clinical Electrophysiology, 29, 1063–1068. DOI 10.1111/j.1540-8159.2006.00499.x.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The authors wish to thank Alejandro Ferreiro, MD for his expert assistance and guidance in the statistical analysis.

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Arrhythmia Service CASMU-INCC, Montevideo, Uruguay

    Gabriel Vanerio, Juan L. Vidal, Pablo Fernández Banizi, Daniel Banina Aguerre, Pablo Viana & Jorge Tejada

  2. British Hospital Montevideo, Av. Italia 2420, Montevideo, 11300, Uruguay

    Gabriel Vanerio

  3. CASMU-INCC, 8 de Octubre 3310, Montevideo, Uruguay

    Juan L. Vidal, Pablo Fernández Banizi, Daniel Banina Aguerre, Pablo Viana & Jorge Tejada

Authors
  1. Gabriel Vanerio
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Juan L. Vidal
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Pablo Fernández Banizi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Daniel Banina Aguerre
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Pablo Viana
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jorge Tejada
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Gabriel Vanerio.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Vanerio, G., Vidal, J.L., Fernández Banizi, P. et al. Medium- and long-term survival after pacemaker implant: Improved survival with right ventricular outflow tract pacing. J Interv Card Electrophysiol 21, 195–201 (2008). https://doi.org/10.1007/s10840-008-9238-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10840-008-9238-x

Keywords

Search

Navigation