Current Concepts in Pacing 2010–2011: The Right and Wrong Way to Pace

  • Simon Modi
  • Andrew Krahn
  • Raymond Yee

Opinion statement

Over five decades have passed since the first permanent cardiac pacemakers were introduced into clinical medicine. Evolving technology and falling costs have demanded adaptation to clinical practice and implantation trends and, with the advent of evidenced-based medicine, the specific roles and benefits of individual pacemaker technologies have never been so carefully scrutinized. Pacing mode choice continues to be a subject of great controversy, and there are great regional variations in practice. We believe that single chamber atrial pacing use (AAI/R) has become an anachronism that should generally be abandoned (obviously with rare exceptional cases) and be replaced by dual chamber pacemakers (DDD/R) equipped with modern pacing algorithms that minimize patient exposure to ventricular pacing. Also, in patients with atrioventricular (AV) block, randomized clinical trials have failed to show improvement in clinically relevant outcomes such as mortality, stroke, and heart failure, particularly in the elderly, which has led some to advocate that DDD/R devices should never be offered to elderly AV block patients. However, we believe that the elderly, like the young, come in many “shapes and sizes” and individualized medicine compels us to consider each pacemaker candidate as unique. Implanting DDD/R devices in chronologically older, yet physiologically younger, patients is justifiable and good medical practice. Where right ventricular (RV) pacing is necessary and unavoidable, physicians should consider routinely placing RV leads on the RV mid- or outflow tract septum because these location are as good, if not better, for patients than the current practice of RV apical lead placement. In patients with AV block and asymptomatic yet moderate to severely depressed left ventricular systolic function, primary cardiac resynchronization therapy (CRT) should be strongly considered. Compelling clinical trial evidence does not yet exist to indicate that CRT should be the standard of care in patients with AV block and intact left ventricular systolic function. Right ventricular septal lead placement remains a reasonable option.


Right Ventricular Cardiac Resynchronization Therapy Right Ventricular Outflow Tract Left Ventricular Lead Left Ventricular Reverse Remodel 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



S. Modi has had travel and/or accommodation expenses covered by St. Jude, Boston Scientific, and Medtronic for attendance at Heart Rhythm Society meetings. A. Krahn’s institution has received grants from St. Jude Medical, Boston Scientific, and Medtronic, as well as payment for development of educational presentations. R. Yee has received consulting fees from and developed patents for Medtronic Inc. His institution has received a grant and payment for lectures from Medtronic of Canada.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Arrhythmia ServiceLondon Health Sciences CentreLondonCanada

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