Pacing-induced heart failure: should we avoid right ventricular pacing or not?

Abstract

This editorial refers to ‘Reduction in unnecessary ventricular pacing fails to affect hard clinical outcomes in patients with preserved LV function: a meta-analysis’ by M. Shurrab et al. Two studies took away the ‘innocence’ from right ventricular pacing (RVP). The DAVID (Dual-Chamber and VVI Implantable Defibrillator) trial has assessed whether prevention of bradycardia prevents bradycardia-dependent ventricular tachyarrhythmia, initiated by long–short cycles. This trial reported that more patients died or developed heart failure with prevention of bradycardia by dual-chamber implantable cardiverter defibrillators (ICDs) than with single-chamber ICDs that basically did not pace.1 This result prompted calls for ‘the simpler the better’ sounding like a win–win situation: the device that is simpler for the physician to implant and programme is also better for the patient! However, the culprits for worse outcomes in DAVID were not the devices but the physicians who did not reprogramme dual-chamber ICDs and thus caused unnecessary RVP. Death or heart failure hospitalization developed during 18 months in 32% of patients if DDDR resulted in RVP for >40% of the time compared with only 8% if DDDR resulted in RVP for ≤ 40% of the time.2 By definition, RVP was unnecessary in the DAVID trial because patients with an indication for pacing were excluded. The results from DAVID were likely so striking because all patients had heart failure at baseline. These data suggest that RVP accelerates progression of heart failure by inducing ventricular dyssynchrony and should therefore be avoided. The second study that created doubt about the ‘innocence’ of RVP was a post hoc analysis of the MOST (MOde Selection Trial) study. It showed that in patients with sinus node disease and narrow QRS at baseline, unnecessary RVP increased the risk of heart failure hospitalization and atrial fibrillation.3 Of note, patients in MOST had a normal left ventricular ejection …