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Evolving Indications for Permanent Pacemakers

Miguel Bryce, MD; Scott R. Spielman, MD; Allan M. Greenspan, MD; and Morris N. Kotler, MD
[+] Article and Author Information

From Albert Einstein Medical Center, Philadelphia, Pennsylvania.


Requests for Single Reprints: Morris N. Kotler, MD, Albert Einstein Medical Center, Division of Cardiovascular Diseases, 5401 Old York Road, Klein Building, Suite 363, Philadelphia, PA 19141.

Current Author Addresses: Drs. Bryce and Kotler: Albert Einstein Medical Center, Division of Cardiovascular Diseases, 5401 Old York Road, Klein Building, Suite 363, Philadelphia, PA 19141.

Drs. Spielman and Greenspan: Albert Einstein Medical Center, Division of Cardiovascular Diseases, 5501 Old York Road, EPS Offices, Levy 3 East, Philadelphia, PA 19141.


Ann Intern Med. 2001;134(12):1130-1141. doi:10.7326/0003-4819-134-12-200106190-00014
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New indications for permanent cardiac pacing have been developed in recent years, with numerous studies demonstrating improved clinical outcomes in a variety of disorders. Because hypertrophic obstructive cardiomyopathy, dilated cardiomyopathy, heart failure, neurocardiogenic syncope, and atrial fibrillation are common conditions, every clinician should be aware of evolving alternative therapies for them.

Observational studies in patients with refractory, symptomatic hypertrophic obstructive cardiomyopathy and significant left ventricular outflow gradient at rest suggest that cardiac pacing may result in symptomatic and hemodynamic improvement. Clinical trials have not shown conclusive evidence regarding the long-term benefit from pacing in these patients, and it is unclear whether pacing will be a preferred treatment option. Preliminary data suggest that pacing is a viable adjunctive therapeutic approach for improving symptoms in patients with dilated cardiomyopathy and heart failure. Mortality benefit has yet to be established, but it is to be hoped that ongoing randomized clinical trials will provide definitive information on that issue. Patients with refractory neurocardiogenic syncope or those who are intolerant of medical treatment may benefit from pacing therapies, especially those that use rate-drop sensor algorithms. Biatrial pacing has emerged as a technique that resynchronizes atrial electrical activity and has been shown to prevent atrial fibrillation. Multisite atrial pacing for the prevention of atrial fibrillation is considered investigational but seems promising. Newer indications for pacing are expected to result in improved clinical outcomes for hypertrophic obstructive cardiomyopathy, dilated cardiomyopathy and heart failure, neurocardiogenic syncope, and the prevention of atrial fibrillation.

Figures

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Figure 1.
Long-term results of dual-chamber pacing (DDD) in 84 patients with obstructive hypertrophic cardiomyopathy.NYHA(11)P

New York Heart Association ( ) functional class improved from an average of 3.16 to 1.55, the number of syncopal episodes decreased from 35 to 5 (42% of patients to 6% of patients), and treadmill exercise performance improved by 35% . For all comparisons,  < 0.001. The white bars represent findings before pacing, and the gray bars represent findings after pacing.

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Figure 2.
Impact of QRS duration on risk for death in patients with heart failure(22).P

*  < 0.001.

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Figure 3.
Dual-chamber pacemaker (DDD) electrocardiogram showing rate-drop responsiveness sensor mode.

A and B = the first two atrioventricular sequential paced beats after the pause at an escape rate of 50 pulses per minute. R = the point at which the rate-drop response sensor is activated and the pacemaker begins atrioventricular sequential pacing at a faster rate.

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Figure 4.
Dual-site right atrial pacing compared with single-site right atrial pacing.(62)

Dual-site right atrial pacing significantly increased the proportion of patients free of atrial fibrillation recurrence at 90 days (89% vs. 62%). All patients in the control group had recurrence of atrial fibrillation by 45 days . The solid line indicates patients who received dual-site right atrial pacing, the dashed line indicates patients who received single-site right atrial pacing, and the dotted line indicates controls.

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