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Cardiac pacing. A look to the future

  • Minimising ventricular pacing, presented by J C Nielsen (Aarhus N, DK) - View the slides
  • Magnetic resonance imaging compatible devices, presented by F Duru (Zurich, CH)
  • Biomonotoring and telemonitoring, presented by R P Ricci (Rome, IT) - View the slides
  • Leadless pacing, presented by P E Vardas (Heraklion, GR) - View the slides

Minimising ventricular pacing

The topic was reviewed by Dr Nielsen who was one of the leaders of the DANPACE trial . Dr Nielsen presented a provocative approach to the topic – claiming that despite the claim that RV pacing may affect cardiac function, it should not always be avoided because the avoidance of RV pacing may sometimes come at the cost of a too long AV delay. Such a long AV delay is nonphysiological and may therefore contribute to increased pressure in the atria with the resultant development of AF. Moreover , Dr Nielsen proposed that some of the adverse effects of RV pacing on function such as the one seen in the SAFE PACE trial could in fact be related to extremely short AV intervals used to ensure 100% RV pacing . He also pointed to some inconsistencies in previous studies that demonstrated adverse effect of RV pacing, such as the post hoc analysis of the MOST trial and to several studies that question the detrimental effect of RV pacing Referring to the DANPACE trial, Dr Nielsen demonstrated that pacing exclusive AAIR caused resulted in very long AV intervals that offset the beneficial effect of avoidance of RV pacing. Some safety issues may result from beats, strict adherence to AAIR (such as sudden AV block ) as well as from the use of MVP algorithm (Torsades following blocked beats ) . He therefore recommended DDDR pacing with moderately prolonged AV interval to all patients with SSS. For patients with AV block DDDR without algorithms that allow AV block should be recommended with conservative use of AV search hysteresis

Magnetic resonance imaging compatible devices

Dr Duru presented a state of the art talk on the use of MRI in pacemaker patients. Radiologists seem to be much more reluctant to perform MRI in patients with CIED than cardiologists. Indeed in the early days of MRI imaging there have been several cases of mortality in patients with devices but recently appropriately performed procedures have a very low complication rate as long as they are performed with < 1.5 TESLA away from the thorax. Higher risk is expected in pacemaker dependent patients and in ICD patients. Appropriate precautions have been detailed in position papers at the AHA as well as ESC. The newer MRI compatible devices demonstrated no complications in clinical trials but the clinical study was limited to MRI exams below or above the thorax

Biomonotoring and telemonitoring

Dr Ricci presented the topic of biomonitoring and telemonitoring . Controlled trials of remote monitoring demonstrated time-saving, reduction of resource utilization as well as early diagnosis of hardware malfunction, atrial fibrillation and heart failure. This will probably translate in future studies to reduction in CVA morbidity and mortality. In fact, a recent analysis of the Altitude registry demonstrated increased mortality in patients who were not monitored remotely.

Leadless pacing

Dr Vardas presented the futuristic topic of leadless pacing. Preliminary studies of this approach date back to the early 70’s. This approach has to deal with several challenges: 1. The delivery of the pacemaker into the heart and leaving it there (this has been achieved in animal studies and in preliminary acute human studies) 2. Power source – different sources have been proposed such as transcutaneous ultrasound stimulation, electrical induction by an external generator, the use of wireless electrical stimulation, or the use of acoustic energy Several conceptual questions remain to be answered such as what to do when the pacemaker reaches ERI, how to upgrade it when newer features come up, and who are the patients who are going to benefit most from such pacing mode




Cardiac pacing. A look to the future

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.