An update on clinical trials in pacing: is dual chamber pacing better?
OBJECTIVE
As pacemaker technology has increased in complexity and now offers a variety of additional capabilities, there is uncertainty as to which pacing mode offers more benefit-dual-chamber or single-chamber.


RESULTS
Two large-scale randomized trials, the Canadian Trial of Physiologic Pacing and the Mode Selection Trial, demonstrated that dual-chamber pacing does not reduce the incidence of stroke or improve survival when compared with ventricular pacing. However, dual-chamber pacing does reduce the incidence of atrial fibrillation and in patients with sinus node dysfunction, reduces heart failure symptoms when compared with ventricular pacing. The modest results of these trials were unexpected when viewed in the context of the very favorable retrospective studies.


CONCLUSIONS
A rethinking of the physiology of cardiac pacing has led to the concept that although atrioventricular synchrony supports an improvement in cardiac output and ventricular pressures, these favorable hemodynamics may be attenuated by ventricular dyssynchrony from right ventricular apical pacing. In patients with a reduced ejection fraction, this dyssynchrony may be especially detrimental. Two trials (DANPACE and SAVE-PACE) are currently underway that will clarify the clinical significance of reducing forced ventricular desynchronization. The results of these trials may direct pacemaker physicians away from the right ventricular apical lead toward a new imperative of atrioventricular and right ventricular-left ventricular synchrony.
Hussein
Steven J
SJ
Cardiovascular Research Institute, Mount Sinai Medical Center and Miami Heart Institute, Miami Beach, Florida 33140, USA.
Hennekens
Charles H
CH
Lamas
Gervasio A
GA
D001146:Arrhythmia, Sinus / Q000628:therapy; D001145:Arrhythmias, Cardiac / Q000628:therapy*; D002304:Cardiac Pacing, Artificial / Q000379:methods* / Q000592:standards; D003657:Decision Making; D005069:Evaluation Studies as Topic; D006801:Humans; D010138:Pacemaker, Artificial / Q000145:classification / Q000592:standards; D011474:Prosthesis Design; D016032:Randomized Controlled Trials as Topic; D015996:Survival Rate; D016896:Treatment Outcome