title: Bifocal right ventricular pacing: an alternative way to achieve resynchronization when left ventricular lead insertion is unsuccessful.
abstract: OBJECTIVE
  Bifocal pacing in the right ventricle is an option for patients with end-stage heart failure in whom biventricular pacing is not possible, due to failure in left ventricular (LV) lead insertion. The purpose of this prospective study was to document the clinical response of these patients, after bifocal pacing.
  
  
  METHODS
  From the patients referred for cardiac resynchronization therapy (CRT), from 2009 to 2010, 13 cardiac CRT candidates who underwent unsuccessful LV lead implantation were included. The bifocal system's leads were implanted in the right atrium, the right ventricular (RV) apex, and the RV outflow tract. Initial patient assessment and follow-up evaluation after 6 months included clinical criteria, echocardiographic indices, and biochemical parameters.
  
  
  RESULTS
  From 13 patients (age 68 ± 9 years, nine male), 10 improved clinically. New York Heart Association classification was reduced by one grade (from 3.6 ± 0.5 to 2.8 ± 0.8, p < 0.005 and respectively), while hospitalizations in 6-month time were reduced from three to one (p < 0.001). Six-minute walk test (in meters) increased from 176 ± 86 to 297 ± 91 (p < 0.001) and quality of life improved (EQ-VAS scale changed from 42 ± 12.5 % to 70.8 ± 20.3 %, p < 0.001). Mean shortening in QRS duration was 31.3 ms (from 165.1 ± 16.3 to 133.8 ± 12.7, p < 0.001) and B-type natriuretic peptide (in picograms per milliliter) dropped from 834 ± 350 to 621 ± 283 (p < 0.001). Ejection fraction (in percent) increased from 27.5 ± 4.6 to 33.3 ± 4.4 (p < 0.001), and mitral regurgitation severity decreased by one grade (from 2.7 ± 0.9 to 1.8 ± 0.7, p < 0.05).
  
  
  CONCLUSIONS
  RV bifocal pacing seems to offer a substantial clinical benefit to heart failure patients with traditional CRT indications and could be an alternative option when LV access is unsuccessful.
authors.affiliation: Cardiology Department, Hippokration Hospital, Athens, Greece.
authors.forename: Skevos
authors.initials: S
authors.lastname: Sideris
authors.forename: Constantina
authors.initials: C
authors.lastname: Aggeli
authors.forename: Emmanouil
authors.initials: E
authors.lastname: Poulidakis
authors.forename: Kostas
authors.initials: K
authors.lastname: Gatzoulis
authors.forename: Ioannis
authors.initials: I
authors.lastname: Vlaseros
authors.forename: Katerina
authors.initials: K
authors.lastname: Avgeropoulou
authors.forename: Ioannis
authors.initials: I
authors.lastname: Felekos
authors.forename: Ilias
authors.initials: I
authors.lastname: Sotiropoulos
authors.forename: Christodoulos
authors.initials: C
authors.lastname: Stefanadis
authors.forename: Ioannis
authors.initials: I
authors.lastname: Kallikazaros
mesh_terms: D000368:Aged; D002304:Cardiac Pacing, Artificial / Q000379:methods*; D015897:Comorbidity; D004452:Echocardiography; D005260:Female; D006333:Heart Failure / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D008297:Male; D011446:Prospective Studies; D017211:Treatment Failure; D016896:Treatment Outcome