title: Managed ventricular pacing compared with conventional dual-chamber pacing for elective replacement in chronically paced patients: results of the Prefer for Elective Replacement Managed Ventricular Pacing randomized study.
abstract: BACKGROUND
  Several studies have shown that unnecessary right ventricular pacing has detrimental effects.
  
  
  OBJECTIVE
  To evaluate whether minimization of ventricular pacing as compared with standard dual-chamber pacing (DDD) improves clinical outcomes in patients referred for pacemaker or implantable cardioverter-defibrillator (ICD) replacement.
  
  
  METHODS
  In an international single-blind, multicenter, randomized controlled trial, we compared DDD with managed ventricular pacing (MVP), a pacing mode developed to minimize ventricular pacing by promoting intrinsic atrioventricular conduction. We included patients referred for device replacement with >40% ventricular pacing, no cardiac resynchronization therapy upgrade indication, no permanent atrial fibrillation (AF), and no permanent complete atrioventricular block. Follow-up was for 2 years. The primary end point was cardiovascular hospitalization. The intention-to-treat analysis was performed by using Kaplan-Meier method and the log-rank test.
  
  
  RESULTS
  We randomized 605 patients (556 referred for pacemaker and 49 referred for ICD replacement; mean age 75 ± 11 years; 365 [60%] men, at 7.7 ± 3.3 years from first device implantation) to MVP (n = 299) or DDD (n = 306). We found no significant differences in the primary end point cardiovascular hospitalization (MVP: 16.3% vs DDD: 14.5%; P = .72) and the secondary end point persistent AF (MVP: 15.4% vs DDD: 11.2%; P = .08), permanent AF (MVP: 4.1% vs DDD: 3.1%; P = .44), and composite of death and cardiovascular hospitalization (MVP: 23.9% vs DDD: 20.2%; P = .48). MVP reduced right ventricular pacing (median 5% vs 86%; Wilcoxon, P < .0001) as compared with DDD.
  
  
  CONCLUSIONS
  In patients referred for pacemaker and ICD replacement with clinically well-tolerated long-term exposure to >40% ventricular pacing in the ventricle, a strategy to minimize ventricular pacing is not superior to standard DDD in reducing incidence of cardiovascular hospitalizations.
authors.affiliation: S. Anna Hospital, Como, Italy. Electronic address: gluca.botto@gmail.com.
authors.forename: Giovanni L
authors.initials: GL
authors.lastname: Botto
authors.affiliation: San Filippo Neri Hospital, Rome, Italy.
authors.forename: Renato P
authors.initials: RP
authors.lastname: Ricci
authors.affiliation: Hospital General de Ciudad, Ciudad Real, Spain.
authors.forename: Juan M
authors.initials: JM
authors.lastname: Bénézet
authors.affiliation: Aarhus University Hospital, Skejby, Aarhus N, Denmark.
authors.forename: Jens Cosedis
authors.initials: JC
authors.lastname: Nielsen
authors.affiliation: Cliniques Universitaires UCL de Mont-Godinne, Yvoir, Belgium.
authors.forename: Luc
authors.initials: L
authors.lastname: De Roy
authors.affiliation: Centre Cardiologique du Nord, Saint-Denis, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Piot
authors.affiliation: Consorcio Hospital General Universitario de Valencia, Valencia, Spain.
authors.forename: Aurelio
authors.initials: A
authors.lastname: Quesada
authors.affiliation: Policlinico Umberto I, Rome, Italy.
authors.forename: Raffaele
authors.initials: R
authors.lastname: Quaglione
authors.affiliation: Presidio Ospedaliero di Montebelluna, Montebelluna, Italy.
authors.forename: Diego
authors.initials: D
authors.lastname: Vaccari
authors.affiliation: Medtronic Bakken Research Center, Maastricht, The Netherlands.
authors.forename: Claudio
authors.initials: C
authors.lastname: Garutti
authors.affiliation: Medtronic Bakken Research Center, Maastricht, The Netherlands.
authors.forename: Lidwien
authors.initials: L
authors.lastname: Vainer
authors.affiliation: Fakultni nemocnice Brno Bohunice, Brno, Czech Republic.
authors.forename: Milan
authors.initials: M
authors.lastname: Kozák
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002304:Cardiac Pacing, Artificial / Q000379:methods*; D017147:Defibrillators, Implantable; D005260:Female; D006801:Humans; D057194:Intention to Treat Analysis; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial; D016896:Treatment Outcome; D014693:Ventricular Fibrillation / Q000628:therapy*
keywords: Cardiac pacing; Dual-chamber pacing; Managed ventricular pacing; Outcomes; Randomized controlled trial