Treatment of Severe Heart Failure: Is Left Ventricular Pacing Alone Enough or Do We Need Biventricular Pacing?
In patients with severe heart failure in spite of “optimal” drug treatment, interventions remain limited. Adjustment of drug treatment may be helpful but its benefit is generally of short duration and the problem is merely delayed; heart transplant is restricted to a few patients due to the small numbers of donors and other non-pharmacological treatments remain investigational (mechanical assistance device) or questionnable (cardiomyoplasty). Since the beginning of the 1990s, many efforts have been directed toward the use of pacing in such situations. After a brief period of hope , it has been demonstrated that right apical pacing has no or little effectiveness in patients with severe heart failure [2–4]. In fact, only some of those with a very long PR interval achieved significant improvement of their symptoms with this pacing site . Other right ventricular pacing sites were evaluated but in most of the patients remained unsuccessful [6, 7]. In 1994, a brief paper was published reporting that the adjoining of a left ventricular pacing site to the right one led to significant improvement in patients with end-stage heart failure . This observation gave the impetus for a flourishing field of research. It was initially thought that hemodynamic improvement was exclusively a direct consequence of the resynchronization of the two ventricles, as this procedure was only effective in patients with left bundle branch block . It rapidly appeared that this explanation was totally insufficient, as we demontrated in acute hemodynamic studies that left ventricular pacing alone was at least as effective as biventricular pacing . The aim of the present paper is to summarize our present knowledge on left ventricular pacing alone. However, we should remained cautious, as developments in this field are coming quickly and it is difficult to assume that the present data will be confirmed by ongoing studies.
KeywordsLeft Bundle Branch Block Severe Heart Failure Ventricular Pace Biventricular Pace Pace Site
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