What is the clinical evidence from this study?

Study design: RCT. Population: Complete atrioventricular block (CAVB) (n=21). Intervention: EAM-guided pacemaker implantation into RVAPS vs. Conventional fluoroscopic-guided implantation into RV apex (RVA). Primary outcome: LV contractility (ejection fraction, Global Longitudinal Strain) and synchrony.

July 10, 2018

Electroanatomic mapping‐guided localization of alternative right ventricular septal pacing sites in children

Key Result

EAM-guided pacemaker implantation at right ventricular septal sites yielded significantly lower global longitudinal strain, narrower paced QRS, and reduced radiation exposure versus RV apex pacing.

Study Design

Type

RCT (n=21)

Randomization

randomized

Structured PICO

Does EAM-guided pacemaker implantation into alternative RV septal sites improve LV contractility and reduce radiation exposure compared to conventional fluoroscopic-guided RV apical pacing in children with CAVB?

Population

21 pediatric patients aged 4-16 years with complete atrioventricular block, evaluated at 1-12 months post-pacemaker implantation.

Intervention

Electroanatomic mapping (EAM)-guided permanent pacemaker and transvenous leads implantation into alternative right ventricular septal pacing sites (EAM-RVAPS).

Comparator

Conventional fluoroscopic-guided pacemaker implantation into the right ventricular apex (RVA).

Outcome

Left ventricular contractility (ejection fraction [EF], Global Longitudinal Strain [GLS]) and synchrony evaluated at 1-12 months.surrogate

In children with complete AV block, EAM-guided RV septal pacing reduces radiation exposure and achieves narrower paced QRS compared to conventional RV apical pacing, despite longer procedure times.

Abstract

BACKGROUND: Alternative right ventricular (RV) sites (RVAPS) have been proposed to prevent or reduce RV pacing-induced left-ventricular (LV) dysfunction. Nonfluoroscopic 3D electroanatomic mapping systems (EAM) have been developed to guide cardiac catheter navigation and reduce fluoroscopy during electrophysiological procedures or pacemaker implantations. AIM: The aim of the study was to compare the results of EAM-guided permanent pacemaker implantation aiming at RVAPS with conventional fluoroscopic-guided implantation in RV apex (RVA) in children and adolescents. METHODS: A prospective, randomized analysis was performed on children/adolescents with complete atrioventricular block (CAVB) who underwent EAM-guided pacemaker and transvenous leads implantation into RVAPS (EAM-RVAPS) or conventional, fluoroscopic-guided implantation into RV apex (RVA). In EAM-RVAPS, a pacing map guided the implantation of ventricular leads in septal sites with narrower QRS. After implantation, LV contractility (ejection fraction EF, Global Longitudinal Strain GLS) and synchrony were evaluated at 1-12 months. RESULTS: Twenty-one pediatric patients with CAVB, with (six patients) or without structural heart diseases, aged 4-16 (median 10.5) years, were divided in two groups: EAM-RVAPS (11 patients, four dual-chamber/DDD, seven single-chamber/VVIR pacemakers) and RVA (10 patients, one DDD/nine VVIR). The two groups did not show significant differences for preoperative parameters. EAM-RVAPS showed: preserved LVEF and synchrony (not significantly different than RVA), significantly lower GLS and radiation doses/exposures, in spite more complex procedures, significantly longer procedure times and narrower paced QRS than RVA. CONCLUSIONS: EAM-guided procedures have been useful to reduce radiation exposure and to localize RVAPS with narrower paced QRS and lower GLS than RVA.

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