Right ventricular pacing

Introduction

Right ventricular (RV) pacing is an important and effective treatment in patients with atrioventricular (AV) block. 

The pacemaker lead is usually in the right ventricular apex; thus, the paced QRS complex has a left bundle branch block (LBBB) configuration since right ventricular activation occurs before activation of the left ventricle, and is negative in the inferior leads. 

Sometimes, the lead may be placed higher up in the right ventricular septum or outflow tract, and while there is still an LBBB pattern, the inferior leads may have variable axis. 

Another option is that the lead is placed to pace the His bundle. In this location, the paced QRS complex is narrow and looks similar to a native beat. 

Indications for right ventricular pacing

Class I indications

  • Permanent ventricular pacing for persistent second degree AV block in the His-Purkinje system with alternating bundle branch block or third degree AV block within or below the His-Purkinje system
  • Permanent ventricular pacing for a transient advanced second or third-degree infranodal AV block and associated bundle branch block
  • Permanent ventricular pacing for persistent and symptomatic second or third degree AV block

Class II indications

  • Permanent ventricular pacing may be considered for the asymptomatic persistent second or third degree AV block at AV node level.

ECG features

  • Pacing spike precedes the QRS complex
  • Right ventricular pacing lead placement results in a QRS morphology similar to LBBB
  • ST segments and T waves should be discordant with the QRS complex i.e. the major terminal portion of the QRS complex is located on the opposite side of the baseline from the ST segment and T wave.

ECG 1 Right ventricular pacing, pacing spike precedes each paced QRS complex (LBBB like)


References

1) Gould J, Sieniewicz B, Porter B, Sidhu B, Rinaldi CA. Chronic Right Ventricular Pacing in the Heart Failure Population. Curr Heart Fail Rep. 2018;15(2):61-69. doi:10.1007/s11897-018-0376-x

2) Dalia T, Amr BS. Pacemaker Indications. [Updated 2020 Aug 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507823/

3) https://www.uptodate.com/contents/ecg-tutorial-pacemakers

4) Authors/Task Force Members, Michele Brignole, Angelo Auricchio, Gonzalo Baron-Esquivias, Pierre Bordachar, Giuseppe Boriani, Ole-A Breithardt, John Cleland, Jean-Claude Deharo, Victoria Delgado, Perry M. Elliott, Bulent Gorenek, Carsten W. Israel, Christophe Leclercq, Cecilia Linde, Lluís Mont, Luigi Padeletti, Richard Sutton, Panos E. Vardas, ESC Committee for Practice Guidelines (CPG), Jose Luis Zamorano, Stephan Achenbach, Helmut Baumgartner, Jeroen J. Bax, Héctor Bueno, Veronica Dean, Christi Deaton, Cetin Erol, Robert Fagard, Roberto Ferrari, David Hasdai, Arno W. Hoes, Paulus Kirchhof, Juhani Knuuti, Philippe Kolh, Patrizio Lancellotti, Ales Linhart, Petros Nihoyannopoulos, Massimo F. Piepoli, Piotr Ponikowski, Per Anton Sirnes, Juan Luis Tamargo, Michal Tendera, Adam Torbicki, William Wijns, Stephan Windecker, Document Reviewers, Paulus Kirchhof, Carina Blomstrom-Lundqvist, Luigi P. Badano, Farid Aliyev, Dietmar Bänsch, Helmut Baumgartner, Walid Bsata, Peter Buser, Philippe Charron, Jean-Claude Daubert, Dan Dobreanu, Svein Faerestrand, David Hasdai, Arno W. Hoes, Jean-Yves Le Heuzey, Hercules Mavrakis, Theresa McDonagh, Jose Luis Merino, Mostapha M. Nawar, Jens Cosedis Nielsen, Burkert Pieske, Lidija Poposka, Frank Ruschitzka, Michal Tendera, Isabelle C. Van Gelder, Carol M. Wilson, 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: The Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA), European Heart Journal, Volume 34, Issue 29, 1 August 2013, Pages 2281–2329, https://doi.org/10.1093/eurheartj/eht150

5) https://litfl.com/pacemaker-rhythms-normal-patterns/