Europace Advance Access originally published online on January 9, 2009
Europace 2009 11(3):356-363; doi:10.1093/europace/eun375
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Pacing and Cardiac Resynchronization Therapy
Effect of right ventricular lead location on response to cardiac resynchronization therapy in patients with end-stage heart failure
1 Department of Pacemaker and Electrophysiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, PO Box: 15745-1341, Mellat Park, Vali-E-Asr Avenue, Tehran 1996911151, Iran; 2 Department of Echocardiography, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
Aims: It is currently recommended to implant the left ventricular (LV) pacing lead at the lateral wall. However, the optimal right ventricular (RV) pacing lead location for cardiac resynchronization therapy (CRT) remains controversial. We sought to investigate whether optimizing the site for placement of the RV lead could further improve the long-term response to CRT in patients with advanced heart failure.
Methods and results: Between October 2006 and December 2007, a total of 73 consecutive patients with standard indication for CRT were enrolled. The enrolled patients were divided into two groups based on the RV lead location. There were 50 patients in RV apex (RVA) group and 23 patients in RV high septum (RVHS). The primary study endpoint was a decrease in LV end-systolic volume (LVESV) by >15% at 6-month follow-up. The secondary endpoints were improvement in New York Heart Association (NYHA) class by 
1 point and decrease in brain-type natriuretic peptide (BNP) levels by >50% after CRT. At 6-month follow-up, improvement in NYHA class by 1 point (RVA: 72% vs. RVHS: 74%, P = 0.76), decrease in LVESV by 15% (RVA: 65% vs. RVHS: 64%, P = 0.76), and decrease in BNP level by >50% (RVA: 70% vs. RVHS: 69%, P = 0.88) were observed in similar proportion of the two groups. When we separately assessed the significance of RV pacing site in three LV stimulation sites, there were no significant differences in terms of clinical improvement (62 vs. 64%, P = 0.74) and decrease in LVESV by >15% (63 vs. 62%, P = 0.78) between RVA and RVHS pacing when the LV stimulation site was lateral cardiac vein. In anterolateral vein pacing site, the RVA stimulation was associated with higher clinical (88 vs. 47%, P = 0.05), echocardiographic (75 vs. 32%, P = 0.02), and neurohormonal responses (80 vs. 50%, P = 0.04) compared with that in RVHS site. When LV was paced from posterolateral vein, RVHS pacing was superior to RVA in terms of the clinical improvement (85 vs. 35%, P = 0.01), echocardiographic response (72 vs. 30%, P = 0.01), and decrease in BNP levels (75 vs. 50%, P = 0.04).
Conclusion: The present study did not show any difference between RVA and RVHS pacing sites in terms of overall improvement in clinical outcome and LV reverse remodelling following CRT. However, effect of RV lead location on CRT response varies depending on LV stimulation site.
Key Words: Cardiac resynchronization therapy, Heart failure, Response, Right ventricular lead
* Corresponding author. Tel: +98 21 2392 2163, Fax: +98 21 2204 8174, Email: majid.haghjoo{at}gmail.com; haghjoo{at}rhc.ac.ir
Manuscript submitted 21 August 2008. Accepted after revision 8 December 2008.