What are the indications for biventricular pacemaker (BivP) implantation in patients with bradycardia and left ventricular (LV) systolic dysfunction?

From the Guidelines

Biventricular pacemakers are indicated in patients with bradycardia and left ventricular systolic dysfunction who are expected to require ventricular pacing and have a conventional indication for pacing, as they may benefit from improved functional capacity, quality of life, and reduced mortality. The primary consideration for biventricular pacemaker (BivP) implantation in these patients is the presence of left ventricular (LV) dysfunction, which can be improved with biventricular pacing, as demonstrated in a prospective randomized trial published in 2006 1. Key factors to consider include:

• The duration of the native QRS complex, although patients with LV dysfunction and a conventional indication for pacing may benefit from biventricular pacing regardless of QRS duration 1
• The expectation that ventricular pacing will predominate, as these patients may benefit from biventricular pacing to improve functional capacity and quality of life 1
• The presence of reduced left ventricular ejection fraction (LVEF) or heart failure at baseline, as these patients tend to show the greatest benefit from biventricular pacing 1 The goal of BivP therapy is to provide cardiac resynchronization therapy (CRT) while addressing the bradycardia, with the aim of improving cardiac output, reducing heart failure hospitalizations, and enhancing quality of life. It is essential to note that patients should be on guideline-directed medical therapy, including beta-blockers, ACE inhibitors/ARBs/ARNI, and mineralocorticoid receptor antagonists, for at least 3 months before considering BivP implantation. The procedure involves placing leads in the right atrium, right ventricle, and a third lead in the coronary sinus to pace the left ventricle, helping to restore synchronous contraction between the ventricles. Overall, BivP therapy has been shown to reduce heart failure hospitalizations, improve quality of life, and decrease mortality in appropriately selected patients with bradycardia and LV systolic dysfunction 1.

From the Research

Indications for Biventricular Pacemaker Implantation

The indications for biventricular pacemaker (BivP) implantation in patients with bradycardia and left ventricular (LV) systolic dysfunction are as follows:

• Patients with heart failure and left bundle branch block (LBBB) or intraventricular conduction delay, as BivP can improve cardiac output and reduce symptoms of heart failure 2
• Patients with severe LV systolic dysfunction and wide QRS complex, as BivP can improve cardiac function and quality of life 2, 3
• Patients with bradycardia and LV systolic dysfunction who are not responsive to medical therapy, as BivP can improve cardiac function and reduce symptoms 4

Patient Selection

Patient selection for BivP implantation is crucial, and the following factors should be considered:

• Presence of LBBB or intraventricular conduction delay
• Severity of LV systolic dysfunction
• Presence of symptoms of heart failure despite optimal medical therapy
• QRS duration and morphology

Alternative Pacing Techniques

Alternative pacing techniques, such as left bundle branch pacing (LBBP) and right ventricular pacing, may be considered in certain patients:

• LBBP may be an alternative to BivP in patients with heart failure and LBBB, as it can improve cardiac function and reduce symptoms 4
• Right ventricular pacing may be considered in patients with heart failure and right bundle branch block (RBBB), as it can improve cardiac function and reduce symptoms 5

Complications and Safety

The complications and safety of BivP implantation are similar to those of standard pacemaker implantation, including:

• Pneumothorax
• Perforation of the great vessels or myocardium
• Air embolus
• Infection
• Bleeding
• Arrhythmias
• Rupture of the coronary sinus 2