What are the recommendations for pacing in patients with a Left Ventricular Assist Device (LVAD) who require a pacemaker?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: August 30, 2025 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Pacing Recommendations for Patients with Left Ventricular Assist Devices (LVADs)

Right ventricular (RV) pacing is preferred over biventricular pacing in patients with LVADs requiring pacemaker therapy, as it improves functional status, quality of life, and reduces ventricular tachyarrhythmias. 1

Physiological Considerations in LVAD Patients

The hemodynamic relationship between pacemakers and LVADs requires special consideration:

  • In LVAD patients, the traditional concerns about RV pacing causing dyssynchrony are less relevant since the LVAD directly unloads the left ventricle
  • Recent evidence shows that RV-only pacing in LVAD patients results in:
    • 29% higher daily step count
    • 11% higher 6-minute walk test distance
    • 7% improved quality of life scores
    • Fewer ventricular tachyarrhythmia episodes compared to biventricular pacing 1

Pacing Mode Selection Algorithm

  1. For LVAD patients with existing CRT devices:

    • Turn off LV lead pacing (switch from BiV to RV-only pacing) 1
    • Maintain RV pacing for necessary bradycardia support

  2. For LVAD patients requiring new pacemaker implantation:

    • Choose single-chamber RV pacing or dual-chamber pacing (depending on atrial function)
    • Avoid biventricular pacing as it offers no hemodynamic benefit and may worsen outcomes 2

  3. For patients with high infection risk:

    • Consider leadless pacemaker technology (e.g., Micra™) which has been successfully used with fully magnetically levitated LVADs like HeartMate 3™ 3

Programming Considerations

  • Rate settings: Lower heart rates may confer better RV performance in LVAD patients 2
  • AV delay: If using dual-chamber pacing, program longer AV delays to minimize unnecessary ventricular pacing when possible
  • Managed Ventricular Pacing (MVP): Consider MVP mode to reduce unnecessary RV pacing in patients with intermittent AV block 4

Monitoring Recommendations

  • Utilize pacemaker diagnostics to monitor for early signs of LVAD complications
  • Intrathoracic impedance measurements from pacemakers may help predict adverse events like suction events or heart failure exacerbations in LVAD patients 5

Important Caveats

  • The detrimental effects of RV pacing seen in non-LVAD heart failure patients do not apply to the LVAD population
  • Traditional concerns about ventricular dyssynchrony from RV pacing are mitigated by the mechanical unloading provided by the LVAD
  • Avoid the common pitfall of assuming biventricular pacing benefits seen in heart failure patients will translate to LVAD patients - evidence shows the opposite 1, 2

Special Situations

  • For patients with pre-existing CRT devices undergoing LVAD implantation, consider deactivating the LV lead to optimize outcomes
  • In patients with intermittent high-grade AV block, dual-chamber pacing with algorithms to minimize ventricular pacing may be appropriate
  • For patients with frequent atrial arrhythmias, consider rate control and anticoagulation strategies alongside appropriate pacing mode selection

The evidence clearly demonstrates that RV pacing is superior to biventricular pacing in the LVAD population, contrary to what might be expected based on traditional heart failure pacing guidelines.

References

4
Research

Percent ventricular pacing with managed ventricular pacing mode in standard pacemaker population.

Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology, 2008

Related Questions

What is the preferred order for reducing fentanyl and midazolam in patients on mechanical ventilation, and how can delirium be prevented without an enteral route?
What are the guidelines for suture techniques in clinical trials, following International Conference on Harmonisation (ICH) guidelines?
What is the optimal management strategy for patients with traumatic brain injury and significant intracranial hemorrhage?
What is the recommended treatment for a patient with subacromial impingement syndrome and intact muscle strength, who tested positive on Hawkins and Neer tests?
What is the role of lidocaine (local anesthetic) injections in the subacromial space for relieving pain associated with subacromial impingement syndrome?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question