What are the recommended types of pacing for patients requiring pacing?

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Last updated: August 30, 2025 • View editorial policy

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Recommended Types of Cardiac Pacing

For patients requiring permanent pacing, dual-chamber pacing is recommended over single-chamber ventricular pacing in most clinical scenarios, with physiologic pacing methods (His bundle pacing or cardiac resynchronization therapy) preferred in patients with reduced left ventricular function who require frequent ventricular pacing. 1

Primary Pacing Modalities

Dual-Chamber Pacing (DDD)

  • First-line choice for most patients with:
    • Sinus node dysfunction and intact AV conduction (Class I, Level A) 1
    • AV block (Class I, Level C) 1
    • Combined sinus node dysfunction and AV block (Class I, Level A) 1

Single-Chamber Atrial Pacing (AAI)

  • May be considered in selected patients with:
    • Normal AV and ventricular conduction (Class IIb, Level B) 1
    • Symptomatic sinus node dysfunction with intact AV conduction 1

Single-Chamber Ventricular Pacing (VVI)

  • Appropriate in specific scenarios:
    • Patients with infrequent need for pacing 1
    • Significant comorbidities likely to impact clinical outcomes 1
    • Permanent or persistent atrial fibrillation 1
    • Technical limitations preventing atrial lead placement 1
    • When pacing simplicity is a prime concern (e.g., advanced age, terminal illness) 1

Physiologic Pacing Options

His Bundle Pacing

  • Provides more physiologic ventricular activation 2
  • Particularly beneficial in patients with:
    • Prolonged PR intervals (>240ms) 2
    • Need for maintaining AV synchrony 2
    • Demonstrated improvement in AV synchrony markers and LV stroke volume 2

Cardiac Resynchronization Therapy (CRT)

  • Recommended for patients with:
    • AV block with LVEF between 36-50% requiring >40% ventricular pacing (Class IIa, Level B-NR) 1
    • Heart failure, mildly to moderately reduced LVEF (36-50%), and LBBB with QRS ≥150ms (Class IIb) 1

Left Bundle Branch Pacing

  • Emerging technique that stimulates the proximal left bundle branch 3
  • May provide physiological left ventricular activation 3
  • Alternative when His bundle pacing is not feasible

Pacing Site Selection

Right Ventricular Pacing Sites

  • Traditional RV apical pacing may lead to:

    • Left ventricular dyssynchrony 4, 5
    • Deterioration in LV function over time 4, 5

  • RV septal pacing:

    • Mixed evidence regarding benefits 4, 5
    • Some studies show better preservation of LV function 5
    • Others demonstrate worse LV function and greater dyssynchrony 4

Left Ventricular Pacing Considerations

  • Epicardial LV lead placement may be considered during cardiac surgery for patients likely to require future CRT or ventricular pacing 1

Special Clinical Scenarios

Infiltrative Cardiomyopathies

  • Permanent pacing with additional defibrillator capability is reasonable for patients with:
    • Cardiac sarcoidosis or amyloidosis 1
    • Second-degree Mobitz type II, high-grade, or third-degree AV block 1
    • Expected meaningful survival >1 year 1

Neuromuscular Diseases

  • Permanent pacing may be considered in patients with:
    • PR interval >240ms 1
    • QRS duration >120ms 1
    • Fascicular block 1
    • Any degree of AV block (including first-degree) 1

Congenital Heart Disease

  • Pacing recommendations must consider long-term hemodynamic effects 1

Common Pitfalls and Caveats

  1. Pacemaker syndrome: Patients with single-chamber ventricular pacemakers who develop pacemaker syndrome should be revised to dual-chamber pacing (Class I, Level B-R) 1

  2. Atrial lead placement: Should not be performed in patients with permanent or persistent AF without plans for rhythm control (Class III: Harm) 1

  3. Physiologic pacing benefits: While physiologic pacing reduces atrial fibrillation incidence (18% relative risk reduction), it provides limited benefit for prevention of stroke or cardiovascular death 6

  4. RV septal pacing heterogeneity: Standard fluoroscopic and ECG techniques for RV septal lead placement result in variable actual pacing sites, affecting outcomes 4

  5. Perioperative complications: Higher with physiologic pacing than with ventricular pacing (9.0% vs. 3.8%) 6

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

3
Research

Novel left ventricular cardiac synchronization: left ventricular septal pacing or left bundle branch pacing?

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, 2020

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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.

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