Right ventricular pacing is associated with impaired overall survival, but not with an increased incidence of ventricular tachyarrhythmias in routine cardioverter/ defibrillator recipients with reservedly programmed pacing

Aims Data from previous defibrillator studies raised concern about right ventricular pacing (RVP) promoting heart failure progression and mortality in implantable cardioverter/defibrillator (ICD) patients. The present observational study re-examined the association of RVP, survival, and ventricular tachyarrhythmias/ventricular fibrillation (VT/VF) in routine ICD patients with restrictively programmed pacing. Methods and results In 213 ICD patients [183 men, left ventricular ejection fraction (LVEF) 37 ± 15%, follow-up 37 ± 18 months, no advanced atrioventricular (AV) block], the RVP proportion, survival, and the time to a first appropriate VT/VF episode were assessed. Electrograms were validated and the overall survival was determined. The RVP prevalence was dichotomized at ≥30% (high RVP) vs. <30% (low RVP). High RVP (RVP 94%, n = 24) and low RVP (RVP 0%, n = 189) patients had similar LVEF, underlying heart disease, ICD indication, and medication. Multivariate Cox regression showed no difference in survival without appropriate VT/VF treatment [odds ratio (OR): 0.92, 95% confidence interval (CI): 0.41–2.04, P = 0.83]. Overall survival was significantly more favourable in low RVP patients (OR: 0.34, CI: 0.13–0.91, P = 0.03). Conclusion Frequent RVP is associated with impaired survival in ICD patients despite conservative pacing settings. Implantable cardioverter/defibrillator patients requiring concomitant bradycardia pacing should be cared for with particular attention to clinical worsening. Right ventricular pacing prevention and alternative modalities of ventricular pacing need prospective evaluation.