Emerging treatments
Alternative pacing sites
Traditionally, pacing in the right ventricle has always been undertaken from the apex, a site affording easy accessibility and good lead stability. Alternative pacing sites such as the right ventricular outflow tract septum or the mid-septum have been explored to provide more physiological pacing. However, the clinical benefit of such sites remains uncertain, with variability in lead positioning increasing the risk of adverse outcomes. A septal position may be preferable in patients at increased risk of perforation, such as elderly patients with a low BMI, and women.[21]
Biological pacemakers
Viral vectors, human embryonic stem cells, and adult human mesenchymal cells have been used to provide biological pacemaking.[41] This therapy is highly experimental and has been performed only in animals, but holds promise for possible therapy in humans in the future.[42]
Leadless pacemakers
Pacemaker lead complications and failures remain significant clinical problems. Lead extraction for lead malfunction is associated with significant morbidity and can be fatal in a small percentage of cases. Hence, leadless device technology is appealing. The use of automatic generating systems[43] and ultrasound energy as power sources[44][45][46] is being explored in animals and humans. It remains largely experimental. The first of such devices has been implanted in humans in Europe and the US. In one multicenter study, a leadless pacemaker was successfully implanted in 504 of the 526 patients.[47] The pacemakers met prespecified pacing and sensing requirements in the majority of patients, with device-related serious adverse events occurring in approximately 1 in 15 patients.
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