Physiological Pacing - Quo Vadis?

Dual chamber pacemaker therapy was considered to be the optimal treatment for most patients with symptomatic bradycardias. During the last decade, the percentage of dual chamber pacing increased to more than 60% in the United States and Western Europe. Yet, recent multicenter trials (CTOPP, MOST, UKPACE) on dual chamber pacemaker therapy failed to demonstrate a clear prognostic advantage compared to single chamber ventricular pacing. Moreover, clinical benefits of dual chamber pacing like a lower incidence of atrial arrhythmias, a reduction of hospitalization for heart failure or quality of life improvements were lower than expected or even absent. This article discusses the above mentioned studies and their limitations, reviews the increasing evidence for avoiding right (apical) ventricular stimulation and presents current approaches to differential pacemaker therapy.