Physiological Ventricular Pacing Vs Managed Ventricular Pacing for Persistent AF Prevention in Prolonged AV Interval (PhysioVP-AF)

Physiological Ventricular Pacing Versus Managed Ventricular Pacing for Persistent Atrial Fibrillation Prevention in Patients With Prolonged Atrioventricular Interval: a Multicenter RCT

A multicenter, prospective, randomized study in a 1:1 ratio, single-blind with double-blind evaluation to evaluate the superiority of physiological ventricular pacing (proposed modality) vs. managed ventricular pacing (control) for prevention of persistent AF (PeAF) occurrence in patients with prolonged atrioventricular interval (PR≥180 ms) and indication for pacing: sinus node disease and/or paroxysmal type 1 or 2-second degree AV block.

Study Overview

• Status: Recruiting
• Conditions: Sinus Node Disease; Atrioventricular; Block, Second Degree (Types I and II)
• Intervention / Treatment: Device: PhysioVP; Device: DDD-VPA

Detailed Description

Study aim: Evaluate the superiority of physiological ventricular pacing (proposed modality) vs. managed ventricular pacing (control) for prevention of persistent AF (PeAF) occurrence in patients with prolonged atrioventricular interval (PR≥180 ms) and indication for pacing: sinus node disease and/or paroxysmal type 1 or 2-second degree AV block. If the efficacy superiority is confirmed, this pacing mode may be considered to reduce the occurrence of persistent atrial fibrillation in this group of patients.

Study design: Independent, multicenter, prospective, randomized study in a 1:1 ratio, single-blind with double-blind evaluation (the actual evaluator of the primary endpoint is the pacemaker device's internal diagnostic algorithm, without intervention by the Investigator). This study will use only CE-marked devices already part of clinical practice.

Groups:

• PhysioVP group: the Physiological Ventricular Pacing is achieved by delivering a pacing stimulus to a cardiac conduction structure, such as the bundle of His or left bundle branch of the His-Purkinje system, with a permanent lead. PhysioVP activates the heart through the native His-Purkinje conduction system, thus offering the most physiologic pacing approach to correct the PR interval and avoiding pacing-induced dyssynchrony.
• DDD-VPA group: In managed ventricular pacing, the right ventricular (RV) lead is implanted in the myocardial right ventricular (septum or apex). In this pacing mode, the ventricular pacing is minimized by using algorithms for right Ventricular Pacing Avoidance.

Devices used:

• PhysioVP group: a specialized delivery sheath for His-Purkinje system pacing with appropriate or standard leads will be used.
• DDD-VPA group: the RV leads will be implanted in the standard right ventricular myocardial sites (septum or apex) using standard bipolar active-fixation leads.

The atrial leads will be placed in the right atrial appendage in both groups. The 13 participating Italian Clinical Centers are proven experience in the PM implantation procedures used in the study.

Enrolled patients will be monitored by in-office clinical checks at 1, 12, 24, and 36 months and by home monitoring at 6, 18, and 30 months after implantation.

• Study Type: Interventional
• Enrollment (Estimated): 640
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Gianni Pastore, MD; Phone Number: ‭+39 (339) 754-4514‬; Email: gianni.pastore@aulss5.veneto.it
• Study Contact Backup: Name: Franco Noventa, MD; Email: franco.noventa@quovadis-ass.it

Study Locations

• Italy
  • Veneto
    • Rovigo, Veneto, Italy, 45100
      • Recruiting
      • Elettrofisiologia, Cardiologia, Ospedale di Rovigo
      • Contact: Gianni Pastore, MD; Email: gianni.pastore@aulss5.veneto.it
      • Principal Investigator: Gianni Pastore, MD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

18 years older patients, able to express Informed Consent, with prolonged atrioventricular interval (PR>180 ms) and one of the following indications for PM implantation according to current guidelines:

• Sinus node disease.
• Paroxysmal type1or 2 second-degree AV-block.

Exclusion Criteria:

• Candidacy for implantable cardioverter-defibrillator or cardiac resynchronization therapy device implantation.
• Severe grade mitral or aortic regurgitation/stenosis.
• Atrial fibrillation ablation (left pulmonary veins).
• Cardiac surgery < 3 months before PM implantation.
• History of long-standing persistent AF.
• Permanent third-degree AV block.
• Participation in another clinical trial in the past 3 months.
• Pregnancy or intention to become pregnant.
• Life expectancy of < 3 years.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: PhysioVP group; Physiological ventricular pacing	Device: PhysioVP; The Physiological ventricular pacing is achieved by delivering a stimulus to a cardiac conduction structure, such as the bundle of His or left bundle branch of the His-Purkinje system, with a permanent lead. PhysioVP activates the heart through the native His-Purkinje conduction system, thus offering the most physiologic pacing approach to correct the PR interval and avoiding pacing-induced dyssynchrony. A specialized delivery sheath for His-Purkinje system pacing with appropriate or standard leads will be used. The atrial leads will be implanted in the right atrial appendage and will connect the leads to the standard dual-chamber PM. By continuously recording a 12-lead ECG, we determine whether cardiac conduction structure, such as the bundle of His or left bundle branch of the His-Purkinje system, will be achieved.
Active Comparator: DDD-VPA group; Dual-chamber pacing with the addition of algorithms for ventricular pacing avoidance	Device: DDD-VPA; In dual-chamber pacing with the addition of algorithms for ventricular pacing avoidance, also called managed ventricular pacing, the right ventricular (RV) lead is implanted in the myocardial right ventricular (septum or apex). In this pacing mode, the ventricular pacing is minimized by using algorithms for right ventricular pacing avoidance. Therefore, the RV leads will be implanted in the right ventricular myocardial sites (septum or apex) and standard bipolar active or passive fixation leads. In addition, the atrial leads will be implanted in the right atrial appendage and connect leads to the standard dual-chamber PM.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
PeAF Free	Freedom from persistent AF occurrences up to 36 months after the pacemaker (PM) implant. The occurrence of PeAF is defined as the first AF / Atrial Flutter / Atrial Tachycardia episode lasting > 7 days, detected by the PM after a 1-month post PM lead-stabilization period. A day of AF is satisfied with a device-detected daily AF burden of ≥ 23 hours. Device-detected AF may also be collected by remote monitoring tools, if available. The definition also includes the occurrence of episodes terminated by cardioversion, whatever its duration or undergoing AF ablation	36 months
Clinical composite outcome	Composite outcome based on the occurrence of one or more of the events: Death from cardiovascular disease, or heart failure, or pacing system upgrading to the conduction system pacing (CSP) or to the biventricular pacing (BVP).	36 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Hemodynamic performance, LV remodeling 1	Echocardiographic parameters: Left Ventriculi end-systolic volume (ml/m2).	12 months
Hemodynamic performance, LV remodeling 2	Echocardiographic parameters: LVEF (%).	12 months
Hemodynamic performance, Diastolic function 1	Echocardiographic parameters: E to A mitral wave amplitude ratio.	12 months
Hemodynamic performance, Diastolic function 2	Echocardiographic parameters: E wave deceleration time (ms).	12 months
Hemodynamic performance, Diastolic function 3	Echocardiographic parameters: pulsed-wave tissue Doppler early diastolic septal mitral annular velocity (e') (cm/s).	12 months
Hemodynamic performance, Diastolic function 4	Echocardiographic parameters: E/e' ratio.	12 months
Hemodynamic performance, Diastolic function 5	Echocardiographic parameters: Diastolic time (from onset E wave to end A wave) normalized for RR interval (ms).	12 months
Hemodynamic performance, Left atrial volume	Echocardiographic parameters: Left atrial volume (ml/m2).	12 months
Hemodynamic performance, Mitral regurgitation	Echocardiographic parameters: vena contracta (mm).	12 months
Clinical evaluations, NYHA	NYHA class variation (I, II, III, IV).	12, 24, and 36 months
Clinical evaluations, MLHFQ	Variation of Quality-of-Life assessment by Minnesota Living with Heart Failure questionnaire (MLHFQ).	12, 24, and 36 months
Clinical evaluations	Number of cardiovascular diseases related to health structure access.	12, 24, and 36 months
Safety endpoints, PRAE	Rate of all procedure-related adverse events (PRAE).	36 months
Safety endpoints, Potentially harmful factor 1	Implantation/s procedure time (mm:ss).	36 months
Safety endpoints, Potentially harmful factor 2	Fluoroscopy time (mm:ss).	36 months
Safety endpoints, Incidence Rate of re-interventions	Rate of re-interventions for lead revision, replacement, or infection.	36 months
Estimated battery longevity	Estimated residual battery longevity (time to end-of-life) by the implanted device every 6-months and/or when the primary endpoint is reached.	36 months

Collaborators and Investigators

• Sponsor: Quovadis Associazione
• Investigators: Principal Investigator: Gianni Pastore, MD, Cardiology Unit, "S.Maria della Misericordia" Hospital, Rovigo, Italy

Publications and helpful links

General Publications

• Pastore G, Bertini M, Bonanno C, Coluccia G, Dell'Era G, De Mattia L, Grieco D, Katsouras G, Maines M, Marcantoni L, Marinaccio L, Paglino G, Palmisano P, Ziacchi M, Zoppo F, Noventa F. The PhysioVP-AF study, a randomized controlled trial to assess the clinical benefit of physiological ventricular pacing vs. managed ventricular pacing for persistent atrial fibrillation prevention in patients with prolonged atrioventricular conduction: design and rationale. Europace. 2023 May 19;25(5):euad082. doi: 10.1093/europace/euad082.

Helpful Links

• Promotor's site

Study record dates

Study Major Dates

• Study Start (Actual): July 27, 2022
• Primary Completion (Estimated): December 1, 2028
• Study Completion (Estimated): December 1, 2028

Study Registration Dates

• First Submitted: January 12, 2022
• First Submitted That Met QC Criteria: May 4, 2022
• First Posted (Actual): May 10, 2022

Study Record Updates

• Last Update Posted (Actual): May 11, 2025
• Last Update Submitted That Met QC Criteria: May 6, 2025
• Last Verified: May 1, 2025

More Information

Terms related to this study

• Keywords: conduction system pacing; persistent atrial fibrillation; Sinus Node Disease; Paroxysmal AV-block
• Additional Relevant MeSH Terms: Cardiac Conduction System Disease; Cardiovascular Diseases; Pathologic Processes; Heart Diseases; Arrhythmias, Cardiac; Heart Block; Arrhythmia, Sinus; Atrioventricular Block; Sick Sinus Syndrome; Atrial Fibrillation
• Other Study ID Numbers: PhysioVP-AF

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: Yes
• product manufactured in and exported from the U.S.: Yes