Detrimental immediate and long-term clinical effects of right ventricular pacing in patients with myocardial fibrosis

Abstract Funding Acknowledgements Type of funding sources: None. Background Long-term right ventricular (RV) pacing leads to heart failure or a decline in left ventricular (LV) function in up to a fifth of patients. Objectives We aimed to establish whether patients with focal fibrosis detected on late gadolinium enhancement cardiovascular magnetic resonance (CMR) have deterioration in LV function after RV pacing. Methods We recruited 110 patients (84 in final analysis) into two observational CMR studies. Patients (n = 34) with a dual chamber device and preserved atrioventricular (AV) conduction underwent CMR in two asynchronous pacing modes (AOO & DOO) to compare intrinsic conduction with RV pacing. Patients (n = 50) with high-grade AV block underwent CMR before and 6 months after pacemaker implantation to investigate the long-term effects of RV pacing. Results: The three key findings were 1) Initiation of RV pacing in patients with fibrosis, compared to those without, was associated with greater immediate changes in both LV end-systolic volume index (LVESVi) (5.3 ± 3.5 vs 2.1 ± 2.4 mL/m2; p < 0.01) and LV ejection fraction (LVEF) (-5.7 ± 3.4% vs -3.2 ± 2.6%; p = 0.02); 2) Long-term RV pacing in patients with fibrosis, compared to those without, was associated with greater changes in LVESVi (8.0 ± 10.4 vs -0.6 ± 7.3 mL/m2; p = 0.008) and LVEF (-12.3 ± 7.9 vs -6.7 ± 6.2%; p = 0.012); 3) Patients with fibrosis did not experience an improvement in quality of life, biomarkers or functional class after pacemaker implantation. Conclusions Fibrosis detected on CMR is associated with immediate and long-term deterioration in LV function following RV pacing and could be used to identify those at risk of heart failure prior to pacemaker implantation. Characteristics before and after pacing Study 1 No fibrosis (n = 16) Fibrosis (n = 18) AOO DOO p-value AOO DOO p-value LVEDVi - mL/m² 66 ± 13 66 ± 12 0.67 78 ± 14 79 ± 13 0.34 LVESVi - mL/m² 30 ± 10 32 ± 9 0.003 38 ± 11 43 ± 12 <0.001 LVEF - % 56 ± 6 53 ± 5 <0.001 52 ± 8 47 ± 9 <0.001 Mechanical Dyssynchrony index - ms 61 ± 17 71 ± 25 0.07 81 ± 18 89 ± 21 0.04 Study 2 No fibrosis (n = 19) Fibrosis (n = 31) Pre-PPM Post-PPM p-value Pre-PPM Post-PPM p-value LVEDVi -mL/m² 88 ± 21 73 ± 14 <0.001 90 ± 18 83 ± 21 0.007 LVESVi -mL/m² 35 ± 9 34 ± 9 0.71 41 ± 14 49 ± 21 0.001 LVEF - % 60 ± 5 54 ± 7 <0.001 56 ± 8 43 ± 12 <0.001 Mechanical Dyssynchrony index - ms 70 ± 29 81 ± 22 0.15 84 ± 30 98 ± 31 0.03 Abstract Figure. Mechanism for heart failure after pacing

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Pacemaker Induced Cardiomyopathy: An Overview of Current Literature

Current Cardiology Reviews ◽

10.2174/2772432816666210901111616 ◽

2021 ◽

Vol 17 ◽

Author(s):

Callan Gavaghan

Keyword(s):

Heart Failure ◽

At Risk ◽

Right Ventricular ◽

Current Literature ◽

Left Ventricular ◽

Lv Function ◽

Patients At Risk ◽

Rv Pacing ◽

Clinical Heart Failure ◽

Potential Methods

: Pacemaker induced cardiomyopathy (PICM) is commonly defined as a reduction in left ventricular (LV) function in the setting of right ventricular (RV) pacing. This condition may be associated with the onset of clinical heart failure in those affected. Recent studies have focused on potential methods of identifying patients at risk of this condition, in addition to hypothesizing the most efficacious ways to manage these patients. Newer pacing options, such as His bundle pacing, may avoid the onset of PICM entirely.

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Adverse effects of atrioventricular synchronous right ventricular pacing on left ventricular sympathetic activity, efficiency, and hemodynamic status

AJP Heart and Circulatory Physiology ◽

10.1152/ajpheart.00254.2006 ◽

2006 ◽

Vol 291 (5) ◽

pp. H2377-H2379 ◽

Cited By ~ 9

Author(s):

Abdul Al-Hesayen ◽

John D. Parker

Keyword(s):

Heart Failure ◽

Right Ventricular ◽

Sympathetic Activity ◽

Left Ventricular ◽

Right Atrial ◽

Lv Function ◽

Atrial Pacing ◽

Ventricular Pacing ◽

Rv Pacing ◽

Norepinephrine Spillover

Right ventricular (RV) pacing is now recognized to play a role in the development of heart failure in patients with and without underlying left ventricular (LV) dysfunction. We used the cardiac norepinephrine spillover method to test the hypothesis that RV pacing is associated with cardiac sympathetic activation. We studied 8 patients with normal LV function using temporary right atrial and ventricular pacing wires. All measurements were carried out during a fixed atrial pacing rate. The radiotracer norepinephrine spillover technique was employed to measure total body and cardiac sympathetic activity while changes in LV performance were evaluated with a high-fidelity manometer catheter. Atrioventricular synchronous RV pacing, compared with atrial pacing alone, was associated with a 65% increase in cardiac norepinephrine spillover, an increase in LV end-diastolic pressure, and a reduction in myocardial efficiency. These responses may play a role in the development of heart failure and poor outcomes that are associated with chronic RV pacing.

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Is left ventricular superior to right ventricular pacing in children with congenital or postoperative complete heart block?

Interactive Cardiovascular and Thoracic Surgery ◽

10.1093/icvts/ivab048 ◽

2021 ◽

Author(s):

Ch Bharat Siddharth ◽

Jay Relan

Keyword(s):

Right Ventricular ◽

Heart Block ◽

Complete Heart Block ◽

Left Ventricular ◽

Lv Function ◽

Ventricular Pacing ◽

Cross Sectional ◽

Right Ventricular Pacing ◽

Rv Pacing

Summary A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘Is left ventricular superior to right ventricular pacing in children with congenital or postoperative complete heart block?’ Altogether, 19 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Two large multicentric showed that site of pacing was the major determinant of left ventricular (LV) function with LV pacing being superior to RV pacing, though the number of patients paced via LV was lesser in comparison to right ventricular (RV). There were 2 prospective, 2 retrospective and 1 cross-sectional studies with fewer patients that demonstrated superiority of LV over RV pacing in preserving LV function. Only 1 small-scale retrospective study showed similar results of LV and RV pacing on LV function. One cross-sectional study showed superiority of LV apical pacing on exercise tolerance. As per the existing literature, LV apex seems to be the most optimal site for epicardial pacing while RV free wall pacing has the highest risk of causing LV dysfunction over the long term. We conclude that LV pacing appears to be superior to RV pacing in terms of long-term effect on cardiac function and ventricular synchrony.

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Abstract 2823: Right Ventricular Septal Versus Apical Pacing: Long Term Impact On Left Ventricular Synchrony And Function

Circulation ◽

10.1161/circ.118.suppl_18.s_781-d ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Arnold Ng ◽

Christine Allman ◽

Jane Vidaic ◽

Hui Tei ◽

Andrew P Hopkins ◽

...

Keyword(s):

Right Ventricular ◽

Circumferential Strain ◽

Radial Strain ◽

Left Ventricular ◽

Volume Index ◽

Lv Function ◽

Systolic Volume ◽

Septal Pacing ◽

Normal Controls

Background: Right ventricular (RV) septal pacing has been advocated as an alternative to RV apical pacing to avoid long term detrimental effects. There is conflicting evidence on the benefits of RV septal pacing. No studies have previously compared left ventricular (LV) strain and dyssynchrony between different pacing sites and utilized echocardiography to determine pacing sites. Methods: 55 patients (22 normal controls, 17 RV septal and 17 RV apical pacing) were recruited. LV circumferential and radial strain were determined in the midventricular short axis views. Circumferential and radial strain synchrony, and longitudinal systolic (SDTs) and diastolic (SDTe) dyssynchrony indices were determined. Echocardiographic determination of pacing sites were compared with ECG and chest x-ray (CXR). Results: The median pacing durations were 436 days for RV septal and 2398 days for RV apical pacing. Mean QRS duration were significantly shorter for septal than apical pacing and normal controls (139.8 ± 22.6 vs. 162.4 ± 22.9 vs. 85.9 ± 15.2 msec respectively, p < 0.001). LV mass index, end-systolic volume index and ejection fraction were more impaired in RV septal than apical pacing (108.2 ± 27.2 vs. 91.5 ± 15.4 g/m 2 , 21.3 ± 3.7 vs. 19.4 ± 9.3mL/m 2 , 47.6 ± 8.5 vs. 54.2 ± 7.8% respectively, all p < 0.05). RV septal pacing was associated with more impaired circumferential strain (p < 0.001) and worse circumferential strain dyssynchrony (p = 0.02) than apical pacing and normal controls. There were no significant differences in radial strain, radial strain dyssynchrony or SDTs. RV septal pacing consisted of a heterogeneous group of different pacing sites on echocardiography, and there was only modest agreement between echocardiographic, ECG and CXR determinations of pacing sites. Conclusions: RV septal pacing was associated with poorer long term LV function and greater dyssynchrony than RV apical pacing and normal controls.

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Detrimental Immediate- and Medium-Term Clinical Effects of Right Ventricular Pacing in Patients With Myocardial Fibrosis

Circulation Cardiovascular Imaging ◽

10.1161/circimaging.120.012256 ◽

2021 ◽

Vol 14 (5) ◽

Author(s):

Christopher E.D. Saunderson ◽

Maria F. Paton ◽

Louise A.E. Brown ◽

John Gierula ◽

Pei G. Chew ◽

...

Keyword(s):

Ejection Fraction ◽

Pacemaker Implantation ◽

Volume Index ◽

Lv Function ◽

Medium Term ◽

Dual Chamber ◽

Systolic Volume ◽

End Systolic Volume ◽

Rv Pacing ◽

Lv Ejection Fraction

Background: Long-term right ventricular (RV) pacing leads to heart failure or a decline in left ventricular (LV) function in up to a fifth of patients. We aimed to establish whether patients with focal fibrosis detected on late gadolinium enhancement cardiovascular magnetic resonance (CMR) have deterioration in LV function after RV pacing. Methods: We recruited 84 patients with LV ejection fraction ≥40% into 2 observational CMR studies. Patients (n=34) with a dual-chamber device and preserved atrioventricular conduction underwent CMR in 2 asynchronous pacing modes (atrial asynchronous and dual-chamber asynchronous) to compare intrinsic atrioventricular conduction with forced RV pacing. Patients (n=50) with high-grade atrioventricular block underwent CMR before and 6 months after pacemaker implantation to investigate the medium-term effects of RV pacing. Results: The key findings were (1) initiation of RV pacing in patients with fibrosis, compared with those without, was associated with greater immediate changes in both LV end-systolic volume index (5.3±3.5 versus 2.1±2.4 mL/m 2 ; P <0.01) and LV ejection fraction (−5.7±3.4% versus −3.2±2.6%; P =0.02); (2) medium-term RV pacing in patients with fibrosis, compared with those without, was associated with greater changes in LV end-systolic volume index (8.0±10.4 versus −0.6±7.3 mL/m 2 ; P =0.008) and LV ejection fraction (−12.3±7.9% versus −6.7±6.2%; P =0.012); (3) patients with fibrosis did not experience an improvement in quality of life, biomarkers, or functional class after pacemaker implantation; (4) after 6 months of RV pacing, 10 of 50 (20%) patients developed LV ejection fraction <35% and were eligible for upgrade to cardiac resynchronization according to current guidelines. All 10 patients had fibrosis on their preimplant baseline scan and were identified by >1.1 g of fibrosis with 90% sensitivity and 70% specificity. Conclusions: Fibrosis detected on CMR is associated with immediate- and medium-term deterioration in LV function following RV pacing and could be used to identify those at risk of heart failure before pacemaker implantation.

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Adverse Consequences of Right Ventricular Apical Pacing and Novel Strategies to Optimize Left Ventricular Systolic and Diastolic Function

Current Cardiology Reviews ◽

10.2174/1573403x15666181129161839 ◽

2019 ◽

Vol 15 (2) ◽

pp. 145-155 ◽

Cited By ~ 1

Author(s):

Mohammad Reeaze Khurwolah ◽

Jing Yao ◽

Xiang-Qing Kong

Keyword(s):

Right Ventricular ◽

Systolic Function ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Lv Function ◽

Ventricular Dyssynchrony ◽

Lv Dysfunction ◽

Rv Pacing ◽

Systolic And Diastolic Function

Several studies have focused on the deleterious consequences of Right Ventricular Apical (RVA) pacing on Left Ventricular (LV) function, mediated by pacing-induced ventricular dyssynchrony. Therapeutic strategies to reduce the detrimental consequences of RVA pacing have been proposed, that includes upgrading of RVA pacing to Cardiac Resynchronization Therapy (CRT), alternative Right Ventricular (RV) pacing sites, minimal ventricular pacing strategies, as well as atrial-based pacing. In developing countries, single chamber RV pacing still constitutes a majority of cases of permanent pacing, and assessment of the optimal RV pacing site is of paramount importance. In chronically-paced patients, it is crucial to maintain as close and normal LV physiological function as possible, by minimizing ventricular dyssynchrony, reducing the chances for heart failure and other complications to develop. This review provides an analysis of the deleterious immediate and long-term consequences of RVA pacing, and the most recent available evidence regarding improvements in pacing options and strategies to optimize LV diastolic and systolic function. Furthermore, the place of advanced echocardiography in the identification of patients with pacing-induced LV dysfunction, the potential role of a new predictor of LV dysfunction in RV-paced subjects, and the long- term outcomes of patients with RV septal pacing will be explored.

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Abstract 15164: Impact of Conventional Right Ventricular Pacing in Patients With Heart Failure With Preserved Ejection Fraction: Insights From Pursuit-hfpef Registry

Circulation ◽

10.1161/circ.142.suppl_3.15164 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Tetsuya Watanabe ◽

Shungo Hikoso ◽

Daisaku D Nakatani ◽

Masamichi Yano ◽

Shunsuke Tamaki ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Right Ventricular ◽

Pacemaker Implantation ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Lv Function ◽

Preserved Ejection Fraction ◽

Ventricular Ejection Fraction ◽

Patients With Heart Failure

Introduction: Previous studies suggest that conventional right ventricular (RV) pacing may have a deleterious effect on left ventricular (LV) function. However, there are no reports examining the effects of permanent pacemakers (PM) in patients with heart failure with preserved ejection fraction (HFpEF) admitted with acute decompensated heart failure (ADHF). Methods and Results: Patients' data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT-HFpEF) study, which is a prospective multicenter observational registry for ADHF patients with LVEF ≥50% in Osaka. Echocardiographic measurements were performed just before and 1 year after discharge. We analyzed 623 patients (median age: 81[30-101] years) after exclusion of patients on dialysis. At the admission, 55 of 623 patients had a previously implanted pacemaker (PM(+)). There were no significant differences in baseline clinical characteristics before discharge such as age, gender, renal function, echocardiographic parameters between PM(+) and PM(-) groups. One year after discharge, left ventricular ejection fraction (LVEF) in PM(+) group was significantly lower (58.3±8.6 vs 62.3±8.4%, p=0.005) than those in PM(-) group. During a mean follow-up period of 1.25±0.84years, 171patients had heart failure hospitalization (HFH). At the multivariate Cox analysis, pacemaker was significantly associated with HFH, independently of age, serum NT-proBNP level, and LVEF after the adjustment with NYHA functional class, sex, and hemoglobin. Kaplan-Meier curve analysis revealed that patients in PM(+) group had a significantly higher risk of HFH than those in PM(-) group. Conclusion: The development of cardiac systolic and diastolic dysfunction occurred in patients with HFpEF with a RV pacemaker implantation, which would be associated with poor outcome.

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Predictors of outcomes in patients with mitral regurgitation undergoing percutaneous valve repair

European Heart Journal ◽

10.1093/ehjci/ehaa946.2008 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Polimeni

Keyword(s):

Heart Failure ◽

Mitral Valve ◽

Mitral Regurgitation ◽

Primary Endpoint ◽

Cardiovascular Death ◽

Volume Index ◽

Valve Repair ◽

Percutaneous Valve Repair ◽

Percutaneous Valve

Abstract Background Percutaneous mitral valve repairs has been increasingly performed worldwide. The MITRA-UMG registry provides a snapshot of a real-world clinical data and outcomes. Purpose We sought to investigate predictors of clinical outcomes in patients with mitral regurgitation undergoing percutaneous valve repair. Methods The MITRA-UMG registry retrospectively collected data from consecutive patients with symptomatic moderate-to-severe or severe MR underwent MitraClip implantation. The primary endpoint of interest was the composite of cardiovascular death or rehospitalization for HF. Results Between March 2012 and July 2018, a total of 133 consecutive patients admitted to our institution were included. Acute procedural success was obtained in 95.4% of patients, with no intraprocedural death. The composite primary endpoint of cardiovascular death or rehospitalization for heart failure was met in 50 patients (38%) with cumulative incidences of 7%, 25%, at 30 days and 1 year, respectively. In the Cox multivariate model, NYHA functional class IV, left ventricular end-diastolic volume index (LVEDVi), Euroscore II, independently increased the risk of the primary endpoint at long-term follow-up. At Kaplan-Meier analysis, a LVEDVi >92 ml/m2 was associated with an increased incidence of the primary endpoint. Conclusions In searching the ideal phenotype of patients who benefit most of percutaneous mitral valve repair, those presenting with severely dilated ventricles (LVEDVi >92 ml/m2), high operative risk (EUROSCORE II >7%) or advanced heart failure symptoms (NYHA IV) at baseline carried the worst prognosis at long-term. Funding Acknowledgement Type of funding source: None

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Long-term outcomes in young patients with atrioventricular block of unknown aetiology

European Heart Journal ◽

10.1093/eurheartj/ehab060 ◽

2021 ◽

Author(s):

Johnni Resdal Dideriksen ◽

Morten K Christiansen ◽

Jens B Johansen ◽

Jens C Nielsen ◽

Henning Bundgaard ◽

...

Keyword(s):

Heart Failure ◽

Atrioventricular Block ◽

Ventricular Tachyarrhythmia ◽

Pacemaker Implantation ◽

Young Patients ◽

Composite Endpoint ◽

Unknown Aetiology ◽

Successful Resuscitation

Abstract Aims Atrioventricular block (AVB) of unknown aetiology is rare in the young, and outcome in these patients is unknown. We aimed to assess long-term morbidity and mortality in young patients with AVB of unknown aetiology. Methods and results We identified all Danish patients younger than 50 years receiving a first pacemaker due to AVB between January 1996 and December 2015. By reviewing medical records, we included patients with AVB of unknown aetiology. A matched control cohort was established. Follow-up was performed using national registries. The primary outcome was a composite endpoint consisting of death, heart failure hospitalization, ventricular tachyarrhythmia, and cardiac arrest with successful resuscitation. We included 517 patients, and 5170 controls. Median age at first pacemaker implantation was 41.3 years [interquartile range (IQR) 32.7–46.2 years]. After a median follow-up of 9.8 years (IQR 5.7–14.5 years), the primary endpoint had occurred in 14.9% of patients and 3.2% of controls [hazard ratio (HR) 3.8; 95% confidence interval (CI) 2.9–5.1; P < 0.001]. Patients with persistent AVB at time of diagnosis had a higher risk of the primary endpoint (HR 10.6; 95% CI 5.7–20.0; P < 0.001), and risk was highest early in the follow-up period (HR 6.8; 95% CI 4.6–10.0; P < 0.001, during 0–5 years of follow-up). Conclusion Atrioventricular block of unknown aetiology presenting before the age of 50 years and treated with pacemaker implantation was associated with a three- to four-fold higher rate of the composite endpoint of death or hospitalization for heart failure, ventricular tachyarrhythmia, or cardiac arrest with successful resuscitation. Patients with persistent AVB were at higher risk. These findings warrant improved follow-up strategies for young patients with AVB of unknown aetiology.

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