Evidence of left ventricular dyssynchrony resulting from right ventricular pacing in patients with severely depressed left ventricular ejection fraction

Abstract

Cardiac resynchronization therapy (CRT) has recently emerged as an effective treatment for patients with moderate-to-severe systolic heart failure and left bundle branch block (LBBB). Right ventricular pacing (RVP) leads to an LBBB-like pattern in the electrocardiogram. The aim of this study was to evaluate the frequency of ventricular mechanical dyssynchrony in patients induced by RVP. The study included 33 patients with a conventional single or dual chamber pacemaker, 18 with ejection fraction (EF) > 35% and 15 with EF < or = 35%. In all patients, an intrinsic rhythm without intraventricular conduction delay (QRS < or = 120 ms) was present without RVP. Two-dimensional and Doppler echocardiographic criteria for mechanical dyssynchrony [aortic pre-ejection delay (APE), interventricular mechanical delay (IVMD), delayed activation of the posterior left ventricular wall (PD), septal-to-posterior wall motion delay (SPWMD)] were evaluated in all patients with and without RVP. QRS duration showed no difference between the two EF-groups without RVP (93 +/- 10 vs. 96 +/- 9 ms), but was significantly longer in patients with low EF with RVP (152 +/- 18 vs. 181 +/- 18 ms; P < 0.001). In patients with EF > 35%, only APE was slightly prolonged by RVP (111 +/- 20 vs. 129 +/- 17 ms; P = 0.03), whereas in patients with EF < or = 35% marked pathological differences in APE (118 +/- 29 vs. 169 +/- 24 ms; P < 0.001), IVMD (22 +/- 17 vs. 58 +/- 14 ms; P < 0.001), SPWMD (103 +/- 28 vs. 125 +/- 29 ms; P = 0.004), and PD (-21 +/- 25 vs. - 39 +/- 25 ms; P = 0.005) were found. A significant correlation between QRS duration and mechanical ventricular dyssynchrony was only found for two echocardiographic parameters (IVMD, APE) with RVP. In patients with a conventional pacemaker, mechanical dyssynchrony with RVP was shown exceptionally in patients with preserved or moderately depressed systolic left ventricular (LV) function, but in nearly all patients with severely depressed systolic LV function. These patients might benefit from CRT when frequent RVP is required.