Impact Of Right Ventricular Pacing Research Articles

Left ventricular global longitudinal strain is a long-term predictor of pacemaker-associated cardiomyopathy

Abstract Background Implantation of a permanent pacemaker is an effective treatment for symptomatic bradycardia. However, chronic right ventricular pacing (RVP) may lead to compromised left ventricular (LV) function, atrial fibrillation, heart failure, and increased mortality via pacing induced electrical and mechanical dyssynchrony. A decrease in LV ejection fraction (LVEF) of ≥ 10% with a baseline LVEF > 50% prior to RVP and no alternative explanation for the decline in LVEF is termed pacing-induced cardiomyopathy (PICM). Predictive clinical and imaging-derived measures to identify patients at high risk for pacemaker induced cardiomyopathy (PMIC) are lacking, but essential. Objective The study is a prospective, single center, double-blinded trial evaluating the impact of right ventricular pacing on left ventricular function and clinical outcome. Methods In 105 patients (59 male / 46 female), who underwent a dual-chamber pacemaker implantation at the Charité Campus Virchow Klinikum, RVP burden, LVEF and left ventricular global longitudinal strain (LV-GLS) were obtained. Mean follow-up per patient was 29.6 ±13.9 months. We used a stepwise analytic approach including ROC analysis, univariate testing, binary regression as well as Cox-regression models and Kaplan-Meier analysis to compare low RVP burden (< 30%) and high RVP burden (≥ 30%) cohorts according to change in echocardiographic parameters and clinical outcome (all-cause mortality). Results Mean LVEF was 61 ± 6% and mean LV-GLS was 18 ± 4% at baseline. We identified 7 patients with a LVEF decline in the course of the study. In Pearson’s Chi-squared test, patients with a high RVP burden were more likely to develop LVEF and LV-GLS deterioration (6 patients versus 1 patient for LVEF, p<0.05; 28 versus 16 patients for LV-GLS, p<0.001). In multivariable binary logistic regression, LV-GLS (OR: 1.410, 95% CI: 1.201-1.610, p<0.001) deterioration was significantly associated with a LVEF decline and a high RVP burden ≥ 30% (OR: 1.358, 95% CI: 1.160-1.534, p<0.01). In a log-rank test, time to LVEF decline was significantly shorter in patients with a RVP burden ≥ 30% compared to a RVP burden < 30% (45.2±2.9 versus 55.7±1.0 months, p<0.05). In the Cox-regression analysis, LV-strain decline within 12 months (HR: 7.210, 95% CI: 4.239-9.516, p<0.05) was a significant predictor for a later LVEF decline. In a log-rank test, time to LVEF deterioration was significantly shorter in patients with LV-strain decline within 12 months compared to those without (34.7 ± 4.2 versus 53.7 ± 1.4 months, p<0.001). No significant difference in all-cause mortality between patients with a high RVP burden compared to those with low RVP burden (log-rank test, p=0.2). Conclusion A decline in LV-GLS is a sensitive long-term parameter of subsequent LVEF deterioration in patients with normal preimplant LVEF, who require RVP ≥ 30%. and is associated with a poor clinical outcome.

ASSESSMENT OF RIGHT VENTRICULAR FUNCTION FOLLOWING PERMANENT PACEMAKER IMPLANTATION BY ECHOCARDIOGRAPHY (INCLUDING 3D ECHOCARDIOGRAPHY)

Objective: Several studies have shown that unfavorable ventricular remodelling & mechanical dyssynchrony caused by Right ventricular (RV) pacing leading to development of Left Ventricular dysfunction. Nevertheless, impact of RV pacing on Right Ventricle function has not been thoroughly assessed. Hence, prospective study was done to assess RV dimensions & function by 2D and three-dimensional (3D) echocardiography at 3 months & 6 months after pacemaker implantation Design and method: This study was a prospective single-centre study. All patients who underwent pacemaker implantation were assessed for RV function by 2D and 3D Echocardiography at baseline (pre-procedure), 3 months & 6 months after pacemaker implantation. The change in follow-up period was evaluated by using single factor analysis of variance ANOVA with repeated measures in normally distributed data & Bonferroni post-hoc test. A p value of <0.05 is considered to be statistically significant Results: From January 2022 to December 2022, a total of 66 patients with permanent pacemaker were enrolled in the study. There was statistically non-significant changes in mean LVEF (%) during follow up (62.13±3.92(Baseline) vs. 62.21±4.15(3-month) vs 62.03+3.83 (6-months), p value>0.05).However, there was statistically significant changes in mean PASP (mm Hg) during follow up (18.45±3.45 (Baseline) vs. 22.18±3.76 (3-month) vs 26.45+3.97, p value <0.05). Also, there was statistically significant changes in mean RIMP during follow up (0.48±0.04(Baseline) vs. 0.50±0.04(3-month) vs 0.50+0.03(6-month),p value<0.05).Likewise, there was statistically significant changes in mean RV E/E’ during follow up (4.47±0.57(Baseline) vs. 4.70±0.74(3-month) vs 4.95+0.82(6-month),p value <0.05).In addition, there was statistically significant changes in mean TR Jet Area (cm2) during follow up (1.68±0.26(Baseline) vs. 2.22±0.43(3-month) vs 2.56+0.53(6-month), p value <0.05). But, there was statistically non-significant changes in mean RVEF % (3D Echo) during follow up (53.51± 2.75(Baseline) vs. 53.02±2.64 (3-month) vs 53.48+2.34 (6-month), p value >0.05).Other echocardiographic parameters of RV function did not show any change in 3-months & 6-months follow-up. Conclusions: There is change in Right Ventricular function after Pacemaker implantation which can be documented as early as 6 months post implantation. Permanent pacemaker was associated with changes in RIMP, RV E/E’, PASP, TR JET AREA during 6 months after Right ventricular pacing

Reduction of left ventricular global longitudinal strain in patients with permanent pacemakers as a predictor of heart failure and mortality outcomes.

Frequent right ventricular (RV) pacing is associated with cardiomyopathy. The impact of RV pacing on left ventricular (LV) global longitudinal strain (GLS) and clinical outcomes is unclear. We analyzed GLS via two-dimensional speckle tracking and LV ejection fraction (EF) on pre- and post-implantation transthoracic echocardiograms of patients undergoing dual chamber pacemaker implantation. We collected long-term data on strain, LVEF, and clinical outcomes. One hundred and ten patients (mean age 76±12years; 59 [54%] female) were followed for mean 23±17months. Mean baseline LVEF was 58±11% and mean GLS was -17±4%. Twenty-four (22%) patients had an absolute decrease in LVEF>10% and 43 (39%) patients had a relative reduction of GLS>15%. Among patients with a reduction of GLS, a larger proportion of patients had RV pacing burden ≥20% (67% vs. 46%; p=.048). Compared to patients without GLS reduction, more patients with a reduction in GLS reached a composite endpoint of HF hospitalization, CRT upgrade or death (47% vs. 16%; p=.001). Reduction in LV GLS was seen in nearly four in 10 patients undergoing pacemaker implantation and was significantly associated with increased RV pacing burden. LV GLS reduction was associated with increased risk of adverse outcomes. LV GLS may have utility in predicting outcomes among patients with RV pacing.

Dual-chamber cardiac pacing short-term effect on left and right atria morphometric parameters and function

Abstract Funding Acknowledgements Type of funding sources: None. Background. Dual-chamber pacemaker implantation is a standard interventional treatment strategy for symptomatic sinus syndrome (SSS) or advanced atrioventricular block (AVB). It is already known that right ventricular pacing might have detrimental effects on cardiac function. However, knowledge about atrial pacing effect on left (LA) and right (RA) atria function is still lacking. Purpose. To assess the impact atrial pacing on left and right atria morphologic and functional parameters in patients after dual-chamber pacemaker implantation. Methods. We conducted a prospective study that included patients who received a dual-chamber pacemaker for an indication of AVB or SSS. A base rate of 40 bpm and no rate response in case of clear AVB indication or a base rate of 60 bpm and rate response if indication was SSS were chosen. A transthoracic echocardiography was done the next day after pacemaker implantation and after 1 and 3 months. To remove the impact of right ventricular pacing, patients with high VP percentage (>40%) were excluded from analysis. Patients were divided into two groups – group A with high AP (>50%), and group B – low AP (<50%). LA expansion fraction reflecting reservoir function, emptying - reflecting conduit, and active emptying reflecting "atrial kick" were analysed. To compare means the Mann Whitney U test, and for categorical variables – X² test were used. Results A total of n = 78 patients underwent dual-chamber implantation and signed informed consent. Due to significant structural heart disease or reduced ejection fraction (<50%) 7 patients were excluded from further analysis. Out of those, n = 21 were excluded due to a high VP percentage. Group A consisted of n = 26 and group B of – n = 24 patients. Average AP in group A was 63,5% and 68,3% at 1 and 3 months and 5,6% and 7,2% in group B respectively. The mean age (group A 74,5 SD 8,6 years vs group B 78,1 SD 8,0 years, p = 0,266), gender distribution (group A males 45,5% vs group B 48,4%, p = 0,774), and mean BMI (group A 26,4 SD 4,8 kg/m2 vs group B 29,5 SD 3,7 kg/m2, p = 0,202) did not differ significantly between the two groups. The mean left ventricular end diastolic diameter (LVEDD) and indexed LVEDD were not significantly different at baseline and did not change during the follow up period. The baseline LA and RA morphometric and functional parameters presented was not different at baseline between the two groups. The change in LA and RA functional parameters presented in figures. A tendency for a lower LA expansion fraction, active emptying fraction and LA ejection fraction were observed in group A. The trend was contant during 1 and 3 month follow-up periods. RA morphometric parameters did not change significantly between the two groups. Conclusion Impaired LA function in a higher percentage of atrial pacing is seen early after pacemaker implantation and could progress over time. Though, even longer observational period is needed. Abstract Figure. Abstract Figure.

The short term influence of right ventricular pacing burden on echocardiographic and spiroergometric parameters in patients with preserved left ventricular ejection fraction

BackgroundThe incidence of worsened clinical outcome due to high right ventricular (RV) pacing burden in patients with preserved left ventricular function remains controversial.ObjectiveTo investigate the impact of RV pacing on several echocardiographic and spiroergometric parameters.MethodsIn 60 pacemaker patients with preserved left ventricular ejection fraction (LVEF) serial echocardiographies and spiroergometries were performed over a time course of 12 months. Additionally, in 48 patients retrospective echocardiographic analyses of the LV- and RV function were carried out up to 24 months after pacemaker implantation.ResultsThe patients were divided into two groups: The high RV pacing burden group (hRVP: ≥ 40%) and the low RV pacing group (lRVP < 40%) according to the definitions in previous randomized MOST and DAVID trials. After a period of 12-month pacemaker therapy no changes to left ventricular end diastolic diameter (LVEDD), left ventricular end systolic diameter (LVESD), LVEF, E/A-ratio; E/E′-ratio and tricuspid annular plane systolic excursion (TAPSE) could be revealed, independently of the RV pacing burden. Additionally, after 24-month long term follow-up there were no differences in LVEF and TAPSE in both groups. Accordingly, no relevant changes of peak exercise capacity, ventilatory anaerobic threshold or maximal oxygen consumption could be demonstrated independently of the RV pacing.ConclusionsIn pacemaker patients with preserved LVEF the burden of RV pacing has no adverse influence on several echocardiographic and spiroergometric surrogate parameters of pacemaker-induced cardiomyopathy after a follow-up of 12 to 24 month. Despite this, screening for pacemaker induced cardiomyopathy should be performed especially in the presence of new heart failure symptoms.

302 Impact of right ventricular pacing in patients with TAVI underwent permanent pacemaker implantation: the Pace-TAVI International Multicentre Study

Abstract Aims Permanent pacemaker implantation after transcatheter aortic valve implantation (TAVI) has emerged as a relevant issue, being more frequent than after surgery and the progressive shift towards low-risk patients stressed the importance to reduce the risk of complications that could impact patient’s long-term prognosis. Long-term right ventricular pacing has been related to an increased risk of electromechanical asynchrony, negative left-ventricular remodelling, atrial fibrillation and heart failure, but there is a lack of evidence regarding the prognostic impact on TAVI patients. The aim of this international multicentre study is to assess the impact of right ventricular pacing on prognosis of TAVI patients undergone pacemaker implantation after the procedure due to conduction disorders. Methods and results All the consecutive patients with severe aortic stenosis treated with TAVI and subsequently underwent pacemaker implantation in each participating centre were enrolled. Patients were divided into two subgroups according to the percentage of ventricular pacing (VP cut-off: 40%) at pacemaker interrogation. The primary endpoint was the composite of cardiovascular mortality and hospitalization for heart failure in subgroups based on the percentage of ventricular stimulation. All cause and cardiovascular mortality in the subgroups according to the percentage of ventricular pacing were the secondary endpoints. In total, 427 patients were enrolled, 153 patients with VP &amp;lt; 40% and 274 with a with VP ≥ 40%. Patients with VP ≥ 40% were older (81.16 ± 6.4 years vs. 80.51 ± 6.8 years), with higher NYHA class, a lower EF (55.26 ± 12.2 vs. 57.99 ± 11.3 P = 0.03), an increased end diastolic ventricular volume (112.11 ± 47.6 vs. 96.60 ± 40.4, P = 0.005) and diameter (48.89 ± 9.7 vs. 45.84 ± 7.5 P = 0.01). A higher incidence of moderate post-procedural paravalvular leak was observed in patients with VP ≥ 40% (37.5% vs. 26.85%, P = 0.03). Ventricular pacing ≥40% was associated with a higher incidence of the composite primary endpoint of CV mortality and HF hospitalization (p at log rank test = 0.006, adjusted HR: 2.41; 95% CI: 1.03–5.6; P = 0.04). Patients with ventricular pacing ≥ 40% had also a higher risk of all-cause (p at log rank test = 0.03, adjusted HR = 1.57; 95% CI: 1.03–2.38; P = 0.03) and cardiovascular (p at log ank test =0.008, adjusted HR: 3.77; CI: 1.32–10.78; P = 0.006) mortality compared to patients with a VP &amp;lt; 40%. Conclusions TAVI Patients underwent permanent pacemaker implantation after the procedure due to conduction disorders and with a VP ≥ 40% at follow-up are at increased risk of cardiovascular death and HF hospitalizations and of all-cause mortality compared to patients with a VP &amp;lt; 40%. It is mandatory to reduce the percentage of ventricular pacing at follow-up when possible or consider left ventricular branch pacing and biventricular pacing in TAVI patients.

Dual-chamber cardiac pacing effect on left and right atria morphometric parameters and function

Abstract Background Dual-chamber pacemaker implantation is a standard interventional treatment strategy for atrioventricular block (AVB) and sick sinus syndrome (SSS). It has been proven that a high percentage of right ventricular pacing might have detrimental effects on cardiac function. However, there is a lack of data on atrial pacing effect on left (LA) and right (RA) atria function. Purpose To assess the impact atrial pacing on left and right atria morphologic and functional parameters in patients after dual-chamber pacemaker implantation. Methods We conducted a prospective study that included patients who received a dual-chamber pacemaker for an indication of AVB or SSS. After signing of the informed consent pacemaker was programmed for base rate of 40 bpm and no rate response in case of clear AVB indication or for base rate of 60 bpm and rate response if indication was SSS. An transthoracic echocardiography was done the next day after pacemaker implantation and after one month at follow up (FU). During the FU the atrial pacing (AP) and ventricular pacing (VP) percentage were captured. To exclude the impact of right ventricular pacing, patients with high VP percentage (&amp;gt;40%) were excluded from analysis. Patients were divided into two groups – group A with high AP (&amp;gt;50%), and group B – low AP (&amp;lt;50%). LA expansion fraction reflecting reservoir function, emptying – reflecting conduit, and active emptying reflecting “atrial kick” were analysed. To compare means the Mann Whitney U test, and for categorical variables – X2 test were used. Results A total of n=100 patients underwent dual-chamber implantation and signed informed consent. Due to significant structural heart disease or reduced ejection fraction (&amp;lt;50%) 11 patients were excluded. Out of those, n=30 were excluded due to a high VP percentage. Group consisted of n=28 and group B of – n=31 patients. Average AP in group A was 66.2% and 5.0% in group B. The mean age (group A 73.6 SD 8.8 years vs group B 79.2 SD 7.3 years, p=0.197), gender distribution (group A males 45.5% vs group B 50.0%, p=0.773), and mean BMI (group A 26.5 SD 4.7 kg/m2 vs group B 29.2 SD 3.3 kg/m2, p=0.191) did not differ significantly between the two groups. The baseline LA and RA morphometric and functional parameters presented in figure 1 and did not differ significantly between the two groups. The change in LA and RA functional parameters presented in figure 2. Even though it did not reach statistical significance, a tendency for lower LA expansion fraction, active emptying fraction and LA ejection fraction were observed in group A. RA morphometric parameters did not change significantly between the two groups at FU. Conclusion A higher percentage of atrial pacing in dual-chamber pacemaker population could lead to impaired LA function over time. Though, longer observational period is needed. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Long‐Term Impact of Right Ventricular Pacing on Left Ventricular Systolic Function in Pacemaker Recipients With Preserved Ejection Fraction: Results From a Large Single‐Center Registry

BackgroundThere is limited evidence of long‐term impact of right ventricular pacing on left ventricular (LV) systolic function in pacemaker recipients with preserved LV ejection fraction (LVEF). The objective of the study was to evaluate the outcome and echocardiographic course of baseline preserved LVEF in a large cohort of pacemaker recipients with respect to pacing indication and degree of right ventricular pacing.Methods and ResultsWe enrolled 991 patients (73±10 years, 54% male) with baseline normal (>55%) LVEF (n=791) or mildly reduced (41–55%) LVEF (n=200) who had paired echocardiographic data on LV systolic function recorded at implantation and last follow‐up. According to pacing indication, patients were divided into atrioventricular block group A (n=500) and sinus node disease group B (n=491). Main outcome measures were all‐cause mortality and deterioration of LV function ≥2 LVEF categories at last follow‐up. Patients were followed for an average of 44 months. Death from any cause occurred in 166 (17%), and deterioration of LV function ≥2 LVEF categories in 56 (6%) patients. There was no significant difference in outcome between group A and group B either in patients with normal LVEF or in those with mildly reduced LVEF. Mean percentage of right ventricular pacing was not predictive of outcome.ConclusionsIn a large cohort of pacemaker recipients with predominantly normal LVEF, clinically relevant LV dysfunction develops rather infrequently. No significant difference in all‐cause mortality and development of severe LV dysfunction is observed between patients with atrioventricular block and sinus node disease. Accordingly, de novo biventricular pacing cannot be recommended for patients with preserved LVEF.

Impact of right ventricular pacing on patients with Chagas cardiomyopathy with chronic systolic heart failure

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Impact of right ventricular pacing on pulse pressure variations

Impact of right ventricular pacing on pulse pressure variations

Impact of Right Ventricular Pacing on Three-Dimensional Global Left Ventricular Dyssynchrony in Children and Young Adults With Congenital and Acquired Heart Block Associated With Congenital Heart Disease

The aim of this study was to determine the effect of long-term right ventricular pacing on left ventricular (LV) mechanical dyssynchrony in children and young adults with congenital and acquired heart block. Eighteen patients aged 19 +/- 7 years with congenital heart block (group I), 9 aged 21 +/- 11 years with acquired heart block after congenital heart surgery (group II), and 15 healthy control subjects (group III) were studied. The LV volumes, ejection fractions, and systolic dyssynchrony index (SDI) values, as determined using 3-dimensional echocardiography, were compared among groups. Groups I (6.68 +/- 2.44%) and II (9.43 +/- 4.44%) had significantly greater SDI values than group III (3.88 +/- 0.63%) (p = 0.011 and p <0.001, respectively). The prevalence of LV mechanical dyssynchrony (SDI >5.14%, mean + 2 SDs of controls) in groups I and II was 72% and 67%, respectively. In 27 patients with right ventricular pacing, LV SDI values were correlated negatively with the LV ejection fractions (r = -0.74, p <0.001). The times to minimum regional volume were significantly longer in lateral, posterior, and inferior segments in group I and septal and inferior segments in group II compared to those in group III (p <0.05). Compared to patients without LV dyssynchrony, patients with LV dyssynchrony had lower LV ejection fractions (p <0.001), had shorter RR intervals (p <0.001), and tended to have dual-chamber pacing (p = 0.088) but had similar durations of pacing, QRS durations, and positions of pacing wires (epicardial vs endocardial). In conclusion, permanent right ventricular pacing in childhood has a negative effect on LV systolic function through the induction of mechanical dyssynchrony, the magnitude and pattern of which differ between congenital and acquired heart block.

Presence of ventricular dyssynchrony and haemodynamic impact of right ventricular pacing in adults with repaired Tetralogy of Fallot and right bundle branch block

Late after surgical repair, adults with Tetralogy of Fallot (TOF) commonly present with right ventricular (RV) dysfunction and right bundle branch block (RBBB). We aimed at (i) investigating whether this prolonged RV conduction induced detrimental electromechanical dyssynchrony in both RV and left ventricle (LV) and (ii) determining the acute haemodynamic effects of pacing at different RV sites. A total of 42 adults with surgically repaired TOF and RBBB were investigated by echocardiography. Intra-RV dyssynchrony (IRVD) and intra-left ventricular dyssynchrony (ILVD) were compared with measurements performed in 30 healthy matched control subjects. An acute haemodynamic study was subsequently performed in a subgroup of 10 patients with New York Heart Association functional class II or class III and echocardiographic signs of RV dysfunction. Cardiac index was measured by a thermodilution technique during spontaneous rhythm (SR) and during atrio-synchronized RV pacing at four different sites (infundibulum, apex, septal, and lateral walls). Fifty-five per cent of the patients with repaired TOF demonstrated abnormal RV and/or LV dyssynchrony. We observed an increased IRVD (37 +/- 12 vs. 18 +/- 8 ms; P= 0.02) and ILVD (34 +/- 12 vs. 20 +/- 10 ms; P= 0.04) in TOF patients when compared with control subjects. We did not observe any significant acute improvement in the cardiac output during atrio-synchronized ventricular pacing vs. SR. Similarly, RV pacing did not induce any significant reduction in the QRS duration. Some TOF adults with RBBB exhibit biventricular electromechanical dyssynchrony. However, in symptomatic patients with RV dysfunction, atrio-synchronized RV pacing does not induce significant acute haemodynamic improvement.

Effect of pacing rate on regional left ventricular wall motion. Assessment by quantitative analysis of equilibrium radionuclide angiography.

We evaluated the hemodynamic impact of right ventricular pacing at different stimulation frequencies. Fourteen patients with a right ventricular pacemaker (VVI pacing with retrograde P wave) but without clinical and electrocardiographic evidence of coronary artery disease underwent two equilibrium radionuclide angiographies: one under low heart rate (50/60 beats per minute) and the other under fast heart rate (90/100 beats per minute). Left ventricular global and sectorial ejection fractions, amplitude and phase images of first harmonic, and sectorial phases of left ventricle were analyzed. In twelve patients (84.7%), sectorial ejection fraction abnormalities in the left ventricular apicoseptal and inferoapical regions were observed under low heart rate, and worsened under fast heart rate, while new onset sectorial ejection fraction abnormalities under fast heart rate were observed in the other two patients with normal sectorial ejection fraction under low heart rate. Sectorial ejection fractions of left ventricular apicoseptal and inferoapical regions significantly changed between low and high heart rate (- 14.1 +/- 3.8%, p < 0.005; - 7.5 +/- 2.4%, p < 0.01 respectively). Left ventricular sectorial phases were abnormal in only two patients (14.3%) under low heart rate, and in twelve patients (84.7%) under fast heart rate. Our study confirms that left ventricular regional wall motion abnormalities during VVI pacing significantly worsen under fast heart rate in comparison to those under low heart rate.