Incidence and predictors of right ventricular pacing-induced cardiomyopathy in patients with complete atrioventricular block and preserved left ventricular systolic function

Heart Rhythm. 2016 Dec;13(12):2272-2278. doi: 10.1016/j.hrthm.2016.09.027.

Abstract

Background: Right ventricular (RV) pacing may worsen left ventricular cardiomyopathy in patients with reduced left ventricular ejection fraction (LVEF) and advanced atrioventricular block.

Objective: The objectives of this study were to calculate incidence and identify predictors of RV pacing-induced cardiomyopathy (PICM) in complete heart block (CHB) with preserved LVEF and to describe outcomes of subsequent cardiac resynchronization therapy (CRT) upgrade.

Methods: An analysis of consecutive patients receiving permanent pacemaker (PPM) from 2000 to 2014 for CHB with LVEF >50% was performed. PICM was defined as CRT upgrade or post-PPM LVEF ≤40%. PICM association was determined via multivariable regression analysis. CRT response was defined by LVEF increase ≥10% or left ventricular end-systolic volume decrease ≥15%.

Results: Of the 823 study patients, 101 (12.3%) developed PICM over the mean follow-up of 4.3 ± 3.9 years, with post-PPM LVEF being 33.7% ± 7.4% in patients with PICM vs 57.6% ± 6.1% in patients without PICM (P < .001). In multivariable analysis, lower pre-PPM LVEF (hazard ratio [HR] 1.047 per 1% LVEF decrease; 95% confidence interval [CI] 1.002-1.087; P = .042) and RV pacing % both as a continuous (HR 1.011 per 1% RV pacing; 95% CI 1.002-1.02; P = .021) and as a categorical (<20% or ≥20% RV pacing) (HR 6.76; 95% CI 2.08-22.0; P = .002) variable were independently associated with PICM. Only 29 patients with PICM (28.7%) received CRT upgrade despite an 84% responder rate (LVEF increase 18.5% ± 8.1% and left ventricular end-systolic volume decrease 45.1% ± 15.0% in responders). CRT upgrade was associated with greater post-PPM LVEF decrease, lower post-PPM LVEF, and post-PPM LVEF ≤35% (P = .006, P = .004, and P = .004, respectively).

Conclusion: PICM is not uncommon in patients receiving PPM for CHB with preserved LVEF and is strongly associated with RV pacing burden >20%. CRT response rate is high in PICM, but is perhaps underutilized.

Keywords: Atrioventricular block; Cardiac resynchronization therapy; Cardiomyopathy; Complete heart block; Ejection fraction; Heart failure; Incidence; Pacing; Pacing-induced cardiomyopathy; Predictors.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Atrioventricular Block / diagnosis
  • Atrioventricular Block / therapy*
  • Cardiac Resynchronization Therapy / adverse effects*
  • Cardiac Resynchronization Therapy / methods
  • Cardiomyopathies* / epidemiology
  • Cardiomyopathies* / etiology
  • Cardiomyopathies* / physiopathology
  • Echocardiography / methods
  • Female
  • Follow-Up Studies
  • Heart Ventricles / physiopathology
  • Humans
  • Incidence
  • Male
  • Middle Aged
  • Predictive Value of Tests
  • Prognosis
  • United States / epidemiology
  • Ventricular Function, Left