Elsevier

Heart Rhythm

Volume 11, Issue 9, September 2014, Pages 1619-1625
Heart Rhythm

Incidence and predictors of right ventricular pacing-induced cardiomyopathy

https://doi.org/10.1016/j.hrthm.2014.05.040Get rights and content

Background

Frequent right ventricular (RV) pacing can lead to a decline in left ventricular ejection fraction (LVEF).

Objective

This study aimed to identify incidence and predictors of RV pacing-induced cardiomyopathy (PICM).

Methods

We retrospectively studied 1750 consecutive patients undergoing pacemaker implantation between 2003 and 2012. Patients were included if baseline LVEF was normal, single-chamber ventricular or dual-chamber pacemaker (but not implantable cardioverter-defibrillator or biventricular pacemaker) was implanted, frequent (≥20%) RV pacing was present, and repeat echocardiogram was available ≥1 year after implantation. PICM was defined as ≥10% decrease in LVEF, resulting in LVEF <50%. Patients with alternative causes of cardiomyopathy were excluded. Predictors of the development of PICM were identified using multivariate Cox proportional hazards modeling.

Results

Of 257 patients meeting study criteria, 50 (19.5%) developed PICM, with a decrease in mean LVEF from 62.1% to 36.2% over a mean follow-up period of 3.3 years. Those who developed PICM were more likely to be men, with lower baseline LVEF and wider native QRS duration (bundle branch blocks excluded; P = .005, P = .03, and P = .001, respectively). In multivariate analysis, male gender (hazard ratio 2.15; 95% confidence interval 1.17–3.94; P = .01) and wider native QRS duration (hazard ratio 1.03 per 1 ms increase; 95% confidence interval 1.01–1.05; P < .001) were independently associated with the development of PICM. Native QRS duration >115 ms was 90% specific for the development of PICM.

Conclusion

PICM may be more common than previously reported, and risk for its occurrence begins below the commonly accepted threshold of 40% pacing burden. Men with wider native QRS duration (particularly >115 ms) are at increased risk. These patients warrant closer follow-up with a lower threshold for biventricular pacing.

Section snippets

Background

Right ventricular (RV) pacing can lead to progressive left ventricular (LV) systolic dysfunction and heart failure, presumably by causing electrical and mechanical dyssynchrony.1, 2, 3 The deleterious effect of RV pacing on LV systolic function has been termed pacing-induced cardiomyopathy (PICM).

While only a subset of patients exposed to frequent RV pacing develop PICM, predictors of risk for its occurrence remain to be defined.4 If accurate predictors could be identified, patients at high

Study population

We retrospectively studied consecutive patients undergoing pacemaker implantation at the Hospital of the University of Pennsylvania between January 2003 and December 2012. Patients were included if they had a baseline echocardiogram performed within 6 months before pacemaker implantation documenting left ventricular ejection fraction (LVEF) ≥50%; a single-chamber ventricular or dual-chamber pacemaker was implanted; frequent (≥20%) RV pacing was present; and a repeat echocardiogram was available

Study population, development of PICM, and comparison of baseline characteristics

Of 1750 patients undergoing pacemaker implantation during the study period, 277 (15.8%) met inclusion criteria (Figure 2). Of these 277 patients, 207 (74.7%) remained with preserved LVEF through the end of follow-up (mean 3.3 years; range 0.08–9.4 years). Of the 70 (25.3%) patients who developed a cardiomyopathy, 20 were excluded for an alternative potential explanation (myocardial infarction in 8, myocardial ischemia in 3, severe valvular heart disease in 6, poorly controlled atrial or

Discussion

In our series of consecutive patients with normal LV function undergoing pacemaker implantation, 20% developed PICM over a decade of follow-up. Male gender and wider native QRS duration, particularly >115 ms (excluding bundle branch blocks), identified patients at increased risk for the development of PICM. The risk for developing PICM likely begins well below the commonly accepted pacing percentage of 40, as 13% of those with pacing percentages between 20 and 40 developed PICM in our series.

Conclusion

PICM may be more common than previously reported. Men with wider native QRS duration, particularly > 115 ms, are at increased risk for the development of PICM. These patients may be most effectively treated with biventricular pacing upfront, given their high risk for the development of PICM, though the effectiveness and cost of this strategy require prospective study. At the very least, men with wider native QRS duration warrant closer clinical and echocardiographic follow-up. Finally, risk for

References (19)

There are more references available in the full text version of this article.

Cited by (257)

View all citing articles on Scopus

This work was supported in part by the F. Harlan Batrus Research Fund and the Susan and Murray Bloom Fund.

Dr Epstein has received consulting fees and/or speaking honoraria from St Jude Medical, Medtronic, Boston Scientific, and Biotronik. Dr Verdino has received speaking honoraria from St Jude Medical and Biotronik. Dr Goldberg has received consulting fees from Medtronic.

View full text