Incidence and predictors of right ventricular pacing-induced cardiomyopathy
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
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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.