Adverse Effects of Long‐Term Right Ventricular Apical Pacing and Identification of Patients at Risk of Atrial Fibrillation and Heart Failure

Abstract

In patients needing a pacemaker (PM) for bradycardia indications, the amount of right ventricular (RV) apical pacing has been correlated with atrial fibrillation (AFib) and heart failure (HF) in both DDD and VVI mode. RV pacing was linked with left ventricular (LV) dyssynchrony in almost 50% of patients with PM implantation and atrioventricular (AV) node ablation for AFib. In patients with normal systolic function needing a PM, apical RV pacing resulted in LV ejection fraction (LVEF) reduction. These negative effects were prevented by cardiac resynchronization therapy (CRT). Algorithms favoring physiological AV conduction are possible useful tools able to maintain both atrial and ventricular support and limit RV pacing. However, when chronic RV pacing cannot be avoided, it appears necessary to reconsider the cut-off value of basic LVEF for CRT. In HF patients, RV pacing can induce greater LV dyssynchrony, enhanced by underlying conduction diseases. In this context, a more deleterious effect of RV pacing in implantable cardioverter-defibrillator (ICD) patients with low LVEF can be expected. In some major ICD trials, DDD mode was correlated with increased mortality/HF. This negative impact was attributed to unnecessary RV pacing >40-50%, virtually absent in VVI-40 mode. However, some data suggest that avoiding RV pacing may also not be the best option for patients requiring an ICD. In patients with impaired LV function, AV synchrony should therefore be ensured. The best pacing mode in ICD patients with HF should be defined on an individual basis.

Permanent Pacemaker Implantation After Transcatheter Aortic Valve Implantation

“…It is well known that pacing induces electric and mechanical dyssynchrony, which in turn, may lead to an adverse left ventricular remodeling and ultimately to the development of heart failure. 7,39,40 The occurrence and extent of pacing-induced heart disease have been associated with ventricular pacing burden and duration, 33 and dual-chamber pacemakers have been associated with a higher percentage of cumulative pacing, leading to a higher risk of rehospitalization for heart failure. 3,7 Interestingly, the implantation of a biventricular pacemaker in patients with preserved LVEF and symptomatic bradycardia and in those with AVB and left ventricular dysfunction has been shown to prevent the adverse effects of pacing on LVEF.…”

Development of a sheep model of atrioventricular block for the application of novel therapies

“…A disadvantage of AV dyssynchrony encountered with this model-because of RV only pacing-is the potential for cardiac dysfunction and cardiomyopathy. There is a body of work that shows single chamber ventricular pacing and AVB can lead to increased risks of atrial fibrillation and decreased quality of life [17][18][19]. It is unknown what the longer-term effects of our model are and whether this could affect the outcomes of experiments assessed over a longer period of time.…”

Non-invasive focus localization, right ventricular epicardial potential mapping in patients with an MRI-conditional pacemaker system ‐ a pilot study

“…Changes in depolarization or repolarization or other signs of adverse pacing effects may be detected at an early stage. Various studies have demonstrated that long-term ventricular pacing may have various unintended adverse electrophysiological and mechanical effects [21, 22]. In order to better understand the underlying (patho-) physiological mechanisms, it is important to further develop clinically applicable, non-invasive techniques that facilitate an integrated electro-mechanical assessment.…”