Heart failure due to right ventricular apical pacing: the importance of flow patterns

Abstract

In patients receiving permanent cardiac electrical stimulation, a high burden of apical right ventricular pacing is associated with an increased incidence of heart failure. Despite the large body of electrocardiographic, echocardiographic, and pathological data, mechanisms underlying this serious complication are not fully understood. Moreover, the empirical use of alternative right ventricular pacing sites, both in the experimental and in the clinical setting, has not provided better results in terms of clinical outcome. Recent data derived by echocardiographic particle image velocimetry of intracardiac flows have shown abnormal flow patterns in patients with dyssynchrony of left ventricular wall contraction, and the reversion to normal flow dynamics after successful electrical cardiac resynchronization therapy. This suggests that a normal intraventricular flow pattern is strongly dependent on the highly coordinated contraction of the ventricular wall segments and that an abnormal sequence of wall contraction may trigger the development of overt heart failure. This review summarizes the state of the art on this topic, highlighting postulated underlying basic mechanisms linking abnormal flow with the development of pacing-induced heart failure. This research line suggests the importance of studying intraventricular fluid dynamics as a new powerful tool for a more complete understanding of mechanisms involved, and ultimately to prevent pacing-related heart failure.

Echocardiographic Predictors of All-Cause Mortality in Patients with Hypertrophic Cardiomyopathy following Pacemaker Implantation

“…To the best of our knowledge, there are at least 2 possible explanations for this difference. Right-sided heart excitation followed by left-sided heart excitation in patients with LVOTO markedly improves obstruction symptoms (such as palpitations, angina, and dyspnea [16]), hemodynamic abnormalities, and quality of life [7,9,10], which may neutralize the poor effects of RV apical pacing [30,31]. Psychologically, more and more studies have focused on mental health and all-cause mortality [32][33][34].…”

The effect of atrial fibrillation intervention on nocturnal respiratory events in elderly patients with persistent AF

“…PPM and AVNA + DCCV resulted in an increase in AHI, central apnoeic events and ESS. Chronic ventricular pacing following AVNA can result in pacing‐induced dyssynchrony and impairment of left ventricular function and has been shown to exacerbate fluid shift to the upper airway overnight . In addition, the majority of the PPM and AVNA + DCCV patients (21/22) remained in AF at 6‐month follow‐up and therefore did not experience the haemodynamic benefits of prolonged SR The reduction in overnight oxygenation is the likely explanation for the increase in ESS because increased desaturation overnight has been shown to correlate with ESS .…”

“…PPM and AVNA + DCCV resulted in an increase in AHI, central apnoeic events and ESS. Chronic ventricular pacing following AVNA can result in pacing-induced dyssynchrony and impairment of left ventricular function 27,28 and has been shown to exacerbate fluid shift to the upper airway overnight. 29,30 In addition, the majority of the PPM and AVNA + DCCV patients (21/22) remained in AF Baseline (in AF)…”

Transient rise in His‐lead threshold due to acute myocardial infarction

“…Right ventricular (RV) pacing has a long‐standing and well‐documented reputation for causing dyssynchronous activation of the ventricles, leading to an increased risk of atrial fibrillation and heart failure . Multiple studies have attempted to determine whether sites different to the RV apex (such as the RV septum) show superior clinical outcomes, and reduce the risk of pacing‐induced ventricular dysfunction, but to date none have been able to show this.…”

“…Right ventricular (RV) pacing has a long-standing and well-documented reputation for causing dyssynchronous activation of the ventricles, leading to an increased risk of atrial fibrillation and heart failure. [1][2][3] Multiple studies have attempted to determine whether sites different to the RV apex (such as the RV septum) show superior clinical His pacing has been around for almost five decades, first demonstrated in man in 1970 by Narula et al 4 Pacing through the His-Purkinje system allows normal activation of the ventricles to be achieved, thus preventing the LV desynchrony caused by RV apical pacing. However, due to the lack of dedicated equipment available to permanently implant such leads, interest dropped, and it is only in the 21st century where the first article was published to support its cause.…”