Long‐Term Impact of Right Ventricular Pacing on Left Ventricular Systolic Function in Pacemaker Recipients With Preserved Ejection Fraction: Results From a Large Single‐Center Registry

Abstract

BackgroundThere is limited evidence of long‐term impact of right ventricular pacing on left ventricular (LV) systolic function in pacemaker recipients with preserved LV ejection fraction (LVEF). The objective of the study was to evaluate the outcome and echocardiographic course of baseline preserved LVEF in a large cohort of pacemaker recipients with respect to pacing indication and degree of right ventricular pacing.Methods and ResultsWe enrolled 991 patients (73±10 years, 54% male) with baseline normal (>55%) LVEF (n=791) or mildly reduced (41–55%) LVEF (n=200) who had paired echocardiographic data on LV systolic function recorded at implantation and last follow‐up. According to pacing indication, patients were divided into atrioventricular block group A (n=500) and sinus node disease group B (n=491). Main outcome measures were all‐cause mortality and deterioration of LV function ≥2 LVEF categories at last follow‐up. Patients were followed for an average of 44 months. Death from any cause occurred in 166 (17%), and deterioration of LV function ≥2 LVEF categories in 56 (6%) patients. There was no significant difference in outcome between group A and group B either in patients with normal LVEF or in those with mildly reduced LVEF. Mean percentage of right ventricular pacing was not predictive of outcome.ConclusionsIn a large cohort of pacemaker recipients with predominantly normal LVEF, clinically relevant LV dysfunction develops rather infrequently. No significant difference in all‐cause mortality and development of severe LV dysfunction is observed between patients with atrioventricular block and sinus node disease. Accordingly, de novo biventricular pacing cannot be recommended for patients with preserved LVEF.

Incidence and Time Course for Developing Heart Failure With High-Burden Right Ventricular Pacing

“…Similar findings were reported recently from a European single-center registry, which suggested that many patients with high-burden RV pacing maintain stable LVEF with a low incidence of new-onset HF. 25 It is likely that the adverse impact of RV pacing may affect individuals in a heterogeneous manner such that some may tolerate high RV pacing burden for many years without developing clinical HF, whereas others experience a rapid adverse impact, as noted in the acute phase of our study. Better tools are needed to identify which patients are most likely to experience a clinically relevant adverse effect of RV pacing on ventricular function.…”

“…7,8,11,12 The inclusion of outpatient encounters in assessing the adverse impact of chronic RV pacing is particularly relevant given estimates that physician visits for HF account for ≈2% of all outpatient office visits and cost the healthcare system >$2 billion per year in the United States, representing an important opportunity for curbing healthcare expenditures. 27 Although it has been suggested that all patients undergoing pacemaker implantation with a predicted high burden of RV pacing should be implanted with a biventricular device, 7 the results of the PREVENT-HF study 28 and the preliminary results of the BioPace study 25,29 suggest that such a broad approach to biventricular pacing may not be justified. In general, patients with PICM seem to benefit from upgrade to biventricular pacing.…”

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)…”

Impact of high‐grade atrioventricular block and cumulative frequent pacing on atrial arrhythmias

“…In the literature, low LVEF has been shown to be both a precipitant of as well as a consequence of AF . While patients with preexisting LV systolic dysfunction experience high rates of LV dysynchrony with RVP, in patients with initially preserved LVEF clinically relevant decline in LV function after DC‐PPM implant is less common . In our study population, the majority of patients had relatively preserved LVEF prior to DC‐PPM and only a small proportion had a significant reduction in LVEF after implant.…”