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. 2021 May;14(5):e012256.
doi: 10.1161/CIRCIMAGING.120.012256. Epub 2021 May 18.

Detrimental Immediate- and Medium-Term Clinical Effects of Right Ventricular Pacing in Patients With Myocardial Fibrosis

Christopher E D Saunderson  1 , Maria F Paton  1 , Louise A E Brown  1 , John Gierula  1 , Pei G Chew  1 , Arka Das  1 , Anshuman Sengupta  2 , Thomas P Craven  1 , Amrit Chowdhary  1 , Aaron Koshy  1 , Hazel White  3 , Eylem Levelt  1 , Erica Dall'Armellina  1 , Pankaj Garg  4 , Klaus K Witte  1 , John P Greenwood  1 , Sven Plein  1 , Peter P Swoboda  1
Affiliations

Detrimental Immediate- and Medium-Term Clinical Effects of Right Ventricular Pacing in Patients With Myocardial Fibrosis

Christopher E D Saunderson et al. Circ Cardiovasc Imaging. 2021 May.

Abstract

Background: Long-term right ventricular (RV) pacing leads to heart failure or a decline in left ventricular (LV) function in up to a fifth of patients. We aimed to establish whether patients with focal fibrosis detected on late gadolinium enhancement cardiovascular magnetic resonance (CMR) have deterioration in LV function after RV pacing.

Methods: We recruited 84 patients with LV ejection fraction ≥40% into 2 observational CMR studies. Patients (n=34) with a dual-chamber device and preserved atrioventricular conduction underwent CMR in 2 asynchronous pacing modes (atrial asynchronous and dual-chamber asynchronous) to compare intrinsic atrioventricular conduction with forced RV pacing. Patients (n=50) with high-grade atrioventricular block underwent CMR before and 6 months after pacemaker implantation to investigate the medium-term effects of RV pacing.

Results: The key findings were (1) initiation of RV pacing in patients with fibrosis, compared with those without, was associated with greater immediate changes in both LV end-systolic volume index (5.3±3.5 versus 2.1±2.4 mL/m2; P<0.01) and LV ejection fraction (-5.7±3.4% versus -3.2±2.6%; P=0.02); (2) medium-term RV pacing in patients with fibrosis, compared with those without, was associated with greater changes in LV end-systolic volume index (8.0±10.4 versus -0.6±7.3 mL/m2; P=0.008) and LV ejection fraction (-12.3±7.9% versus -6.7±6.2%; P=0.012); (3) patients with fibrosis did not experience an improvement in quality of life, biomarkers, or functional class after pacemaker implantation; (4) after 6 months of RV pacing, 10 of 50 (20%) patients developed LV ejection fraction <35% and were eligible for upgrade to cardiac resynchronization according to current guidelines. All 10 patients had fibrosis on their preimplant baseline scan and were identified by >1.1 g of fibrosis with 90% sensitivity and 70% specificity.

Conclusions: Fibrosis detected on CMR is associated with immediate- and medium-term deterioration in LV function following RV pacing and could be used to identify those at risk of heart failure before pacemaker implantation.

Keywords: atrioventricular block; biomarkers; fibrosis; heart failure; heart ventricles.

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Figures

Figure 1.
Figure 1.
Study design and protocol. AOO indicates atrial asynchronous pacing; AV, atrioventricular; CMR, cardiovascular magnetic resonance; DOO, dual chamber asynchronous pacing; ICD, implantable cardioverter defibrillator; LGE, late gadolinium enhancement; LVEF, left ventricular ejection fraction; MRI, magnetic resonance imaging; PM, pacemaker; and VOO, ventricular asynchronous pacing. *Or 10bpm above the intrinsic heart rate when the intrinsic rate was greater than 80bpm.
Figure 2.
Figure 2.
Late gadolinium imaging in study participants. Representative short-axis late gadolinium enhancement (LGE) images in bradycardic patients before pacemaker implantation (A–C) and in patients with implanted pacemakers (D–F). Examples demonstrate the presence of LGE (blue arrows) and artifact from the right ventricular pacing lead (green arrows).
Figure 3.
Figure 3.
Absolute change in ventricular volumes and function before and after ventricular pacing. Values are mean±SE. Absolute changes between those with (blue bars) and without (red bars) myocardial fibrosis. Study 1 (left): immediate change between atrial asynchronous and dual chamber asynchronous pacing modes in patients with preserved atrioventricular (AV) conduction. Study 2 (right): change from baseline (before pacemaker) to 6 mo follow-up in patients implanted with permanent pacemakers for AV block. LVEDVi indicates left ventricular end-diastolic volume index; LVEF, left ventricular ejection fraction; and LVESVi, left ventricular end-systolic volume index.
Figure 4.
Figure 4.
Change in the New York Heart Association functional class before and after pacemaker implantation.
See this image and copyright information in PMC

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