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

Author:

Saunderson Christopher E.D.1,Paton Maria F.1ORCID,Brown Louise A.E.1ORCID,Gierula John1,Chew Pei G.1ORCID,Das Arka1,Sengupta Anshuman2,Craven Thomas P.1,Chowdhary Amrit1,Koshy Aaron1,White Hazel3,Levelt Eylem1,Dall’Armellina Erica1,Garg Pankaj4ORCID,Witte Klaus K.1ORCID,Greenwood John P.1,Plein Sven1,Swoboda Peter P.1ORCID

Affiliation:

1. Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.E.D.S., M.F.P., L.A.E.B., J.G., P.G.C., A.D., T.P.C., A.C., A.K., E.L., E.D., K.K.W., J.P.G., S.P., P.P.S.).

2. Department of Cardiology, Leeds Teaching Hospitals NHS Trust, United Kingdom (A.S.).

3. Department of Cardiology, Mid Yorkshire Hospitals NHS Trust, Wakefield, West Yorkshire, United Kingdom (H.W.).

4. Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, United Kingdom (P.G.).

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/m 2 ; 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/m 2 ; 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.

Publisher

Ovid Technologies (Wolters Kluwer Health)

Subject

Cardiology and Cardiovascular Medicine,Radiology, Nuclear Medicine and imaging

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