Incidence and predictors of right ventricular pacing-induced cardiomyopathy in patients with complete atrioventricular block and preserved left ventricular systolic function

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• 作者：Erich L. Kiehl ; MD^* ; Tarek Makki ; MD^&dagger ; ; Rahul Kumar ; MD^&dagger ; ; Divya Gumber ; MD^&dagger ; ; Deborah H. Kwon ; MD^&Dagger ; ; John W. Rickard ; MD ; FHRS^§ ; ; Mohamed Kanj ; MD ; FHRS^§ ; ; Oussama M. Wazni ; MD ; FHRS^§ ; ; Walid I. Saliba ; MD ; FHRS^§ ; ; Niraj Varma ; MD ; FHRS^§ ; ; Bruce L. Wilkoff ; MD ; FHRS^§ ; ; Daniel J. Cantillon ; MD ; FHRS^§ ; ; ^{cantild@ccf.org" class="auth_mail" title="E-mail the corresponding author}
• 关键词：Atrioventricular block ; Cardiac resynchronization therapy ; Cardiomyopathy ; Complete heart block ; Ejection fraction ; Heart failure ; Incidence ; Pacing ; Pacing-induced cardiomyopathy ; Predictors
• 刊名：Heart Rhythm
• 出版年：2016
• 出版时间：December 2016
• 年：2016
• 卷：13
• 期：12
• 页码：2272-2278
• 全文大小：806 K

文摘

Right ventricular (RV) pacing may worsen left ventricular cardiomyopathy in patients with reduced left ventricular ejection fraction (LVEF) and advanced atrioventricular block.

Objective

The objectives of this study were to calculate incidence and identify predictors of RV pacing-induced cardiomyopathy (PICM) in complete heart block (CHB) with preserved LVEF and to describe outcomes of subsequent cardiac resynchronization therapy (CRT) upgrade.

Methods

An analysis of consecutive patients receiving permanent pacemaker (PPM) from 2000 to 2014 for CHB with LVEF >50% was performed. PICM was defined as CRT upgrade or post-PPM LVEF ≤40%. PICM association was determined via multivariable regression analysis. CRT response was defined by LVEF increase ≥10% or left ventricular end-systolic volume decrease ≥15%.

Results

Of the 823 study patients, 101 (12.3%) developed PICM over the mean follow-up of 4.3 ± 3.9 years, with post-PPM LVEF being 33.7% ± 7.4% in patients with PICM vs 57.6% ± 6.1% in patients without PICM (P < .001). In multivariable analysis, lower pre-PPM LVEF (hazard ratio [HR] 1.047 per 1% LVEF decrease; 95% confidence interval [CI] 1.002–1.087; P = .042) and RV pacing % both as a continuous (HR 1.011 per 1% RV pacing; 95% CI 1.002–1.02; P = .021) and as a categorical (<20% or ≥20% RV pacing) (HR 6.76; 95% CI 2.08–22.0; P = .002) variable were independently associated with PICM. Only 29 patients with PICM (28.7%) received CRT upgrade despite an 84% responder rate (LVEF increase 18.5% ± 8.1% and left ventricular end-systolic volume decrease 45.1% ± 15.0% in responders). CRT upgrade was associated with greater post-PPM LVEF decrease, lower post-PPM LVEF, and post-PPM LVEF ≤35% (P = .006, P = .004, and P = .004, respectively).

Conclusion

PICM is not uncommon in patients receiving PPM for CHB with preserved LVEF and is strongly associated with RV pacing burden >20%. CRT response rate is high in PICM, but is perhaps underutilized.