Three-dimensional echocardiography with left ventricular strain analyses helps earlier prediction of right ventricular pacing-induced cardiomyopathy

Right ventricular (RV) pacing can lead to progressive ventricular dysfunction over a certain period. This pacemaker-induced cardiomyopathy (PiCMP) may be more common than previously reported. Speckle tracking imaging is a recent development in echocardiography that can identify left ventricular (LV) dysfunction even before the LV ejection fraction (LVEF) value decreases. Three-dimensional (3D) echocardiography has made more accurate assessment of LVEF possible. The objectives of this study are to study the incidence of RV PiCMP using 3D echocardiography and LV strain analysis over a follow-up of 6 months, and to identify its predictors.

This is an observational study of consecutive patients without structural heart disease and with a baseline EF of more than 45% who received a permanent pacemaker. They were observed over a 6-month period. PiCMP was defined as a decrease in LVEF by 10 percentage points or a decrease in LV strain by 15% from baseline in the absence of other known causes of cardiomyopathy. PiCMP incidence and its associations were analyzed over a 6-month period.

The incidence of PiCMP was not only significant over a period of 6 months but also at 24 hours. Significant drops in 3D EF were noted in one (2.8%) patient at 24 hours and in another four (11.1%) patients at 6 months. A significant decrease in LV global longitudinal strain was noted in 23 (63.9%) patients by 6 months. In seven of these patients, there was significant decrease in global longitudinal strain 24 hours after implantation. In analyzing longitudinal strain, the parameter significantly influencing a decrease was a pacing percentage of ≥20% (p = 0.023).

PiCMP is not uncommon in patients undergoing pacemaker implantation and is associated with RV pacing. PiCMP was associated with a ventricular pacing percentage of ≥20%. 3D echocardiography with LV strain analysis plays a vital role in identifying LV dysfunction at an earlier stage compared to EF. PiCMP, if picked up and intervened upon early, can help impede its progression.