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Pacing-Induced Cardiomyopathy in Leadless and Traditional Pacemakers: A Single-Center Retrospective Analysis

Khalid Saeed Al-Asad¹, Adolfo Martinez¹, Rohan M Prasad²

¹Department of Internal Medicine, Michigan State University, East Lansing, USA.

|July 7, 2023

Insights

Leadless pacemakers (LPs) and transvenous pacemakers (TVPs) showed similar rates of pacing-induced cardiomyopathy (PICM), with 44% of LP patients and 37% of TVP patients developing the condition. No significant difference in cardiac resynchronization therapy (CRT) upgrade was observed between the two pacemaker types.

Area of Science:

Cardiology
Biomedical Engineering
Medical Device Technology

Background:

Pacing-induced cardiomyopathy (PICM) is a decline in left ventricular ejection fraction (LVEF) caused by chronic, high-burden right ventricular (RV) pacing.
Leadless pacemakers (LPs) are hypothesized to reduce PICM risk compared to transvenous pacemakers (TVPs), but the extent of this risk reduction remains unclear.

Purpose of the Study:

To compare the incidence of PICM and the need for cardiac resynchronization therapy (CRT) upgrade between patients receiving LPs and TVPs.
To investigate the relationship between RV pacing burden and PICM development in patients with LPs and TVPs.

Main Methods:

A retrospective analysis of 198 adult patients who received either an LP or TVP between 2014 and 2022.
Echocardiograms were used to assess changes in LVEF before and after pacemaker implantation.
RV pacing percentage and a calculated 'RV time' (RV pacing percentage multiplied by follow-up duration) were used as measures of pacing burden.

Main Results:

The incidence of PICM was 44% in the LP group and 37% in the TVP group (p=0.3).
The need for CRT upgrade was similar between groups (9.7% for LP vs. 9.5% for TVP, p>0.9).
Patients with LPs had significantly more RV time (13.54 ± 14.21 months) compared to TVP patients (9.26 ± 13.95 months) (p=0.009).

Conclusions:

This study found a high incidence of PICM in both LP and TVP groups, with no significant difference between them.
Despite greater RV pacing time in the LP group, PICM rates were comparable to the TVP group.
No difference in CRT upgrade rates was observed between LP and TVP recipients.

Read full analysis

Abstract

Background:

Pacing-induced cardiomyopathy (PICM) is a clinical syndrome that is characterized by a drop in the left ventricular ejection fraction (LVEF) due to chronic high-burden right ventricular (RV) pacing. It has been postulated that leadless pacemakers (LPs) cause decreased risk of PICM compared to transvenous pacemakers (TVPs), but the exact risk reduction is unknown.

Methods:

We performed a single-center retrospective analysis of adults who received an LP or TVP between January 1, 2014, and April 1, 2022, and had echocardiograms before and after the pacemaker implant. This study's outcomes were the RV pacing percentage, change in EF, the need for cardiac resynchronization therapy (CRT) upgrade, and follow-up duration. A Wilcoxon rank-sum test calculated the change in EF. RV time, defined as the duration from pacemaker placement to the follow-up echocardiogram in months multiplied by the RV pacing percentage, served as a surrogate for how long the RV was paced.

Results:

A total of 614 patients were screened, and 198 patients were included in the study, where 72 received LP and 126 received TVP. The median follow-up was 480 days. The average of the reported RV percentage pacing was 63.43% for LP and 71.30% for TVP (p=0.14). The incidence of PICM and CRT upgrade was 44% and 9.7% in the LP group and 37% and 9.5% in the TVP group (p=0.3 and p>0.9), respectively. After accounting for age, sex, LP versus TVP, atrioventricular nodal ablation, RV pacing percentage, and follow-up duration, univariate analysis showed that RV time was significantly different between the two types of pacemakers (13.54 ± 14.21 months (LP) versus 9.26 ± 13.95 months (TVP), p=0.009). The difference in RV time between patients who underwent CRT upgrade and those who did not was statistically insignificant (12.11 ± 14.47 months (no CRT) versus 9.19 ± 12.00 months (CRT), p=0.5).

Conclusions:

This analysis demonstrated that the incidence of PICM was high in both groups (44% (LP) versus 37% (TVP)), despite significantly more RV time in patients with LP. There was no difference in CRT upgrade between LP and TVP.

Keywords:

cardiac resynchronization therapy (crt)leadless pacemaker pacing-induced cardiomyopathy right ventricular time transvenous pacemaker

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