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Baseline Echocardiographic Parameters Associated With Post-Pacing Cardiomyopathy in Patients With Normal Left
Andrew E Volio1, Katelyn R Bennett1, Nicholas W Bradley2
1Section of Cardiology, Department of Internal Medicine, OhioHealth Doctors Hospital, Columbus, USA.
Insights
Patients with atrioventricular (AV) block receiving dual-chamber pacemakers (DCPM) may develop post-pacing cardiomyopathy (PPCMP). Larger left atrial (LA) size and signs of diastolic dysfunction before implantation are linked to increased PPCMP risk.
Area of Science:
- Cardiology
- Cardiac Electrophysiology
- Echocardiography
Background:
- Dual-chamber pacemaker (DCPM) implantation is standard for atrioventricular (AV) block with preserved left ventricular ejection fraction (LVEF > 50%).
- The risk of post-pacing cardiomyopathy (PPCMP) in this population is not fully understood, particularly concerning baseline echocardiographic predictors.
- Identifying these predictors is crucial for risk stratification and optimizing pacing strategies.
Purpose of the Study:
- To identify preimplant echocardiographic parameters associated with the development of PPCMP.
- To investigate the relationship between baseline diastolic function markers and PPCMP in patients undergoing DCPM for AV block.
Main Methods:
- Retrospective analysis of 111 patients with AV block who underwent DCPM implantation.
- PPCMP defined as a 10% LVEF reduction or LVEF < 50% with ≥ 20% ventricular pacing.
- Analysis of preimplant echocardiographic parameters including left atrial (LA) dimension and E/e' ratios.
Main Results:
- 41% of patients developed PPCMP over a mean follow-up of 4 years.
- Patients who developed PPCMP had significantly larger preimplant LA dimensions and LA index.
- Larger LA size correlated with higher E/e' ratios and was independently associated with increased risk of heart failure admissions.
Conclusions:
- Pre-existing left ventricular diastolic dysfunction, indicated by larger LA size and elevated E/e' ratios, is strongly associated with PPCMP development.
- These echocardiographic findings may help identify high-risk patients.
- Consideration of alternative pacing strategies like biventricular or conduction system pacing might mitigate PPCMP risk in these individuals.
Abstract:
In patients with atrioventricular (AV) block and left ventricular ejection fraction (LVEF) of > 50%, dual-chamber pacemaker (DCPM) implantation remains the standard of care. However, in this population the relationship between other baseline echocardiographic parameters and the development of post-pacing cardiomyopathy (PPCMP) remains poorly defined.
Objective:
To identify preimplant echocardiographic parameters associated with the development of PPCMP in patients with normal LVEF undergoing DCPM implantation for AV block.
Methods:
Among 140 consecutive patients who underwent DCPM implant for AV block between January 1st 2016 and December 31st, 2019, data from 111 patients with available follow-up through December 31, 2024, was retrospectively analyzed. PPCMP was defined as a 10% reduction in LVEF and/or absolute LVEF < 50% with an average ventricular pacing burden of ≥ 20%.
Results:
Of 140 patients, 111 with complete data were included (mean age: 76 ± 10 years; 55% male and 88% white). Preimplant LVEF was 61 ± 4% with echocardiogram performed 2(0-26) days before DCPM implant. Over a mean follow-up of 4 ± 2.3 years, 46 patients (41%) developed PPCMP (LVEF%: 45[35-50] vs 62[58-64]; p < 0.001). Preimplant left atrial (LA) dimension (cm; 4.3[3.8-4.5] vs 3.8[3.5-4.3]; p = 0.03) and LA dimension index (mL/m2; 38 ± 12 vs 32 ± 11; p = 0.008) were larger in patients who developed PPCMP. Among PPCMP patients, LVEF reduction correlated inversely with mitral annular septal and lateral E/e' ratios (r = -0.33, p = 0.03 and r = -0.34, p = 0.04, respectively), early diastolic mitral inflow velocity (r = -0.34, p = 0.02) and LA size (r = -0.35, p = 0.01). Larger LA size also correlated with higher E/e' ratios (r = 0.4, p < 0.02) but not with history of AF, HTN, obesity and mitral valve disease. In multivariable regression analyses, each 1-cm increase in LA size was associated with a 5.54-fold higher hazard of first heart failure (HF) admission (Cox, p = 0.0008) and a ~125% increase in total HF admissions (Poisson, p = 0.006) during the study period.
Conclusion:
Among patients with normal LV systolic function undergoing DCPM for AV block, pre-existing LV diastolic dysfunction, reflected by larger LA size, elevated E/e' ratios, and higher early diastolic mitral inflow velocity, is strongly associated with development of PPCMP. Preimplant recognition of these parameters may help identify patients who would benefit from upfront biventricular or conduction system pacing to mitigate the risk of PPCMP.
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