Effect of Right Ventricular Pacing on Right Ventricular Mechanics and Tricuspid Regurgitation in Patients With High-Grade Atrioventricular Block and Sinus Rhythm (from the Protection of Left Ventricular Function During Right Ventricular Pacing Study)

Published:October 05, 2015DOI:
      Right ventricular (RV) pacing has been linked with lead-induced tricuspid regurgitation (TR), left ventricular (LV) dysfunction, and dyssynchrony, but the effect of pacing on RV function is unclear. We sought to investigate the effect of pacing on RV synchrony, RV function, and TR, and their association with LV function. In this substudy of the PROTECT-PACE (Protection of left ventricular function during right ventricular pacing) study of the effects of RV pacing in patients with preserved ejection fraction, 145 patients (76 RV apex and 69 non-RV apex pacing) had measurable RV parameters. We assessed tricuspid annular plane systolic excursion (TAPSE), time difference between peak TAPSE and peak mitral annular plane systolic excursion (TM-APSE-dif), global LV longitudinal strain, E/e’, TR vena contracta, and TR peak gradient. Echocardiography was performed just after implantation and at 2 years. TR parameters significantly worsened after 2 years, but pacing site was not associated with changes in RV and TR parameters. No temporal change in TAPSE and TM-APSE-dif was observed overall, but worsening of TM-APSE-dif was associated with worsening TAPSE. Global longitudinal strain and E/e’ both deteriorated over 2 years; these changes were significantly associated. In a multivariate regression, worsening global longitudinal strain and worsening TM-APSE-dif were significantly associated with deterioration of TAPSE. Furthermore, increased E/e’ and its deterioration were associated with worsening TR vena contracta and TR peak gradient, respectively. Decreased TAPSE was also associated with deterioration of TR vena contracta. In conclusion, RV pacing appears to worsen TR, an effect which might be caused by elevated LV filling pressure due to LV dysfunction. In this study, RV pacing did not affect RV function during 2-year follow-up, but such an effect might occur if RV dyssynchrony or LV dysfunction occurred after pacing. The effect of RV pacing site on RV and TR mechanics was minor.
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        • Wilkoff B.L.
        • Cook J.R.
        • Epstein A.E.
        • Greene H.L.
        • Hallstrom A.P.
        • Hsia H.
        • Kutalek S.P.
        • Sharma A.
        Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial.
        JAMA. 2002; 288: 3115-3123
        • Sweeney M.O.
        • Hellkamp A.S.
        • Ellenbogen K.A.
        • Greenspon A.J.
        • Freedman R.A.
        • Lee K.L.
        • Lamas G.A.
        Adverse effect of ventricular pacing on heart failure and atrial fibrillation among patients with normal baseline QRS duration in a clinical trial of pacemaker therapy for sinus node dysfunction.
        Circulation. 2003; 107: 2932-2937
        • Zhang X.H.
        • Chen H.
        • Siu C.W.
        • Yiu K.H.
        • Chan W.S.
        • Lee K.L.
        • Chan H.W.
        • Lee S.W.
        • Fu G.S.
        • Lau C.P.
        • Tse H.F.
        New-onset heart failure after permanent right ventricular apical pacing in patients with acquired high-grade atrioventricular block and normal left ventricular function.
        J Cardiovasc Electrophysiol. 2008; 19: 136-141
        • Shimony A.
        • Eisenberg M.J.
        • Filion K.B.
        • Amit G.
        Beneficial effects of right ventricular non-apical vs. apical pacing: a systematic review and meta-analysis of randomized-controlled trials.
        Europace. 2012; 14: 81-91
        • Ahmed M.
        • Gorcsan 3rd, J.
        • Marek J.
        • Ryo K.
        • Haugaa K.
        • R Ludwig D.
        • Schwartzman D.
        Right ventricular apical pacing-induced left ventricular dyssynchrony is associated with a subsequent decline in ejection fraction.
        Heart Rhythm. 2014; 11: 602-608
        • Chen J.Y.
        • Tsai W.C.
        • Liu Y.W.
        • Li W.H.
        • Li Y.H.
        • Tsai L.M.
        • Lin L.J.
        Long-term effect of septal or apical pacing on left and right ventricular function after permanent pacemaker implantation.
        Echocardiography. 2013; 30: 812-819
        • Porapakkham P.
        • Assavahanrit J.
        • Kijsanayotin B.
        • Shing K.W.
        Impact of right ventricular pacing on right ventricular function.
        J Med Assoc Thai. 2012; 95: S44-S50
        • Nunes M.C.
        • Abreu C.D.
        • Ribeiro A.L.
        • Barbosa M.M.
        • Rincon L.G.
        • Reis R.C.
        • Rocha M.O.
        Effect of pacing-induced ventricular dyssynchrony on right ventricular function.
        Pacing Clin Electrophysiol. 2011; 34: 155-162
        • Friedberg M.K.
        • Dubin A.M.
        • Van Hare G.F.
        • McDaniel G.M.
        • Niksch A.
        • Rosenthal D.N.
        Pacing-induced electromechanical ventricular dyssynchrony does not acutely influence right ventricular function and global hemodynamics in children with normal hearts.
        J Cardiovasc Electrophysiol. 2009; 20: 539-544
        • Friedberg M.K.
        • Redington A.N.
        Right versus left ventricular failure: differences, similarities, and interactions.
        Circulation. 2014; 129: 1033-1044
        • Mediratta A.
        • Addetia K.
        • Yamat M.
        • Moss J.D.
        • Nayak H.M.
        • Burke M.C.
        • Weinert L.
        • Maffessanti F.
        • Jeevanandam V.
        • Mor-Avi V.
        • Lang R.M.
        3D echocardiographic location of implantable device leads and mechanism of associated tricuspid regurgitation.
        JACC Cardiovasc Imaging. 2014; 7: 337-347
        • Hoke U.
        • Auger D.
        • Thijssen J.
        • Wolterbeek R.
        • van der Velde E.T.
        • Holman E.R.
        • Schalij M.J.
        • Bax J.J.
        • Delgado V.
        • Marsan N.A.
        Significant lead-induced tricuspid regurgitation is associated with poor prognosis at long-term follow-up.
        Heart. 2014; 100: 960-968
        • Al-Mohaissen M.A.
        • Chan K.L.
        Prevalence and mechanism of tricuspid regurgitation following implantation of endocardial leads for pacemaker or cardioverter-defibrillator.
        J Am Soc Echocardiogr. 2012; 25: 245-252
        • Seo Y.
        • Ishizu T.
        • Nakajima H.
        • Sekiguchi Y.
        • Watanabe S.
        • Aonuma K.
        Clinical utility of 3-dimensional echocardiography in the evaluation of tricuspid regurgitation caused by pacemaker leads.
        Circ J. 2008; 72: 1465-1470
        • Lin G.
        • Nishimura R.A.
        • Connolly H.M.
        • Dearani J.A.
        • Sundt 3rd, T.M.
        • Hayes D.L.
        Severe symptomatic tricuspid valve regurgitation due to permanent pacemaker or implantable cardioverter-defibrillator leads.
        J Am Coll Cardiol. 2005; 45: 1672-1675
        • Kaye G.C.
        • Linker N.J.
        • Marwick T.H.
        • Pollock L.
        • Graham L.
        • Pouliot E.
        • Poloniecki J.
        • Gammage M.
        Effect of right ventricular pacing lead site on left ventricular function in patients with high-grade atrioventricular block: results of the Protect-Pace study.
        Eur Heart J. 2014; 36: 856-862
        • Lang R.M.
        • Bierig M.
        • Devereux R.B.
        • Flachskampf F.A.
        • Foster E.
        • Pellikka P.A.
        • Picard M.H.
        • Roman M.J.
        • Seward J.
        • Shanewise J.S.
        • Solomon S.D.
        • Spencer K.T.
        • Sutton M.S.
        • Stewart W.J.
        • Chamber Quantification Writing Group; American Society of Echocardiography's Guidelines and Standards Committee; European Association of Echocardiography
        Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology.
        J Am Soc Echocardiogr. 2005; 18: 1440-1463
        • Nagueh S.F.
        • Appleton C.P.
        • Gillebert T.C.
        • Marino P.N.
        • Oh J.K.
        • Smiseth O.A.
        • Waggoner A.D.
        • Flachskampf F.A.
        • Pellikka P.A.
        • Evangelista A.
        Recommendations for the evaluation of left ventricular diastolic function by echocardiography.
        J Am Soc Echocardiogr. 2009; 22: 107-133
        • Rudski L.G.
        • Lai W.W.
        • Afilalo J.
        • Hua L.
        • Handschumacher M.D.
        • Chandrasekaran K.
        • Solomon S.D.
        • Louie E.K.
        • Schiller N.B.
        Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography.
        J Am Soc Echocardiogr. 2010; 23: 685-713
        • Singh J.P.
        • Evans J.C.
        • Levy D.
        • Larson M.G.
        • Freed L.A.
        • Fuller D.L.
        • Lehman B.
        • Benjamin E.J.
        Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study).
        Am J Cardiol. 1999; 83: 897-902
        • Zoghbi W.A.
        • Enriquez-Sarano M.
        • Foster E.
        • Grayburn P.A.
        • Kraft C.D.
        • Levine R.A.
        • Nihoyannopoulos P.
        • Otto C.M.
        • Quinones M.A.
        • Rakowski H.
        • Stewart W.J.
        • Waggoner A.
        • Weissman N.J.
        Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography.
        J Am Soc Echocardiogr. 2003; 16: 777-802
        • Grayburn P.A.
        • Appleton C.P.
        • DeMaria A.N.
        • Greenberg B.
        • Lowes B.
        • Oh J.
        • Plehn J.F.
        • Rahko P.
        • St John Sutton M.
        • Eichhorn E.J.
        Echocardiographic predictors of morbidity and mortality in patients with advanced heart failure: the Beta-blocker Evaluation of Survival Trial (BEST).
        J Am Coll Cardiol. 2005; 45: 1064-1071
        • Mor-Avi V.
        • Lang R.M.
        • Badano L.P.
        • Belohlavek M.
        • Cardim N.M.
        • Derumeaux G.
        • Galderisi M.
        • Marwick T.
        • Nagueh S.F.
        • Sengupta P.P.
        • Sicari R.
        • Smiseth O.A.
        • Smulevitz B.
        • Takeuchi M.
        • Thomas J.D.
        • Vannan M.
        • Voigt J.U.
        • Zamorano J.L.
        Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on methodology and indications endorsed by the Japanese Society of Echocardiography.
        J Am Soc Echocardiogr. 2011; 24: 277-313
        • Saito M.
        • Kaye G.
        • Negishi K.
        • Linker N.
        • Gammage M.
        • Kosmala W.
        • Marwick T.H.
        Dyssynchrony, contraction efficiency and regional function with apical and non-apical RV pacing.
        Heart. 2015; 101: 600-608
        • Vaturi M.
        • Kusniec J.
        • Shapira Y.
        • Nevzorov R.
        • Yedidya I.
        • Weisenberg D.
        • Monakier D.
        • Strasberg B.
        • Sagie A.
        Right ventricular pacing increases tricuspid regurgitation grade regardless of the mechanical interference to the valve by the electrode.
        Eur J Echocardiogr. 2010; 11: 550-553
        • Osmancik P.
        • Stros P.
        • Herman D.
        • Curila K.
        • Petr R.
        The insufficiency of left anterior oblique and the usefulness of right anterior oblique projection for correct localization of a computed tomography-verified right ventricular lead into the midseptum.
        Circ Arrhythm Electrophysiol. 2013; 6: 719-725
        • Kalam K.
        • Otahal P.
        • Marwick T.H.
        Prognostic implications of global LV dysfunction: a systematic review and meta-analysis of global longitudinal strain and ejection fraction.
        Heart. 2014; 100: 1673-1680
        • de Agustin J.A.
        • Viliani D.
        • Vieira C.
        • Islas F.
        • Marcos-Alberca P.
        • Gomez de Diego J.J.
        • Nunez-Gil I.J.
        • Almeria C.
        • Rodrigo J.L.
        • Luaces M.
        • Garcia-Fernandez M.A.
        • Macaya C.
        • Perez de Isla L.
        Proximal isovelocity surface area by single-beat three-dimensional color Doppler echocardiography applied for tricuspid regurgitation quantification.
        J Am Soc Echocardiogr. 2013; 26: 1063-1072