Pre-implant global longitudinal strain as an early sign of pacing-induced cardiomyopathy in patients with complete atrioventricular block

Abstract

Introduction: Long-term right ventricular pacing is the only treatment for patients with a complete atrioventricular block (CAVB); however, it frequently triggers ventricular dys-synchrony with left ventricular (LV) dysfunction. Previous studies showed that an early decline of LV global longitudinal strain (GLS) predicts pacing-induced LV dysfunction. We aimed to investigate the potential ability of the initial LV strain to predict pacing-induced cardiomyopathy (PICM) through long-term follow-ups.

Methods: We retrospectively enrolled 80 patients with CAVB with normal LV function who were implanted with dual-chamber pacemakers between 2008 and 2018. Echocardiographic data and parameters (including longitudinal, radial, and circumferential strain based on speckle-tracking) were analyzed for the pre-implant (≤6 months) and post-implant periods. PICM was defined as a ≥10% reduction in the left ventricular ejection fraction (LVEF) resulting in an LVEF of <50% during the post-implant period. Predictors of PICM were identified using Cox proportional hazard models.

Results: Patients who developed PICM were more likely to exhibit lower baseline LV GLS, as well as wider native and pacing QRS durations, than those who did not develop PICM (P = .016, P = .011, and P = .026, respectively). In the multivariate analysis, pre-implant LV GLS (hazard ratio: 1.27; 95% confidence interval 1.009-1.492; P = .004) was independently associated with the development of PICM.

Conclusion: A lower baseline LV GLS predicts an increased risk of PICM. Patients with CAVB exhibiting low GLS are at increased risk of PICM. More frequent follow-up visits are warranted in these patients, who may also require de novo His-bundle pacing or an upgrade to biventricular pacing.

Keywords: cardiomyopathy; left ventricular function; myocardial strain.

Conflict of interest statement

None declared.

© 2021 The Authors. Echocardiography published by Wiley Periodicals LLC.

Figures

Figure 1

Patient flowchart after pacemaker implantation. AV = atrioventricular; LVEF = left ventricular ejection fraction; MI = myocardial infarct; MV = mitral valve; PICM = pacing‐induced cardiomyopathy

Figure 2

Left ventricular ejection fraction decreased from 70.5% (interquartile range 64.3–73.0) to 46.0% (interquartile range 33.5–48.0) in patients with pacing‐induced cardiomyopathy

Figure 3

Two representative cases of initial LV GLS values. The initial LV GLS of patient (A) without PICM was −19.9%, while the LVEF was 65%. The initial LV GLS of patient (B) with PICM was −12.4%, although the initial LVEF was 64%. LVEF = left ventricular ejection fraction; LV GLS = left ventricular global longitudinal strain; PICM = pacing‐induced cardiomyopathy

Figure 4

With a global longitudinal peak systolic strain (GLPSS) cutoff value of

Figure 5

Kaplan–Meier curve showed no significant difference between the two groups. However, pacing‐induced cardiomyopathy tended to occur more frequently in patients with a global longitudinal strain