|Year : 2020 | Volume
| Issue : 2 | Page : 171-175
Value of Speckle Tracking Echocardiography as a Predictor of the Deleterious Effect of Right Ventricular Pacing on Left Ventricular Function
Samir Rafla, Amr Zaki, Aly Aboelhoda, Moustafa Sappaq, Gehan Magdy
Department of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
|Date of Submission||20-Mar-2020|
|Date of Decision||04-May-2020|
|Date of Acceptance||21-Jun-2020|
|Date of Web Publication||19-Aug-2020|
Prof. Samir Rafla
Department of Cardiology, Faculty of Medicine, Alexandria University, Alexandria
Source of Support: None, Conflict of Interest: None
Background: Pacemaker-induced cardiomyopathy (PICM) is reported in different articles but with variable incidence. Aim: The aim of the study is to determine the validity of speckle tracking echocardiography as a predictor of the deleterious effect of right ventricular (RV) pacing on left ventricular (LV) function, using two-dimensional guided global and segmental longitudinal strain. Materials and Methods: Fifty patients with conventional indications for permanent pacemaker implantation were studied; they were classified to Group A (37 = 74%) patients who didn't show a significant reduction of ejection fraction (EF) (>10%) and Group B (13 = 26%) represent patients who showed a significant reduction of EF. Group C constituted 25 healthy persons (control group). We defined PICM when EF is reduced >10%. Results: The incidence of pacemaker-induced ventricular dysfunction was 26%. Statistical analysis revealed that left atrial volume index (LAVI), global longitudinal strain (GLS), native-QRS duration, and ischemic heart disease were significant predictors of reduction of LV function, however, on multivariate regression analysis, only the LAVI and GLS were independent predictors of reduction of LVEF after permanent pacing. Conclusions: Speckle tracking echocardiography is a new, unique and evolving tool to assess the myocardial deformation which can detect LV systolic dysfunction much earlier than can be reflected in LVEF. The importance of defining predictors is to predict whom patient will be at risk for the deleterious effect of RV pacing on LV function, and who will need observation with possible upgrading to biventricular pacing.
Keywords: Global longitudinal strain, pacemaker-induced cardiomyopathy, right ventricular pacing, speckle tracking
|How to cite this article:|
Rafla S, Zaki A, Aboelhoda A, Sappaq M, Magdy G. Value of Speckle Tracking Echocardiography as a Predictor of the Deleterious Effect of Right Ventricular Pacing on Left Ventricular Function. J Indian Acad Echocardiogr Cardiovasc Imaging 2020;4:171-5
|How to cite this URL:|
Rafla S, Zaki A, Aboelhoda A, Sappaq M, Magdy G. Value of Speckle Tracking Echocardiography as a Predictor of the Deleterious Effect of Right Ventricular Pacing on Left Ventricular Function. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2020 [cited 2020 Oct 26];4:171-5. Available from: https://www.jiaecho.org/text.asp?2020/4/2/171/292619
| Introduction|| |
Pacemaker-induced cardiomyopathy (PICM) is reported in different articles but with variable incidence depending on definitions, methods, and substrates. Multiple studies had been done to assess the validity of global longitudinal strain (GLS) for detecting subclinical left ventricular (LV) dysfunction and its role as a predictor of the outcome on different cardiac conditions, including the effect of right ventricular (RV) pacing on LV function.,,,,,,,,,,,,,,,,,,
Aim of the work
The aim was to assess the validity of speckle tracking echocardiography as a predictor of the deleterious effect of RV pacing on LV function.
| Methods|| |
The study included fifty patients scheduled for permanent RV pacing and 25 healthy controls served as a control group for the echocardiographic measurements.
Inclusion criteria: Patients with conventional indications for permanent RV pacing and ejection fraction (EF) ≥50%. Exclusion criteria: (1) Baseline EF of <50%, (2) patients with RV pacing <40% of the time on follow-up, (3) acute coronary syndrome and/or coronary revascularization within 3 months before enrollment to 6 months after enrollment, (4) new-onset myocarditis during follow-up, and (5) atrial fibrillation.
All patients were subjected to the following: (1) Sign an informed consent after explanation of procedures and possible complications to the patient; (2) preimplantation assessment: history taking and clinical examination; NYHA functional class; resting, 12-lead electrocardiography (ECG): QRS duration, morphology, and axis; (3) echocardiography:,
- LVEF: LVEF (modified Simpson's method)
- LVEDD: LV end-diastolic dimension by using M-mode. LVEDV: LV end diastolic volume by using the biplane disk summation method. LVESD: LV end systolic dimension by using M-mode. LVESV: LV end systolic volume by using the biplane disk summation method.
- Left atrial dimensions and volume and by using the biplane method. Mitral valve regurgitation evaluation if present
- Peak systolic GLS using speckle tracking echocardiography, ECG-gated images were obtained in apical long-axis, four- and two-chamber views at the frame rate of 50–70/s and stored digitally. EF was calculated from tracing the endocardial border. Segmental strain was presented as a bull-eye map and GLS was automatically calculated ,
- Implantation data: Pacing mode, site of RV lead implantation
- Follow-up: Follow-up done after 6 months for the assessment of (a) NYHA functional classification; (b) evidence of HF by clinical examination; (c) resting, 12-lead ECG: QRS duration, morphology, and axis; (d) device interrogation for assessment of the percentage of RV pacing.
(a) Echocardiography after 6 months of implantation: LVEF, LVEDD, LVEDV, LVESD, LVESV left atrial volume, and dimensions, Mitral valve regurgitation evaluation if present. (b) After follow-up, the patients were classified to Groups A and B according to follow-up EF. Group A represents patients who did not show a significant reduction of EF at follow-up and Group B represents patients who showed a reduction of EF >10% from baseline measurement.
The ultrasonography system: Philips IE33
Statistical analysis of the study data: Data were fed to the computer and analyzed using the IBM SPSS software package version 20.0. (IBM Corp., Armonk, NY, USA). The used tests were: (1) Chi-square test, (2) Fisher's exact or Monte Carlo correction, (3) paired t-test, and (4) ANOVA with repeated measures.
| Results|| |
Patients were classified at 6-month follow-up post pacemaker implantation for Group A and B, Group A (37 patients (74%)) represents patients who did not show a significant reduction of (EF) from baseline measurement and Group B (13 patients [26%]) represents patients who showed reduction of EF >10% from baseline measurement as described below: Group C represents the control group of healthy individuals with no pacemaker implantation [Table 1], [Table 2], [Table 3].
|Table 1: Comparison between the two studied groups according to change on ejection fraction (%); end-systolic dimension; end diastolic dimension; end-systolic volume|
Click here to view
|Table 2: Comparison between the three studied groups according to global longitudinal strain|
Click here to view
|Table 3: Comparison between the two studied groups according to L-AT volume|
Click here to view
Type of pacing and site of pacing
- Cardiac pacing data: Indication: Sick sinus syndrome 5 (10%); AV block 45 (90%)
- Type of pacing: DDD 45% (90%); VVI 5 (10%)
- Site of pacing: Apical 49 (98%); septal 1 (2%).
In the current study, we used the term pacemaker induced ventricular dysfunction (PIVD) to represent the deleterious effect of RV pacing on LV function, and it was defined as the reduction of EF >10% from baseline. The incidence of PIVD on our study was 26%, but also 10% of our cohort showed a reduction of EF >10% to reach EF <50% [Figure 1], [Figure 2], [Figure 3], [Figure 4].
|Figure 1: Two-dimensional speckle tracking echocardiography, apical three-chamber view. Patient number 23|
Click here to view
|Figure 2: Two-dimensional speckle tracking echocardiography, apical four-chamber view. Patient number 23|
Click here to view
|Figure 3: Two-dimensional speckle tracking echocardiography, apical two-chamber view. Patient number 23|
Click here to view
|Figure 4: Two-dimensional speckle tracking echocardiography, peak systolic strain. Patient number 23|
Click here to view
As regard age and gender, there was no statistically significant difference. The prevalence of different diseases was not significant, except for the prevalence of ischemic heart disease (IHD), which was more in the reduction group.
The baseline EF mean values were 65.47 ± 5.36, 64.15 ± 6.49, and 62.36 ± 3.29 for Groups A, B, and C, respectively; there was no significant difference between the three studied groups.
As regards the baseline ESD, there was no significant difference and at follow-up, there was a significant difference. As regards the baseline EDD, there was no significant difference and at follow-up, there was no significant difference between Groups A and B.
As regards the baseline left atrial volume index (LAVI), there was a significant difference. At follow-up the LAVI values were higher than the baseline in both groups. The presence of mitral regurgitation was not significant statistically.
There was a significant difference between the three studied groups in GLS. The segmental strain values of cases were smaller than the control group. In addition, the patient's segmental strain values showed a significant statistical difference between Group A and B on the API, MIS, BI, BIL, BIS, MI, MAS, MA, MAL, and BAL segments.
As regards the indications, type of pacing, and site of pacing, there was no significant statistical difference. As regard the percentage of pacing, there was a significant difference.
There was a significant difference in native QRS duration. The paced QRS duration did not show a significant difference.
As regards arrhythmias, there was no significant difference. As regards the medical treatment used during the period of research, it did not show significant difference statistically. The NYHA functional class did not show a significant difference at baseline, but it showed a significant difference at follow-up. As regards the clinical evidence of heart failure, there was no statistical difference at baseline, but at follow-up, only the lower limb edema showed significant difference statistically.
Follow-up was done for 6 months at least post pacemaker implantation in Groups A and B and also Group C (the control group).
Univariate logistic regression analysis for the statistically significant predictors revealed that LAVI, GLS, Native-QRS duration, and IHD were significant predictors of reduction of LV function, however on multivariate regression analysis only the LAVI and GLS were independent predictors of reduction of LVEF after permanent pacing. Prevalence of IHD was more in the reduction group, this is an explanation of the higher percentage of deterioration of EF in ischemic patients. IHD total 12 patients in the 50 studied patients, 7 out of the 13 EF deteriorated (53.8%), P < 0.003.
The NYHA functional class did not show a significant difference at baseline but it showed a significant difference at follow-up. As regards the clinical evidence of heart failure, there was no statistical difference at baseline but at follow-up, only the LL edema showed significant difference statistically.
The importance of defining predictors, is to predict who will be at risk for the deleterious effect of RV pacing on LV function, and who will need more close observation and follow-up with possible upgrading to biventricular pacing, if the patient showed a significant reduction of EF and fulfilled the criteria for upgrading, to reduce hospitalization and improve symptoms and cardiac performance.,
| Discussion|| |
The baseline characteristics of our study population are not significantly different from other studies.,,
Incidence and definitions of pacemaker-induced cardiomyopathy
The published articles have shown variable incidence values of PICM, based on different definitions used to identify the syndrome. The most commonly used definitions included a reduction in LVEF ≥10% from baseline and resulting LVEF <50% and associated with a high burden of RV pacing unless it is explained by alternative causes of cardiomyopathy.,,,,
In 2016, Kiehl et al. analyzed 823 patients with permanent pacemaker (PPM). The incidence of PICM was (12.3%) over a mean follow-up period of 4.3 ± 3.9 years, with a mean LVEF (58.1 ± 5.4 vs. 33.7% ±7.4%) in patients with PICM at follow-up.
In 2018 Kim et al., studied 130 patients with complete AVB with baseline mean LVEF (65% ±10%), who underwent PPM implantation between 2001 and 2015. PICM was defined as >10% decrease in LVEF, with a resultant LVEF <50%. The incidence of PICM was (16.1%) over a mean duration of the follow-up period (4.7 ± 3.5 years). The postimplant mean LVEF at PICM group was (65 ± 10 vs. 31% ± 8%).
Left atrial volume index
According to Kim et al.'s study, there was no significant difference in the left atrial diameter between the groups of patients who showed PICM and those who did not show it at baseline or at follow-up.
In accordance with our study, Zou  reported that mitral incompetence was not a statistically significant predictor of PICM.
Global longitudinal strain
Univariate Cox regression analysis was done, which revealed that GLS is a significant predictor of PIVD (P = 0.
002), on multivariate analysis it revealed that GLS is an independent predictor of PIVD (P = 0.040).
In 2018, Kim et al. retrospectively studied 131 patients who underwent PPM implantation for AV block. The incidence of PICM was 25.8%, with a reduction in mean LVEF from 67.1% to 40.1% over a mean follow-up period of 4.8 years. In multivariate analysis, LV GLS (−21.1 ± 4.2 vs. −18.2 ± 4.2 for no PICM and PICM, respectively, P = 0.001).
Segmental speckle tracking values
According to Algazzar et al. they found a significant reduction of apical segment strain values after pacing and they found a positive correlation with the reduction of GLS after 6 months of baseline measurement and they reached to a conclusion that RV apical pacing induces a significant reduction of apical, relative apical and septal regional strain more than RV septal pacing.
| Conclusions|| |
- Speckle tracking echocardiography is a new, unique, and evolving tool to assess the myocardial deformation function, and also a strong predictor method even with subclinical LV dysfunction that could not be assessed by traditional methods
- GLS is an independent measure of the deleterious effect of RV pacing on LV function even with normal EF measurement prior to pacing
- Patients with GLS ≤ -16 have a particular risk for developing pacemaker induced LV dysfunction with a sensitivity of 92.31% and a specificity of 51.35%
- The left atrial volume index could be defined as an independent predictor of pacemaker-induced LV dysfunction, with cut off value >32 ml/m2.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Merchant FM, Hoskins MH, Musat DL, Prillinger JB, Roberts GJ, Nabutovsky Y, et al
. Incidence and time course for developing heart failure with high-burden right ventricular pacing. Circ Cardiovasc Qual Outcomes 2017;10. pii: e003564.
Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al
. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015;28:1-39.e14.
Kocabay G, Muraru D, Peluso D, Cucchini U, Mihaila S, Padayattil-Jose S, et al
. Normal left ventricular mechanics by two-dimensional speckle-tracking echocardiography. Reference values in healthy adults. Rev Esp Cardiol (Engl Ed) 2014;67:651-8.
Stanton T, Leano R, Marwick TH. Prediction of all-cause mortality from global longitudinal speckle strain: Comparison with ejection fraction and wall motion scoring. Circ Cardiovasc Imaging 2009;2:356-64.
Voigt JU, Pedrizzetti G, Lysyansky P, Marwick TH, Houle H, Baumann R, et al
. Definitions for a common standard for 2D speckle tracking echocardiography: Consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging. Eur Heart J Cardiovasc Imaging 2015;16:1-11.
Mignot A, Donal E, Zaroui A, Reant P, Salem A, Hamon C, et al
. Global longitudinal strain as a major predictor of cardiac events in patients with depressed left ventricular function: A multicenter study. J Am Soc Echocardiogr 2010;23:1019-24.
Xu H, Li J, Bao Z, Xu C, Zhang Y, Liu H, et al
. Early change in global longitudinal strain is an independent predictor of left ventricular adverse remodelling in patients with right ventricular apical pacing. Heart Lung Circ 2019;28:1780-7.
Kaye GC, Linker NJ, Marwick TH, Pollock L, Graham L, Pouliot E, et al
. 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 2015;36:856-62.
Delgado V, Tops LF, Trines SA, Zeppenfeld K, Marsan NA, Bertini M, et al
. Acute effects of right ventricular apical pacing on left ventricular synchrony and mechanics. Circ Arrhythm Electrophysiol 2009;2:135-45.
Ahmed FZ, Motwani M, Cunnington C, Kwok CH, Fullwood C, Oceandy D, et al
. One-month global longitudinal strain identifies patients who will develop pacing-induced left ventricular dysfunction over time: The pacing and ventricular dysfunction (PAVD) study. PLoS One 2017;12:e0162072.
Zou C, Song J, Li H, Huang X, Liu Y, Zhao C, et al
. Right ventricular outflow tract septal pacing is superior to right ventricular apical pacing. J Am Heart Assoc 2015;4:e001777.
Baronaitė-Dūdonienė K, Vaškelytė J, Puodžiukynas A, Zabiela V, Kazakevičius T, Šakalytė G. Evaluation of left ventricular longitudinal function and synchrony after dual chamber pacemaker implantation. Medicina (Kaunas) 2014;50:340-4.
Babu NM, Srinath SC, Lahiri A, Chase D, John B, Roshan J. Three-dimensional echocardiography with left ventricular strain analyses helps earlier prediction of right ventricular pacing-induced cardiomyopathy. J Saudi Heart Assoc 2018;30:102-7.
Khurshid S, Epstein AE, Verdino RJ, Lin D, Goldberg LR, Marchlinski FE, et al
. Incidence and predictors of right ventricular pacing-induced cardiomyopathy. Heart Rhythm 2014;11:1619-25.
Kim JH, Kang KW, Chin JY, Kim TS, Park JH, Choi YJ. Major determinant of the occurrence of pacing-induced cardiomyopathy in complete atrioventricular block: a multicentre, retrospective analysis over a 15-year period in South Korea. BMJ Open 2018;8:e019048. Published online 2018 Feb 8.
Kiehl EL, Makki T, Kumar R, Gumber D, Kwon DH, Rickard JW, et al
. Incidence and predictors of right ventricular pacing-induced cardiomyopathy in patients with complete atrioventricular block and preserved left ventricular systolic function. Heart Rhythm 2016;13:2272-8.
Lee SA, Cha MJ, Cho Y, Oh IY, Choi EK, Oh S. Paced QRS duration and myocardial scar amount: Predictors of long-term outcome of right ventricular apical pacing. Heart Vessels 2016;31:1131-9.
Ebert M, Jander N, Minners J, Blum T, Doering M, Bollmann A, et al
. Long-term impact of right ventricular pacing on left ventricular systolic function in pacemaker recipients with preserved ejection fraction: Results from a large single-center registry. J Am Heart Assoc 2016;5. pii: E003485.
Rafla S, Aboelhoda A, Nawar M, Geller J Ch, Mohamed Lotfi M. Upgrading patients with pacemakers to resynchronization pacing: Predictors of success. Alexandria J Med 2018;54:311-3.
Kirkpatrick LA, Feeney BC. A Simple Guide to IBM SPSS: For Version 20.0. 12th ed. Belmont, CA: Wadsworth Publishing; 2012.
Cho SW, Gwag HB, Hwang JK, Chun KJ, Park KM, On YK, et al
. Clinical features, predictors, and long-term prognosis of pacing-induced cardiomyopathy. Eur J Heart Fail 2019;21:643-51.
Tse HF, Yu C, Wong KK, Tsang V, Leung YL, Ho WY, et al
. Functional abnormalities in patients with permanent right ventricular pacing: The effect of sites of electrical stimulation. J Am Coll Cardiol 2002;40:1451-8.
Lee KH, Cho JG, Park HW, Yoon NS, Kim SS, Kim MR, et al
. QRS morphology and ventricular dyssynchrony in patients with chronic right ventricular pacing. Int J Cardiol 2014;176:962-8.
Kim SM, Cho KI, Cha TJ, Heo JH, Kim HS, Lee JW. Left atrial responses to acute right ventricular apical pacing in patients with sick sinus syndrome. Echocardiography 2013;30:1042-50.
Patel DA, Lavie CJ, Gilliland YE, Shah SB, Dinshaw HK, Milani RV. Prediction of all-cause mortality by the left atrial volume index in patients with normal left ventricular filling pressure and preserved ejection fraction. Mayo Clin Proc 2015;90:1499-505.
Ha SJ, Song YJ, Lee WK, Bang WD, YOO SY, Cheong SS. Global longitudinal strain improve prediction of right ventricular pacing induced left ventricular dyssynchrony in patients with permanent pacemaker. Heart Lung Circ 2019;28:1780-7.
Algazzar AS, Moharram MA, Katta AA, Soltan GM, Abd Elaziz WF. Early effects of right ventricular pacing on the left ventricle in single-chamber and dual-chamber pacemakers. Menoufia Med J 2016;29:52-9. [Full text]
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]