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DDD mode-switching and loss of atrioventricular synchrony evokes heart failure: A rare but possible trigger of pacing-induced cardiomyopathy. J Cardiol Cases 2021; 23:158-162. [PMID: 33841592 DOI: 10.1016/j.jccase.2020.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/20/2020] [Accepted: 10/27/2020] [Indexed: 11/21/2022] Open
Abstract
Pacing-induced cardiomyopathy (PICM), defined as left ventricular dysfunction, occurs in the setting of chronic, high burden right ventricular pacing. We describe an unusual case of PICM. A 64-year-old man underwent a medical check-up and was diagnosed with complete atrioventricular block (AVB) with regular and slow ventricular contractions at 38 beats/min (bpm). The patient underwent a pacemaker implantation with a dual-chamber pacing (DDD) pacemaker. This patient had no symptoms or signs of PICM during complete AVB or the period after undergoing dual-chamber pacing. However, PICM developed within a short time after the onset of atrial flutter (AFL). During AFL, the automatic mode switch of the DDD pacemaker to the DDIR mode worked normally, and the ventricles were paced with a stable and regular rate (60 bpm). Despite the administration of ß-blockers and diuretics, his symptoms and status did not improve. After the elimination of the AFL and restoration of AV synchrony with a DDD mode by catheter ablation, the deteriorated condition rapidly improved. In this patient, the coexistence of the loss of AV synchrony and high burden RV pacing during AFL might have caused this unusual PICM. Learning objective: Even when patients have no symptoms or signs of pacing-induced cardiomyopathy (PICM) during complete atrioventricular block or the period after undergoing dual-chamber pacing, automatic mode-switching to the DDI mode during atrial tachyarrhythmias could rapidly cause PICM. PICM could occur with a much more rapid time course than the historical model of PICM where cardiomyopathy may take several years to develop. Much attention should be paid during the follow-up to patients receiving DDD pacemakers to avoid any unusual PICM as in this case.
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Heggermont W, Iliodromitis K, Van Bockstal K, Backers J, Lau CW, Missiaen D, De Cooman J, Timmermans W, Geelen P, De Potter T. Clinical symptoms of limited exercise capacity linked to AAI-DDD functionality: An in silico and in vivo approach. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:943-951. [PMID: 33829506 DOI: 10.1111/pace.14239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/13/2021] [Accepted: 03/28/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Exercise capacity is an important aspect of quality of life in patients undergoing pacemaker implantation. Device algorithms for ventricular pacing avoidance have been developed to avoid unnecessary and potentially harmful effects of right ventricular pacing. However, little data exists on the immediate response of these algorithms to sudden AV block during exercise. METHODS The ventricular pacing avoidance algorithms of four pacemaker manufacturers were tested in an ex-vivo model. The RSIM-1500-USB Device-Interactive Heart Simulator (Rivertek Medical Systems, Inc.) was used to simulate three different scenarios: the first one starting with an initially conducted atrial pacing rate of 60 min-1 , the second one starting with an atrial rate of 120 min-1 and finally a scenario starting with an atrial rate of 150 min-1 . In all three scenarios, the initially conducted atrial rate was followed by a sudden, long lasting episode of third-degree AV-block. The response to those scenarios was recorded for each of the (brand-specific) ventricular pacing avoidance algorithms. RESULTS In the first scenario, the simulation resulted in a ventricular pause of 1333 ms (Boston Scientific), 2000 ms (Medtronic and Microport), and 2340 ms (Biotronik). In the second and third scenario, different results were observed across devices. All simulations of the second and third scenario resulted in repetitive 2:1 block response (during eight cycles) in Boston Scientific and Biotronik devices. These scenarios were confirmed in patient cases. CONCLUSION Simulator based observations of unanticipated pacemaker-induced 2:1 block response during exercise may explain clinical symptoms experienced by some patients having a two-chamber pacemaker.
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Affiliation(s)
- Ward Heggermont
- Cardiovascular Research Center, Onze-Lieve-Vrouw Hospital Aalst, Moorselbaan 164, Aalst, B-9300, Belgium.,Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 50, Maastricht, AZ-6202, The Netherlands
| | - Konstantinos Iliodromitis
- Cardiovascular Research Center, Onze-Lieve-Vrouw Hospital Aalst, Moorselbaan 164, Aalst, B-9300, Belgium
| | - Koen Van Bockstal
- Cardiovascular Research Center, Onze-Lieve-Vrouw Hospital Aalst, Moorselbaan 164, Aalst, B-9300, Belgium
| | - Jos Backers
- Cardiovascular Research Center, Onze-Lieve-Vrouw Hospital Aalst, Moorselbaan 164, Aalst, B-9300, Belgium
| | - Chirik-Wah Lau
- Cardiovascular Research Center, Onze-Lieve-Vrouw Hospital Aalst, Moorselbaan 164, Aalst, B-9300, Belgium
| | - Dieter Missiaen
- Cardiovascular Research Center, Onze-Lieve-Vrouw Hospital Aalst, Moorselbaan 164, Aalst, B-9300, Belgium
| | - Jan De Cooman
- Cardiovascular Research Center, Onze-Lieve-Vrouw Hospital Aalst, Moorselbaan 164, Aalst, B-9300, Belgium
| | - Willy Timmermans
- Cardiovascular Research Center, Onze-Lieve-Vrouw Hospital Aalst, Moorselbaan 164, Aalst, B-9300, Belgium
| | - Peter Geelen
- Cardiovascular Research Center, Onze-Lieve-Vrouw Hospital Aalst, Moorselbaan 164, Aalst, B-9300, Belgium
| | - Tom De Potter
- Cardiovascular Research Center, Onze-Lieve-Vrouw Hospital Aalst, Moorselbaan 164, Aalst, B-9300, Belgium
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Abstract
Long-term right ventricular pacing is associated with electrical and mechanical dyssynchrony and ultimately development of pacing-induced cardiomyopathy (PICM) in a subset of patients. Patients with a high degree of pacing burden and reduced left ventricular (LV) function prior to pacemaker implantation are at the greatest risk for developing PICM. Cardiac resynchronization therapy (CRT) has an established role in the treatment of patients with LV systolic heart failure and intraventricular delay and has been used to successfully treat PICM. This review evaluates predictors for PICM, as well as highlights the role for CRT in prevention and treatment in high risk patients.
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Affiliation(s)
- Tharian S Cherian
- Section of Cardiology, The University of Chicago Medicine, Pritzker School of Medicine, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - Gaurav A Upadhyay
- Section of Cardiology, Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Medicine, Pritzker School of Medicine, 5841 South Maryland Avenue, MC 9024, Chicago, IL 60637, USA.
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Herweg B, Singh R, Barold SS. Cardiac resynchronization therapy is appropriate for all patients requiring chronic right ventricular pacing: the pro perspective. Card Electrophysiol Clin 2015; 7:433-44. [PMID: 26304523 DOI: 10.1016/j.ccep.2015.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Long-term right ventricular pacing has deleterious effects on the left ventricle (LV). The risk of pacemaker-induced cardiomyopathy (PICM) seems to be lower in patients with a normal LV ejection fraction (LVEF). Patients developing PICM respond favorably to a cardiac resynchronization therapy upgrade, suggesting that the dysfunction is partially reversible. Biventricular pacing has emerged as a treatment and/or prevention of PICM. Cumulative pacing greater than 40% of the time is considered the most important risk factor for PICM. No organizational guidelines exist for preventive biventricular pacing. The decision to pursue biventricular pacing should be individualized.
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Affiliation(s)
- Bengt Herweg
- Electrophysiology and Arrhythmia Services, Department of Cardiovascular Disease, Tampa General Hospital, University of South Florida Morsani College of Medicine, South Tampa Campus (5th Floor), Two Tampa General Circle, Tampa, FL 33606, USA.
| | - Robin Singh
- Department of Cardiovascular Disease, Tampa General Hospital, University of South Florida Morsani College of Medicine, South Tampa Campus (5th Floor), Two Tampa General Circle, Tampa, FL 33606, USA
| | - S Serge Barold
- Clinical Cardiac Electrophysiology, Department of Cardiovascular Disease, University of Rochester Medical Center, 2613 W Henrietta Road, Rochester, NY 14623, USA
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Ferrari ADL, Borges AP, Albuquerque LC, Pelzer Sussenbach C, Rosa PRD, Piantá RM, Wiehe M, Goldani MA. Cardiomyopathy induced by artificial cardiac pacing: myth or reality sustained by evidence? Braz J Cardiovasc Surg 2014; 29:402-13. [PMID: 25372916 PMCID: PMC4412332 DOI: 10.5935/1678-9741.20140104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 08/05/2014] [Indexed: 01/27/2023] Open
Abstract
Implantable cardiac pacing systems are a safe and effective treatment for symptomatic
irreversible bradycardia. Under the proper indications, cardiac pacing might bring
significant clinical benefit. Evidences from literature state that the action of the
artificial pacing system, mainly when the ventricular lead is located at the apex of
the right ventricle, produces negative effects to cardiac structure (remodeling,
dilatation) and function (dissinchrony). Patients with previously compromised left
ventricular function would benefit the least with conventional right ventricle apical
pacing, and are exposed to the risk of developing higher incidence of morbidity and
mortality for heart failure. However, after almost 6 decades of cardiac pacing, just
a reduced portion of patients in general would develop these alterations. In this
context, there are not completely clear some issues related to cardiac pacing and the
development of this cardiomyopathy. Causality relationships among QRS widening with a
left bundle branch block morphology, contractility alterations within the left
ventricle, and certain substrates or clinical (previous systolic dysfunction,
structural heart disease, time from implant) or electrical conditions (QRS duration,
percentage of ventricular stimulation) are still subjecte of debate. This review
analyses contemporary data regarding this new entity, and discusses alternatives of
how to use cardiac pacing in this context, emphasizing cardiac resynchronization
therapy.
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Affiliation(s)
| | - Anibal Pires Borges
- São Lucas Hospital, Catholic University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | | | | | | | - Mario Wiehe
- São Lucas Hospital, Catholic University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Marco Antônio Goldani
- São Lucas Hospital, Catholic University of Rio Grande do Sul, Porto Alegre, RS, Brazil
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