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Pacing induced cardiomyopathy: recognition and management
  1. Shunmuga Sundaram Ponnusamy1,
  2. Thabish Syed1,
  3. Pugazhendhi Vijayaraman2
  1. 1 Division of Cardiology, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
  2. 2 Geisinger Heart Institute, Geisinger Commonwealth School of Medicine, Wilkes-Barre, Pennsylvania, USA
  1. Correspondence to Dr Pugazhendhi Vijayaraman, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA 18711, USA; pvijayaraman{at}


Right ventricle (RV) apex continues to remain as the standard pacing site in the ventricle due to ease of implantation, procedural safety and lack of convincing evidence of better clinical outcomes from non-apical pacing sites. Electrical dyssynchrony resulting in abnormal ventricular activation and mechanical dyssynchrony resulting in abnormal ventricular contraction during RV pacing can result in adverse LV remodelling predisposing some patients for recurrent heart failure (HF) hospitalisation, atrial arrhythmias and increased mortality. While there are significant variations in the definition of pacing induced cardiomyopathy (PIC), combining both echocardiographic and clinical features, the most acceptable definition for PIC would be left ventricular ejection fraction (LVEF) of <50%, absolute decline of LVEF by ≥10% and/or new-onset HF symptoms or atrial fibrillation (AF) after pacemaker implantation. Based on the definitions used, the prevalence of PIC varies between 6% and 25% with overall pooled prevalence of 12%. While most patients undergoing RV pacing do not develop PIC, male sex, chronic kidney disease, previous myocardial infarction, pre-existing AF, baseline LVEF, native QRS duration, RV pacing burden, and paced QRS duration are the factors associated with increased risk for PIC. While conduction system pacing (CSP) using His bundle pacing and left bundle branch pacing appear to reduce the risk for PIC compared with RV pacing, both biventricular pacing and CSP may be used to effectively reverse PIC.

  • bradycardia
  • electrocardiography
  • cardiomyopathy, dilated
  • pacemaker, artificial
  • heart failure, systolic

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  • Contributors All authors made substantial contributions to the conception/design of the work, drafting the work or revising it critically for important intellectual content, in the final approval of the version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests SSP has received honoraria for lectures from Medtronic. PV has received lecture fees, provided consultation and received research and fellowship support from Medtronic; received honoraria from Abbott, Biotronik and Boston Scientific; and holds a patent for His bundle pacing delivery tool.

  • Provenance and peer review Commissioned; internally peer reviewed.

  • Author note References which include a * are considered to be key references.