Intraventricular flow patterns during right ventricular apical pacing

Objectives To assess differences in blood flow momentum (BFM) and kinetic energy (KE) dissipation in a model of cardiac dyssynchrony induced by electrical right ventricular apical (RVA) stimulation compared with spontaneous sinus rhythm.

Methods We cross-sectionally enrolled 12 consecutive patients (mean age 74 +/- 8 years, 60% male, mean left ventricular ejection fraction 58%+/- 6 %), within 48 hours from pacemaker (PMK) implantation. Inclusion criteria were: age> 18 years, no PMK-dependency, sinus rhythm with a spontaneous narrow QRS at the ECG, preserved ejection fraction (> 50%) and a low percentage of PMKstimulation (< 20%). All the participants underwent a complete echocardiographic evaluation, including left ventricular strain analysis and particle image velocimetry.

Results Compared with sinus rhythm, BFM shifted from 27 +/- 3.3 to 34 +/- 7.6 degrees (p=0.016), while RVA-pacing was characterised by a 35% of increment in KE dissipation, during diastole (p=0.043) and 32% during systole (p=0.016). In the same conditions, left ventricle global longitudinal strain (LV GLS) significantly decreased from 17 +/- 3.3 to 11%+/- 2.8% (p=0.004) during RVA-stimulation. At the multivariable analysis, BFM and diastolic KE dissipation were significantly associated with LV GLS deterioration (Beta Coeff.=0.54, 95% CI 0.07 to 1.00, p=0.034 and Beta Coeff.=0.29, 95% CI 0.02 to 0.57, p=0.049, respectively).

Conclusions In RVA-stimulation, BFM impairment and KE dissipation were found to be significantly associated with LV GLS deterioration, when controlling for potential confounders. Such changes may favour the onset of cardiac remodelling and sustain heart failure.