Advertisement

Right ventricular pacing–induced electrophysiological remodeling in the human heart and its relationship to cardiac memory

Published:August 15, 2007DOI:https://doi.org/10.1016/j.hrthm.2007.08.001

      Background

      Right ventricular apical (RVA) pacing induces electrophysiological and structural remodeling. Cardiac memory (CM) evolves during the course of pacing and is readily apparent on electrocardiography (ECG) or vectorcardiography (VCG) when normal ventricular activation resumes.

      Objective

      This study sought to assess ventricular repolarization (VR) changes during pacing and intermittent normal ventricular conduction by ECG and VCG and to determine the temporal and conformational evolution of CM.

      Methods

      Twenty sick sinus patients received a dual-chamber rate-adaptive (DDD-R) pacemaker and were paced from the RVA endocardium. The pacemakers were programmed to a short AV delay to maximize ventricular preexcitation. The ECG and VCG were recorded before and 1 day after implantation, and then daily for the first week (n = 6) or weekly for 5 to 8 weeks (n = 14), with the pacemakers temporarily programmed to AAI (normal ventricular activation).

      Results

      The first parameters to change were T-vector amplitude, Tarea, and Tpeak-Tend (Tp-e), which decreased within 1 day after initiating pacing. CM became apparent between day 1 and day 3, was fully established after 1 week, and then remained stable. Signs of increased VR heterogeneity were observed as the T loop became more circular (decreased Tegenv) and distorted (increased Tavplan), which have previously been observed in conditions with increased risk for arrhythmias. Over weeks, VR duration was prolonged (increased QTc). In contrast, during ventricular pacing, a gradual shortening of the repolarization time was observed, suggesting a stabilizing adaptive process.

      Conclusion

      In sick sinus syndrome patients in whom ventricular pacing is indicated, switching between normal AV conduction and ventricular pacing should be minimized to avoid periods of repolarization instability.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Heart Rhythm
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Karpawich P.P.
        • Justice C.D.
        • Cavitt D.L.
        • Chang C.H.
        Developmental sequelae of fixed-rate ventricular pacing in the immature canine heart: an electrophysiologic, hemodynamic, and histopathologic evaluation.
        Am Heart J. 1990; 119: 1077-1083
        • Lee M.A.
        • Dae M.W.
        • Langberg J.J.
        • Griffin J.C.
        • Chin M.C.
        • Finkbeiner W.E.
        • O’Connell J.W.
        • Botvinick E.
        • Scheinman M.M.
        • Rosenqvist M.
        Effects of long-term right ventricular apical pacing on left ventricular perfusion, innervation, function and histology.
        J Am Coll Cardiol. 1994; 24: 225-232
        • Alessandrini R.S.
        • McPherson D.D.
        • Kadish A.H.
        • Kane B.J.
        • Goldberger J.J.
        Cardiac memory: a mechanical and electrical phenomenon.
        Am J Physiol. 1997; 272: H1952-H1959
        • van Oosterhout M.F.
        • Prinzen F.W.
        • Arts T.
        • Schreuder J.J.
        • Vanagt W.Y.
        • Cleutjens J.P.
        • Reneman R.S.
        Asynchronous electrical activation induces asymmetrical hypertrophy of the left ventricular wall.
        Circulation. 1998; 98: 588-595
        • Chatterjee K.
        • Harris A.
        • Davies G.
        • Leatham A.
        Electrocardiographic changes subsequent to artificial ventricular depolarization.
        Br Heart J. 1969; 31: 770-779
        • Rosenbaum M.B.
        • Blanco H.H.
        • Elizari M.V.
        • Lazzari J.O.
        • Davidenko J.M.
        Electrotonic modulation of the T wave and cardiac memory.
        Am J Cardiol. 1982; 50: 213-222
        • Rosen M.R.
        • Cohen I.S.
        • Danilo Jr, P.
        • Steinberg S.F.
        The heart remembers.
        Cardiovasc Res. 1998; 40: 469-482
        • Wecke L.
        • Gadler F.
        • Linde C.
        • Lundahl G.
        • Rosen M.R.
        • Bergfeldt L.
        Temporal characteristics of cardiac memory in humans: vectorcardiographic quantification in a model of cardiac pacing.
        Heart Rhythm. 2005; 2: 28-34
        • Shvilkin A.
        • Danilo Jr, P.
        • Wang J.
        • Burkhoff D.
        • Anyukhovsky E.P.
        • Sosunov E.A.
        • Hara M.
        • Rosen M.R.
        Evolution and resolution of long-term cardiac memory.
        Circulation. 1998; 97: 1810-1817
        • Plotnikov A.N.
        • Shvilkin A.
        • Xiong W.
        • de Groot J.R.
        • Rosenshtraukh L.
        • Feinmark S.
        • Gainullin R.
        • Danilo P.
        • Rosen M.R.
        Interactions between antiarrhythmic drugs and cardiac memory.
        Cardiovasc Res. 2001; 50: 335-344
        • Sweeney M.O.
        • Hellkamp A.S.
        • Ellenbogen K.A.
        • Greenspon A.J.
        • Freedman R.A.
        • Lee K.L.
        • Lamas G.A.
        Adverse effect of ventricular pacing on heart failure and atrial fibrillation among patients with normal baseline QRS duration in a clinical trial of pacemaker therapy for sinus node dysfunction.
        Circulation. 2003; 107: 2932-2937
        • Wilkoff B.L.
        • Cook J.R.
        • Epstein A.E.
        • Greene H.L.
        • Hallstrom A.P.
        • Hsia H.
        • Kutalek S.P.
        • Sharma A.
        Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial.
        JAMA. 2002; 288: 3115-3123
        • Lepeschkin E.
        • Surawicz B.
        The measurement of the Q-T interval of the electrocardiogram.
        Circulation. 1952; 6: 378-388
        • Rubulis A.
        • Jensen J.
        • Lundahl G.
        • Tapanainen J.
        • Wecke L.
        • Bergfeldt L.
        T vector and loop characteristics in coronary artery disease and during acute ischemia.
        Heart Rhythm. 2004; 1: 317-325
        • Rubulis A.
        • Jensen J.
        • Lundahl G.
        • Tapanainen J.
        • Bergfeldt L.
        Ischemia induces aggravation of baseline repolarization abnormalities in left ventricular hypertrophy: a deleterious interaction.
        J Appl Physiol. 2006; 101: 102-110
        • Fayn J.
        • Robel P.
        • Arnaud P.
        A new methodology for optimal comparison of serial vectorcardiograms.
        Comput Cardiol. 1983; : 467-470
        • Antzelevitch C.
        • Oliva A.
        Amplification of spatial dispersion of repolarization underlies sudden cardiac death associated with catecholaminergic polymorphic VT, long QT, short QT and Brugada syndromes.
        J Int Med. 2006; 259: 48-58
        • Xia Y.
        • Liang Y.
        • Kongstad O.
        • Liao Q.
        • Holm M.
        • Olsson B.
        • Yuan S.
        In vivo validation of the coincidence of the peak and end of the T wave with full repolarization of the epicardium and endocardium in swine.
        Heart Rhythm. 2005; 2: 162-169
        • Xia Y.
        • Liang Y.
        • Kongstad O.
        • Holm M.
        • Olsson B.
        • Yuan S.
        Tpeak-Tend interval as an index of global dispersion of ventricular repolarization: evaluations using monophasic action potential mapping of the epi- and endocardium in swine.
        J Interv Cardiol Electrophysiol. 2005; 14: 79-87
        • Opthof T.
        • Coronel R.
        • Wilms-Schopman F.J.
        • Plotnikov A.N.
        • Shlapakova I.N.
        • Danilo Jr, P.
        • Rosen M.R.
        • Janse M.J.
        Dispersion of repolarization in canine ventricle and the electrocardiographic T wave: Tp-e interval does not reflect transmural dispersion.
        Heart Rhythm. 2007; 4: 341-348
        • Costard-Jackle A.
        • Goetsch B.
        • Antz M.
        • Franz M.R.
        Slow and long-lasting modulation of myocardial repolarization produced by ectopic activation in isolated rabbit hearts.
        Circulation. 1989; 80: 1412-1420
        • Nowinski K.
        • Gadler F.
        • Jensen-Urstad M.
        • Bergfeldt L.
        Transient proarrhythmic state following atrioventricular junction radiofrequency ablation: pathophysiologic mechanisms and recommendations for management.
        Am J Med. 2002; 113: 596-602
        • Medina-Ravell V.A.
        • Lankipalli R.S.
        • Yan G.X.
        • Antzelevitch C.
        • Medina-Malpica N.A.
        • Medina-Malpica O.A.
        • Droogan C.
        • Kowey P.R.
        Effect of epicardial or biventricular pacing to prolong QT interval and increase transmural dispersion of repolarization: does resynchronization therapy pose a risk for patients predisposed to long QT or torsade de pointes?.
        Circulation. 2003; 107: 740-746
        • Shukla G.
        • Chaudhry G.M.
        • Orlov M.
        • Hoffmeister P.
        • Haffajee C.
        Potential proarrhythmic effect of biventricular pacing: fact or myth?.
        Heart Rhythm. 2005; 2: 951-956
        • Braunschweig F.
        • Pfizenmeyer H.
        • Rubulis A.
        • Linde C.
        • Bergfeldt L.
        Pro-arrhythmic state following the initiation of cardiac resynchronization therapy in patients with heart failure.
        J Am Coll Cardiol. 2005; 45 (abstr): 127A-128A
        • Jackman W.M.
        • Friday K.J.
        • Anderson J.L.
        • Aliot E.M.
        • Clark M.
        • Lazzara R.
        The long QT syndromes: a critical review, new clinical observations and a unifying hypothesis.
        Progr Cardiovasc Dis. 1988; 31: 115-172
        • Yu H.
        • McKinnon D.
        • Dixon J.E.
        • Gao J.
        • Wymore R.
        • Cohen I.S.
        • Danilo Jr, P.
        • Shvilkin A.
        • Anyukhovsky E.P.
        • Sosunov E.A.
        • Hara M.
        • Rosen M.R.
        Transient outward current, Ito1, is altered in cardiac memory.
        Circulation. 1999; 99: 1898-1905
        • Coronel R.
        • Opthof T.
        • Plotnikov A.N.
        • Wilms-Schopman F.J.
        • Shlapakova I.N.
        • Danilo Jr, P.
        • Sosunov E.A.
        • Anyukhovsky E.P.
        • Janse M.J.
        • Rosen M.R.
        Long-term cardiac memory in canine heart is associated with the evolution of a transmural repolarization gradient.
        Cardiovasc Res. 2007; 74: 416-425
        • Nowinski K.
        • Gadler F.
        • Jensen-Urstad M.
        • Bergfeldt L.
        Transient proarrhythmic state following atrioventricular junctional radiofrequency ablation.
        Pacing Clin Electrophysiol. 2002; 25: 291-299
        • Pak P.H.
        • Nuss H.B.
        • Tunin R.S.
        • Kaab S.
        • Tomaselli G.F.
        • Marban E.
        • Kass D.A.
        Repolarization abnormalities, arrhythmia and sudden death in canine tachycardia-induced cardiomyopathy.
        J Am Coll Cardiol. 1997; 30: 576-584
        • Darpö B.
        Spectrum of drugs prolonging QT interval and the incidence of torsade de pointes.
        Eur Heart J. 2001; 3: K70-K80
        • Roden D.M.
        Drug-induced prolongation of the QT interval.
        N Engl J Med. 2004; 350: 1013-1022
        • Badilini F.
        • Maison Blanche P.
        • Fayn J.
        • Forlini M.C.
        • Rubel P.
        • Coumel P.
        Relationship between 12-lead ECG QT dispersion and 3D-ECG repolarization loop.
        Comput Cardiol. 1995; : 785-788
        • Kors J.A.
        • van Herpen G.
        • van Bemmel J.H.
        QT dispersion as an attribute of T-loop morphology.
        Circulation. 1999; 99: 1458-1463
        • Nowinski K.
        • Jensen S.
        • Lundahl G.
        • Bergfeldt L.
        Changes in ventricular repolarization during percutaneous transluminal coronary angioplasty in humans assessed by QT interval, QT dispersion and T vector loop morphology.
        J Int Med. 2000; 248: 126-136
        • Nowinski K.
        • Wecke L.
        • Gadler F.
        • Linde C.
        • Bergfeldt L.
        Pacing-induced electrophysiological remodeling in hypertrophic obstructive cardiomyopathy—observations on cardiac memory.
        Pacing Clin Electrophysiol. 2005; 28: 561-567
        • Nowinski K.
        • Bergfeldt L.
        “Normal” response of the QT interval and QT dispersion following intravenous injection of the sodium channel blocker disopyramide: methodological aspects.
        Cardiovasc Drugs Ther. 1995; 9: 573-580