title: Adverse impact of chronic subpulmonary left ventricular pacing on systemic right ventricular function in patients with congenitally corrected transposition of the great arteries.
abstract: BACKGROUND
  Patients with congenitally corrected transposition of the great arteries (ccTGA) are at high risk of heart block requiring subpulmonary left ventricular (LV) pacing. Long-term right ventricular (RV) pacing in congenitally normal hearts is associated with LV dysfunction. We examined the effects of univentricular subpulmonary LV pacing on the systemic RV in a ccTGA cohort.
  
  
  METHODS
  ccTGA patients with two echocardiographic studies at least 6 months apart were included. Records of 52 patients, 22 with pacing, were retrospectively reviewed. Seven patients with biventricular pacing were included for comparison.
  
  
  RESULTS
  The LV-Paced Group experienced deterioration in the RV fractional area change (RVFAC) (28.7 ± 10.0 vs. 21.9 ± 9.1%; P=0.003), systemic atrioventricular valve regurgitation (P=0.019) and RV dilatation (end-diastolic area 32.7 ± 8.7 vs. 37.2 ± 9.0 cm(2); P=0.004). There was a corresponding deterioration in NYHA class (P=0.013). Multivariate Cox regression analysis showed that pacing was an independent predictor of deteriorating RV function and RV dilation (hazard ratio 2.7(10-7.0) and 4.7(1.1-20.6) respectively). None of these parameters changed significantly in the Un-paced Group. The CRT Group showed improvement in RVFAC (22.0% to 30.7% (P=0.030) and NYHA class (P=0.030), despite having lower baseline RVFAC (22.0±5.7 vs. 31 ± 9.7%; P=0.025) and greater dyssynchrony (RV total isovolumic time 13.4 ± 2.1 vs. 9.3 ± 4.2s/min; P=0.016) when compared to the Un-Paced Group.
  
  
  CONCLUSIONS
  Univentricular subpulmonary LV pacing in patients with ccTGA predicted deterioration in RV function and RV dilatation over time associated with deteriorating NYHA class. Alternative primary pacing strategies such as biventricular pacing may need consideration in this vulnerable group already highly prone to mortality from systemic RV failure.
authors.affiliation: Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom; National University Heart Centre, Singapore.
authors.forename: Wee Tiong
authors.initials: WT
authors.lastname: Yeo
authors.affiliation: Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom.
authors.forename: Julian W E
authors.initials: JW
authors.lastname: Jarman
authors.affiliation: Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom.
authors.forename: Wei
authors.initials: W
authors.lastname: Li
authors.affiliation: Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Gatzoulis
authors.affiliation: Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom. Electronic address: tom.wong@imperial.ac.uk.
authors.forename: Tom
authors.initials: T
authors.lastname: Wong
mesh_terms: D000328:Adult; D002304:Cardiac Pacing, Artificial / Q000009:adverse effects* / Q000379:methods; D058406:Cardiac Resynchronization Therapy / Q000379:methods*; D000080041:Congenitally Corrected Transposition of the Great Arteries; D005260:Female; D006327:Heart Block / Q000209:etiology* / Q000628:therapy*; D006352:Heart Ventricles / Q000503:physiopathology; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D014188:Transposition of Great Vessels / Q000150:complications*; D014463:Ultrasonography; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy; D018497:Ventricular Dysfunction, Right / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy; D055815:Young Adult
keywords: Cardiac pacing; Cardiac resynchronization; Congenital heart disease; Congenitally corrected transposition of the great arteries