Effect of Dual-Chamber Pacing on Systolic and Diastolic Function in Patients with Hypertrophic Cardiomyopathy: Acute Doppler Echocardiographic and Catheterization Hemodynamic Study

Objectives. This study sought to evaluate prospectively the acute hemodynamic effect of dual-chamber pacing by using a combined hemodynamic approach of high fidelity pressure and Doppler velocity measurements. Background. Dual-chamber pacing has been proposed recently as an alternative in the symptomatic treatment of patients with hypertrophic obstructive cardiomyopathy. Although early reports documented a decrease in left ventricular outflow tract gradient and symptomatic improvement, questions remain about the hemodynamic effects of dual-chamber pacing on systolic and diastolic function. Methods. Twenty-nine patients with hypertrophic cardiomyopathy underwent a combined cardiac catheterization and Doppler echocardiographic study during normal sinus rhythm and P-synchronous pacing at various atrioventricular (AV) intervals. High fidelity pressure measurements of left ventricular inflow and left atrial pressures, ascending aortic pressure, thermodilution cardiac output and Doppler mitral flow velocity curves were obtained to evaluate both systolic and diastolic left ventricular function. Results. During AV pacing at the shortest delay of 60 ms, there was a significant decrease in cardiac output (p < 0.05) and peak positive dP/dt (p < 0.05), an increase in mean left atrial pressure (p < 0.05) and a prolongation of T, the time constant of relaxation (p < 0.05), compared with that during normal sinus rhythm. During pacing at the optimal AV delay (longest AV interval with pre-excitation), there was a similar trend, with deterioration in both systolic and diastolic function variables but of lesser magnitude than that during pacing at the shortest AV intervals. The deterioration in both systolic and diastolic function was present in 21 patients with and 8 without left ventricular outflow obstruction. There was a modest decrease in left ventricular outflow tract gradient from 73.3 ± 45.0 (mean ± SD) to 61.3 ± 40.5 mm Hg (p = 0.03) during dual-chamber pacing at the optimal AV delay compared with that during normal sinus rhythm. Conclusions. The acute effect of pacing the right atrium and ventricle may be detrimental to both systolic and diastolic function of the left ventricle, particularly at the short AV intervals. Further studies of the long-term effects of dual-chamber pacing in carefully performed randomized studies are needed.