Heart, Lung and Circulation
Original Article| Volume 32, ISSUE 3, P373-378, March 2023

Biventricular Function is Impaired in Right Ventricular Septal Pacing—A Prospective Study Using Myocardial Strain Imaging

Published:December 20, 2022DOI:


      Left ventricular (LV) dysfunction is known to occur after right ventricular (RV) pacing; the effect on RV function is less well studied. The aim of this study was to assess the impact of RV mid-septal pacing upon RV function using the novel parameters of speckle-tracking derived RV global longitudinal strain (RV GLS) and RV free wall strain (RV FWS), as well as the conventional parameters RV fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), and tricuspid annular systolic velocity (RV S').


      Thirty-two (32) consecutive patients with normal baseline LV and RV function requiring permanent pacemaker insertion (for high-grade AV block or sinus node dysfunction) were prospectively recruited. Echocardiography was performed prior to implantation, at 1 day, 1 month and 1 year after implantation, with 29 patients completing follow-up.


      After 1 year, three patients (10%) with otherwise normal RV parameters developed abnormal RV strain patterns. Compared to 1 day after implantation, at 1 year significant reductions were observed in mean RV GLS (-24.8 to -21.8%) RV S' (15.1 to 12.2 cm/s), TAPSE (24.2 to 21.9 mm), RV GLS (-24.8 to -21.8%), left ventricular ejection fraction (LVEF) (66.0 to 57.9%), LV GLS (-19.9 to 17.0), all p<0.01. There was a non-significant reduction for RV FWS (-29.0 to -26.7%, p=0.06) and there was no change in RV FAC (49.1 to 46.9%, p=0.24).


      We report abnormalities of RV strain developing 1 year after pacemaker insertion. Measurement of myocardial strain is emerging as an additional method to detect patients at risk of RV dysfunction in those who have undergone pacemaker implantation.


      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 to Heart, Lung and Circulation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kusumoto F.M.
        • Schoenfeld M.H.
        • Barrett C.
        • Edgerton J.R.
        • Ellenbogen K.A.
        • Gold M.R.
        • et al.
        2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.
        Circulation. 2019; 140: e382-e482
        • Sweeney M.O.
        • Hellkamp A.S.
        • Ellenbogen K.A.
        • Greenspon A.J.
        • Freedman R.A.
        • Lee K.L.
        • et al.
        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
        • Steinberg J.S.
        • Fischer A.
        • Wang P.
        • Schuger C.
        • Daubert J.
        • McNitt S.
        • et al.
        The clinical implications of cumulative right ventricular pacing in the multicenter automatic defibrillator trial II.
        J Cardiovasc Electrophysiol. 2005; 16: 359-365
        • Wilkoff B.L.
        • Cook J.R.
        • Epstein A.E.
        • Greene H.L.
        • Hallstrom A.P.
        • Hsia H.
        • et al.
        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
        • Flevari P.
        • Leftheriotis D.
        • Fountoulaki K.
        • Panou F.
        • Rigopoulos A.G.
        • Paraskevaidis I.
        • et al.
        Long-term nonoutflow septal versus apical right ventricular pacing: relation to left ventricular dyssynchrony.
        PACE. 2009; 32: 354-362
        • Hussain M.A.
        • Furuya-Kanamori L.
        • Kaye G.
        • Clark J.
        • Doi S.A.
        The effect of right ventricular apical and nonapical pacing on the short- and long-term changes in left ventricular ejection fraction: a systematic review and meta-analysis of randomized-controlled trials.
        PACE. 2015; 38: 1121-1136
        • Longobardo L.
        • Suma V.
        • Jain R.
        • Carerj S.
        • Zito C.
        • Zwicke D.L.
        • et al.
        Role of two-dimensional speckle-tracking echocardiography strain in the assessment of right ventricular systolic function and comparison with conventional parameters.
        J Am Soc Echocardiogr. 2017; 30: 937-946.e6
        • Mitchell C.
        • Rahko P.S.
        • Blauwet L.A.
        • Canaday B.
        • Finstuen J.A.
        • Foster M.C.
        • et al.
        Guidelines for performing a comprehensive transthoracic echocardiographic examination in adults: recommendations from the American Society of Echocardiography.
        J Am Soc Echocardiogr. 2019; 32: 1-64
        • Das A.
        • Kahali D.
        Ventricular septal pacing: Optimum method to position the lead.
        Indian Heart J. 2018; 70: 713-720
        • Mond H.G.
        • Hillock R.J.
        • Stevenson I.H.
        • McGavigan A.D.
        The right ventricular outflow tract: the road to septal pacing.
        PACE. 2007; 30: 482-491
        • Sharma A.D.
        • Rizo-Patron C.
        • Hallstrom A.P.
        • O'Neill G.P.
        • Rothbart S.
        • Martins J.B.
        • et al.
        Percent right ventricular pacing predicts outcomes in the DAVID trial.
        Heart Rhythm. 2005; 2: 830-834
        • Addetia K.
        • Miyoshi T.
        • Citro R.
        • Daimon M.
        • Gutierrez Fajardo P.
        • Kasliwal R.R.
        • et al.
        Two-dimensional echocardiographic right ventricular size and systolic function measurements stratified by sex, age, and ethnicity: results of the World Alliance of Societies of Echocardiography Study.
        J Am Soc Echocardiogr. 2021; 34: 1148-11457.e1
        • Chen J.Y.
        • Tsai W.C.
        • Liu Y.W.
        • Li W.H.
        • Li Y.H.
        • Tsai L.M.
        • et al.
        Long-term effect of septal or apical pacing on left and right ventricular function after permanent pacemaker implantation.
        Echocardiography. 2013; 30: 812-819
        • Vijayaraman P.
        • Chung M.K.
        • Dandamudi G.
        • Upadhyay G.A.
        • Krishnan K.
        • Crossley G.
        • et al.
        His bundle pacing.
        J Am Coll Cardiol. 2018; 72: 927-947
        • Amundsen B.H.
        • Helle-Valle T.
        • Edvardsen T.
        • Torp H.
        • Crosby J.
        • Lyseggen E.
        • et al.
        Noninvasive myocardial strain measurement by speckle tracking echocardiography: validation against sonomicrometry and tagged magnetic resonance imaging.
        J Am Coll Cardiol. 2006; 47: 789-793
        • Lu K.J.
        • Chen J.X.
        • Profitis K.
        • Kearney L.G.
        • DeSilva D.
        • Smith G.
        • et al.
        Right ventricular global longitudinal strain is an independent predictor of right ventricular function: a multimodality study of cardiac magnetic resonance imaging, real time three-dimensional echocardiography and speckle tracking echocardiography.
        Echocardiogr. 2015; 32: 966-974
        • Morris D.A.
        • Krisper M.
        • Nakatani S.
        • Köhncke C.
        • Otsuji Y.
        • Belyavskiy E.
        • et al.
        Normal range and usefulness of right ventricular systolic strain to detect subtle right ventricular systolic abnormalities in patients with heart failure: a multicentre study.
        Eur Heart J Cardiovasc Imaging. 2017; 18: 212-223
        • Nagy V.K.
        • Széplaki G.
        • Apor A.
        • Kutyifa V.
        • Kovács A.
        • Kosztin A.
        • et al.
        Role of right ventricular global longitudinal strain in predicting early and long-term mortality in cardiac resynchronization therapy patients.
        PloS one. 2015; 10e0143907
        • Mukherjee M.
        • Rudski L.G.
        It takes more than a village to get it right.
        J Am Soc Echocardiogr. 2021; 34: 1158-1159