High right ventricular pacing burden is associated with heart failure following leadless pacemaker implantations
H Iwakawa, M Middeldorp, A Puvrez, S Kakarla, S Evans, T Deering, A Russo, J Freeman, A Kroman, E Fu, T Baykaner, S Mittal, B Donovan, R Leahy, P SandersAbstract
Background
Recent guidelines suggest that an RVP burden of 40% or more increases the risk of pacing-induced cardiomyopathy and heart failure (HF) in patients with transvenous pacemakers. However, the optimal RVP threshold for predicting HF in patients with leadless pacemakers (LP) is unclear.
Purpose
To assess the current RVP burden cutoff and explore how increased RVP burden influences HF development in patients with LPs.
Methods
Patients who underwent LP implantation from January 2015 to September 2025 were included. Patients with LPs implanted only in the right atrium were excluded. The RVP burden (%RVP) for each patient was extracted from the initial transmission via a vendor-neutral remote monitoring platform. The first date recorded with I50.x codes in ICD-10 was used to estimate the time to first HF after device implantation. These codes encompass all HF types, regardless of left ventricular ejection fraction (LVEF).
Results
We included 3210 patients with LPs, of whom the vast majority (99.4%) had a single-chamber device. The mean age was 76±13 years, 45.4% were female, and the baseline LVEF was 55.6±9.7%. Of 1769 patients with a documented LP indication, 1157 (65.4%) had atrioventricular (AV) block. The median %RVP was 70.1% [7.9–98.2%]. During a median follow-up of 2.3 [1.4–3.7] years, 589 (18.3%) patients experienced new-onset or worsened clinical HF. Patients with RVP ≥40% showed a higher incidence of HF than those with RVP <40% (P=0.0056) (Figure A). The multivariable Cox proportional hazards model, adjusted for age, sex, and AV block, showed that %RVP ≥95% was associated with a higher risk of HF than %RVP <10% (hazard ratio, 1.46 [1.16–1.84]), whereas the risk in %RVP from 10% to <95% did not differ significantly from that in %RVP <10% (Figure B).
Conclusions
The 40% RVP cutoff may be applicable for predicting HF in patients with LPs. However, the risk is most pronounced in patients who are highly dependent on RVP. These findings have implications for patient selection for LP.Figure