Pacing Induced Cardiomyopathy: What is The Solution?

  • Maruli Wisnu Wardhana Butarbutar Cardiology and Vascular Medicine Resident, National Cardiovascular Center Harapan Kita, Medical Faculty of University of Indonesia, Jakarta – Indonesia
  • Sunu Budhi Raharjo Division of Arrhythmia, National Cardiovascular Center Harapan Kita, Department of Cardiology and Vascular Medicine, Medical Faculty of University of Indonesia, Jakarta – Indonesia
Keywords: Pacemaker, Cardiomyopathy, CRT, HBP




Right ventricular pacing is associated with adverse outcome including increased risks of cardiovascular morbidity and mortality. RV pacing causes abnormal ventricular activation results in an inefficient contraction pattern with ventricular dyssynchrony and loss of myocardial work that may lead to LV dilation, systolic dysfunction, and clinical HF. Pacing induced cardiomyopathy (PICM) is caused by chronic and high burden RV pacing that may occur several months or years after pacemaker implantation.



To present a case of pacing induced cardiomyopathy (PICM) managed by CRT-P implantation.


Case Illustration

A male, 56 years old, was referred from dr. M. Djamil General Hospital with CHF Fc II-III, s/p PPM DDDR due to high degree AV block (2016) and history of failed CRT-P implantation (2018). He complained DOE (+), PND (+) and OP (+) since April 2017. Physical examination revealed pansystolic murmur grade 2/6 at apex, no rales and no oedema at both legs. ECG showed pacing rhythm and intrinsic rhythm was type 2 second degree AV block and RBBB with QRS duration 150 ms. Echocardiography showed global hypokinetic and dilated LV (LV EDD 71 mm, LV ESD 63 mm) with progressively reduced EF 38% à  33% (Simpson), functional moderate MR and mild TR. CAG showed non-significant coronary artery stenosis with 20% stenosis at distal LAD. Patient was diagnosed as pacing induced cardiomyopathy (PICM). At catheter laboratory, there was stenosis of left subclavian vein. His-Bundle pacing (HBP) was planned at first, however CRT-P with biventricular epicardial pacing was then performed in which LV lead was inserted through right axillary vein. During follow up at general ward, ECG showed biventricular pacing rhythm. There was no signs and symptoms of heart failure. Patient was hospitalized for 3 days and then discharged in a good condition.





We reported a case of pacing induced cardiomyopathy in male patient 56 years old. Pacing induced cardiomyopathy is a complication of high burden RV pacing. Options to treat PICM once it has developed, or to prevent it from developing in the first place, may include conduction system pacing (e.g.: HBP) or CRT-P implantation.



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1. Ferrari ADL, Borges AP, Albuquerque LC, Sussenbach CP, da Rosa PR, Piantá RM, et al. Miocardiopatia dilatada induzida por estimulação cardíaca artificial: Mito ou realidade sustentada pelas evidências? Brazilian J Cardiovasc Surg. 2014;29(3):402–13.
2. Merchant FM, Mittal S. Pacing induced cardiomyopathy. J Cardiovasc Electrophysiol. 2020;31(1):286–92.
3. Kaye G, Ng JY, Ahmed S, Valencia D, Harrop D, Ng ACT. The Prevalence of Pacing-Induced Cardiomyopathy (PICM) in Patients With Long Term Right Ventricular Pacing − Is it a Matter Of Definition? Hear Lung Circ [Internet]. 2019;28(7):1027–33. Available from:
4. Khurshid S, Epstein AE, Verdino RJ, Lin D, Goldberg LR, Marchlinski FE, et al. Incidence and predictors of right ventricular pacing-induced cardiomyopathy. Hear Rhythm [Internet]. 2014;11(9):1619–25. Available from:
5. Kiehl EL, Makki T, Kumar R, Gumber D, Kwon DH, Rickard JW, et al. Incidence and predictors of right ventricular pacing-induced cardiomyopathy in patients with complete atrioventricular block and preserved left ventricular systolic function. Hear Rhythm [Internet]. 2016;13(12):2272–8. Available from:
6. Tayal B, Fruelund P, Sogaard P, Riahi S, Polcwiartek C, Atwater BD, et al. Incidence of heart failure after pacemaker implantation: A nationwide Danish Registry-based follow-up study. Eur Heart J. 2019;40(44):3641–8.
7. Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, et al. 213 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J. 2013;34(29):2281–329.
8. Khurshid S, Obeng-Gyimah E, Supple GE, Schaller R, Lin D, Owens AT, et al. Reversal of Pacing-Induced Cardiomyopathy Following Cardiac Resynchronization Therapy. JACC Clin Electrophysiol [Internet]. 2018;4(2):168–77. Available from:
9. Yu CM, Chau E, Sanderson JE, Fan K, Tang MO, Fung WH, et al. Tissue Doppler echocardiographic evidence of reverse remodeling and improved synchronicity by simultaneously delaying regional contraction after biventricular pacing therapy in heart failure. Circulation. 2002;105(4):438–45.
10. Vijayaraman P, Herweg B, Dandamudi G, Mittal S, Bhatt AG, Marcantoni L, et al. Outcomes of His-bundle pacing upgrade after long-term right ventricular pacing and/or pacing-induced cardiomyopathy: Insights into disease progression. Hear Rhythm [Internet]. 2019;16(10):1554–61. Available from:
11. Abu-El-Haija B, Bhave PD, Campbell DN, Mazur A, Hodgson-Zingman DM, Cotarlan V, et al. Venous Stenosis After Transvenous Lead Placement: A Study of Outcomes and Risk Factors in 212 Consecutive Patients. J Am Heart Assoc. 2015;4(8):e001878.
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How to Cite
Butarbutar, M., & Raharjo, S. (2022). Pacing Induced Cardiomyopathy: What is The Solution?. Indonesian Journal of Cardiology, 43(1), 37-44.