Alternatives to right ventricular pacing in patients with atrioventricular block: can we prevent pacing-induced cardiomyopathy?

INTRODUCTION

Right ventricular apical pacing (RVAP) has been a standard treatment for patients experiencing symptomatic advanced atrioventricular (AV) block. However, due to electrical and subsequent mechanical dyssynchrony, RVAP might lead to pacing-induced cardiomyopathy (PICM). Various predisposing risk factors for PICM have been identified.

AREAS COVERED: This review, based on a literature search of PubMed and Scopus databases (up to April 2025), focuses on alternative pacing strategies, including conduction system pacing (CSP) and biventricular pacing (BiVP), to reduce PICM.

EXPERT OPINION: Implementing pacing strategies that encourage physiological ventricular activation, like CSP and BiVP, can greatly diminish the risk of PICM in patients with AV block. Implementing alternative pacing strategies necessitates careful patient selection and consideration of individual anatomical and clinical factors. A team-based approach should be utilized to identify the most suitable pacing method for each patient, with the goal of optimizing cardiac function and reducing the risk of PICM.