Pacemaker Induced Cardiomyopathy??????

I had a dual lead PM placed 4/2015 for complete heart block with coronary sinus ventricle lead to avoid my surgically repaired tricuspid valve.  There was a dip in echocardiogram a few months later (7/15) in low 40% but the next 2 echos after that 2016 and 2017 showed normal ejection fraction (mid-high 50's). Coronary sinus lead appears to have lost capture sometime in late 2017 and a holter monitor in 9/2017 showed nearly 30% PVC burden. The next echo in 3/18 showed a 42% EF and PM was replaced in 5/18 due to lead losing capture and battery drain. Coronary sinus lead could not be removed so a RV lead was placed. Subsequent echos in 9/18 and this week do not show improvement with EF in low 40's and some mild/moderate RV/LV dilation. PM check the other day did show that ventricles had been paced 93% of the time and it was adjusted to increase delay and pace less of the time. Apparently my sinus node does talk to AV node some of the time so I guess I'm technically not in complete heart block?

All my issues seem to have started either with the high PVC burden and/or the change in pacing. Any idea how EP's cut through all the clutter to try and nail down what causes these types of issues as it seems incredibly complicated? Suggestions/comments?



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