Advanced Cardiac Imaging for Risk Prediction of Pacing-Induced Cardiomyopathy: A Narrative Literature Review

<b>Background/Objective</b>: Pacing-induced cardiomyopathy (PICM) is a common complication of right ventricular (RV) pacing, affecting 6-25% of patients with frequent RV pacing, due to electrical and mechanical dyssynchrony. Certain clinical and electrocardiographic risk factors have been identified, including high RV-pacing burden and longer paced QRS, but their ability to predict the development PICM remains limited. Additionally, other forms of PICM have been described, including heart failure with preserved ejection fraction and RV failure. The goal of this narrative review is to summarize the current evidence utilizing noninvasive imaging to identify patients predisposed to a high risk of PICM. <b>Methods</b>: Using a literature search in the PubMed, Scopus, Google Scholar, and the Cochrane databases from 2000 to 2025, which included but was not limited to the keywords right ventricular pacing, pacemaker-related cardiomyopathy, pacemaker-induced cardiomyopathy, biventricular pacing, conduction system pacing, His bundle pacing, left bundle pacing, echocardiography, computed tomography imaging, and cardiac magnetic resonance imaging, we reviewed randomized control trials, observational retrospective and prospective cohort studies, societal guidelines, and systematic review articles. <b>Conclusions</b>: Essential in the diagnosis of PICM, cardiac imaging can identify patients at risk, even before left ventricular (LV) dysfunction or symptoms develop. Pre- and early post-implantation 2- and 3-dimensional echocardiography with global longitudinal strain provides sensitive parameters for the potential development of PICM. Relative indices of contractile asymmetry have been described. Cardiac magnetic resonance imaging offers an accurate assessment of cardiac volumes and LV synchrony and can also quantify myocardial fibrosis, a significant predictor of PICM. Performing pre-device implantation imaging may help predict subsequent heart failure development and potentially can guide pacing modality selection that can mitigate this risk. Thus, an imaging-guided framework will advance the management of PICM.