51
|
Fang F, Luo XX, Zhang Q, Azlan H, Razali O, Ma Z, Gan SF, Xie JM, Yu CM. Deterioration of left ventricular systolic function in extended Pacing to Avoid Cardiac Enlargement (PACE) trial: the predictive value of early systolic dyssynchrony. Europace 2016; 17 Suppl 2:ii47-53. [PMID: 26842115 DOI: 10.1093/europace/euv130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
AIMS Biventricular (BiV) pacing was superior to right ventricular apical (RVA) pacing at extended follow-up in the Pacing to Avoid Cardiac Enlargement (PACE) trial. Early pacing-induced systolic dyssynchrony (DYS) might be related to mid-term result. However, it remains unknown whether early pacing-induced DYS can predict long-term reduction of left ventricular (LV) systolic function. METHODS AND RESULTS Patients with standard pacing indications and normal LV ejection fraction (LVEF) were randomized either to BiV (n = 89) or RVA (n = 88) pacing. Seventy-four patients in the RVA group and 72 in the BiV pacing group completed follow-up longer than 2 years. Serial echocardiography was performed with DYS assessed by tissue Doppler imaging, and the early pacing-induced DYS was defined as >33 ms by using standard deviation of the time to peak systolic velocity (Dyssynchrony Index) in a 12-segment model of LV at 1 month. There were 46 (32%) patients having early pacing-induced DYS that was more prevalent in the RVA pacing group than that in the BiV pacing group (50.7 vs. 12.3%, χ(2) = 25.1, P < 0.001) despite the similar DYS between the two groups at baseline (30 ± 13 vs. 26 ± 11 ms, P = 0.051). At a median follow-up of 4.8 years, patients developing early DYS had lower LVEF (53.2 ± 9.4 vs. 60.9 ± 8.0%, P < 0.001) and larger LV end-systolic volume (40.3 ± 23.7 vs. 29.3 ± 13.4 mL, P < 0.001) than those without DYS. Significant EF reduction (defined as ≥5%) occurred in 71.7% (33 in 46) of patients with DYS, but only in 30% (30 in 100) in those without DYS (χ(2) = 22.4, P < 0.001). Further analysis showed that both DYS at 1 month [odds ratio (OR): 3.113, P = 0.013] and RVA pacing (OR: 7.873, P < 0.001) independently predicted the deterioration of LV systolic function with pacing period of 4.8 years. CONCLUSION Early pacing-induced DYS is a significant predictor of reduction of LV systolic function for long-term pacing, which could be prevented by BiV pacing at relatively long-period follow-up. CLINICAL TRIAL REGISTRATION Centre for Clinical Trials number, CUHK_CCT00037 (URL: http://www.cct.cuhk.edu.hk/Registry/publictrialrecord.aspx?trialid=CUHK_CCT00037).
Collapse
Affiliation(s)
- Fang Fang
- Division of Cardiology, Department of Medicine and Therapeutics, Institute of Vascular Medicine, Institute of Innovative Medicine, Heart Education And Research Training (HEART) Center, and Li Ka Shing Institute of Health Sciences, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong SAR
| | - Xiu-Xia Luo
- Division of Cardiology, Department of Medicine and Therapeutics, Institute of Vascular Medicine, Institute of Innovative Medicine, Heart Education And Research Training (HEART) Center, and Li Ka Shing Institute of Health Sciences, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong SAR
| | - Qing Zhang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Hussin Azlan
- Department of Cardiology, National Heart Institute, Kuala Lumpur, Malaysia
| | - Omar Razali
- Department of Cardiology, National Heart Institute, Kuala Lumpur, Malaysia
| | - Zhan Ma
- Department of Cardiology, Beijing Jishuitan Hospital, Peking University, Beijing, China
| | - Shu-Fen Gan
- Department of Ultrasound, Xiamen Zhongshan Hospital, Xiamen, China
| | - Jun-Min Xie
- Division of Cardiology, Department of Medicine and Therapeutics, Institute of Vascular Medicine, Institute of Innovative Medicine, Heart Education And Research Training (HEART) Center, and Li Ka Shing Institute of Health Sciences, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong SAR
| | - Cheuk-Man Yu
- Division of Cardiology, Department of Medicine and Therapeutics, Institute of Vascular Medicine, Institute of Innovative Medicine, Heart Education And Research Training (HEART) Center, and Li Ka Shing Institute of Health Sciences, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong SAR
| |
Collapse
|
52
|
Israel CW, Ekosso-Ejangue L, Sheta MK. [Device therapy of chronic heart failure: Update 2015]. Herz 2015; 40:1121-32; quiz 1133-4. [PMID: 26631395 DOI: 10.1007/s00059-015-4375-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cardiac pacemakers, implantable cardioverter defibrillators (ICD) and systems for cardiac resynchronization therapy (CRT) represent an important component of heart failure therapy. Pacemakers only play a role in bradycardia-associated heart failure and require optimal programming to prevent ventricular desynchronization. Primary prophylactic ICD implantation is indicated in patients with a left ventricular ejection fraction of ≤ 35 %, clinical stages NYHA II-III and a life expectancy > 1 year. The CRT is indicated in patients with a left bundle branch block but only in individual cases for other QRS morphologies of < 150 ms duration. The combination of CRT with a pacemaker or defibrillator must be decided on an individual basis. Device therapy in heart failure should always include remote monitoring to detect events early and to implement treatment accordingly. New developments include quadripolar left ventricular leads and pacing from multiple sites simultaneously thus enabling better resynchronization. Stimulation for modulation of cardiac contractility and the autonomous nervous system are currently being clinically tested. The optimal utilization of device therapy improves the course of heart failure and prevents cardiac decompensation and fatalities.
Collapse
Affiliation(s)
- C W Israel
- Klinik für Innere Medizin - Kardiologie, Diabetologie & Nephrologie, Evangelisches Krankenhaus Bielefeld, Burgsteig 13, 33617, Bielefeld, Deutschland.
| | - L Ekosso-Ejangue
- Klinik für Innere Medizin - Kardiologie, Diabetologie & Nephrologie, Evangelisches Krankenhaus Bielefeld, Burgsteig 13, 33617, Bielefeld, Deutschland
| | - M-K Sheta
- Klinik für Innere Medizin - Kardiologie, Diabetologie & Nephrologie, Evangelisches Krankenhaus Bielefeld, Burgsteig 13, 33617, Bielefeld, Deutschland
| |
Collapse
|
53
|
Kaye G. Pacing site in pacemaker dependency: is right ventricular septal lead position the answer? Expert Rev Cardiovasc Ther 2015; 12:1407-17. [PMID: 25418757 DOI: 10.1586/14779072.2014.979791] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The right ventricular apex has been the traditional site for lead placement in patients with atrioventricular block. Pacing at the right ventricular apex may have long-term deleterious effects on left ventricular (LV) function, promoting heart failure and increasing mortality. Pacing at the right ventricular septum has been proposed to minimize deterioration in LV function. Although experimental data suggest that septal pacing protects LV function, clinical studies have provided conflicting results. A recent large study in patients with heart block did not show a protective effect with septal pacing. Other pacing approaches are becoming increasingly relevant; however, prediction of what method should be employed in which patient is not currently possible. Other factors such as baseline LV function and associated co-morbidities impact LV function, irrespective of pacing site. Continued monitoring of cardiac function post-implant is therefore critical to ongoing care. An algorithm for managing patients with atrioventricular block is proposed.
Collapse
Affiliation(s)
- Gerry Kaye
- Department of Cardiology, Princess Alexandra Hospital, Woolloongabba and University of Queensland, Brisbane 4102, Australia
| |
Collapse
|
54
|
Herweg B, Singh R, Barold SS. Cardiac resynchronization therapy is appropriate for all patients requiring chronic right ventricular pacing: the pro perspective. Card Electrophysiol Clin 2015; 7:433-44. [PMID: 26304523 DOI: 10.1016/j.ccep.2015.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Long-term right ventricular pacing has deleterious effects on the left ventricle (LV). The risk of pacemaker-induced cardiomyopathy (PICM) seems to be lower in patients with a normal LV ejection fraction (LVEF). Patients developing PICM respond favorably to a cardiac resynchronization therapy upgrade, suggesting that the dysfunction is partially reversible. Biventricular pacing has emerged as a treatment and/or prevention of PICM. Cumulative pacing greater than 40% of the time is considered the most important risk factor for PICM. No organizational guidelines exist for preventive biventricular pacing. The decision to pursue biventricular pacing should be individualized.
Collapse
Affiliation(s)
- Bengt Herweg
- Electrophysiology and Arrhythmia Services, Department of Cardiovascular Disease, Tampa General Hospital, University of South Florida Morsani College of Medicine, South Tampa Campus (5th Floor), Two Tampa General Circle, Tampa, FL 33606, USA.
| | - Robin Singh
- Department of Cardiovascular Disease, Tampa General Hospital, University of South Florida Morsani College of Medicine, South Tampa Campus (5th Floor), Two Tampa General Circle, Tampa, FL 33606, USA
| | - S Serge Barold
- Clinical Cardiac Electrophysiology, Department of Cardiovascular Disease, University of Rochester Medical Center, 2613 W Henrietta Road, Rochester, NY 14623, USA
| |
Collapse
|
55
|
Ruwald MH. Co-Morbidities and Cardiac Resynchronization Therapy: When Should They Modify Patient Selection? J Atr Fibrillation 2015; 8:1238. [PMID: 27957175 DOI: 10.4022/jafib.1238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 06/16/2015] [Accepted: 06/17/2015] [Indexed: 11/10/2022]
Abstract
Cardiac resynchronization therapy (CRT) improves symptoms, reduces heart failure related hospitalizations and death in selected patients with heart failure. Based on thousands of patients enrolled in major clinical landmark trials, current guidelines describe in relatively precise terms which cardiac patients should receive a device. However, clinical trials often excluded sicker patients leaving clinicians with the dilemma of how to treat real-life patients with major co-morbidities, frailty, and increasing age, who are otherwise candidates for CRT implantation. This review investigates results from clinical trials and available observational data on the influence of co-morbidities on CRT benefit in order to provide better insight of when and why co-morbidities should modify patient selection for CRT.
Collapse
|
56
|
Hai OY, Mentz RJ, Zannad F, Gasparini M, De Ferrari GM, Daubert JC, Holzmeister J, Lam CS, Pochet T, Vincent A, Linde C. Cardiac resynchronization therapy in heart failure patients with less severe left ventricular dysfunction. Eur J Heart Fail 2014; 17:135-43. [DOI: 10.1002/ejhf.208] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 10/20/2014] [Accepted: 10/24/2014] [Indexed: 01/14/2023] Open
Affiliation(s)
- Ofek Y. Hai
- Division of Cardiovascular Medicine, Department of Medicine; State University of New York (SUNY) Downstate Medical Center; Brooklyn NY USA
| | - Robert J. Mentz
- Division of Cardiology, Department of Medicine; Duke University Medical Center; Durham NC USA
| | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques; Université de Lorraine and CHU de Nancy; Nancy France
| | | | - Gaetano M. De Ferrari
- Department of Cardiology and Cardiovascular Clinical Research Center; Fondaizone IRCCS Policlinico San Matteo; Pavia Italy
| | - Jean-Claude Daubert
- Cardiology Department and CIC-IT U804; Centre Hospitalier Universitaire; Rennes France
| | - Johannes Holzmeister
- Cardiovascular Center, Cardiology; University Hospital Zurich; Zurich Switzerland
| | | | - Thierry Pochet
- Global Clinical Trials; Rhythm Management, Boston Scientific; Diegem Belgium
| | | | - Cecilia Linde
- Karolinska Institutet, Department of Medicine, and Karolinska University Hospital; Department of Cardiology; Stockholm Sweden
| |
Collapse
|
57
|
Linde C. How do patients with previous RV pacing respond to upgrading to CRT? Important messages for pacemaker and ICD follow-up. Eur J Heart Fail 2014; 16:1157-9. [PMID: 25367226 DOI: 10.1002/ejhf.189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Cecilia Linde
- Karolinska Institutet, Department of Medicine, Stockholm, Sweden; Karolinska University Hospital, Department of Cardiology, Stockholm, Sweden
| |
Collapse
|
58
|
Yu CM, Fang F, Luo XX, Zhang Q, Azlan H, Razali O. Long-term follow-up results of the pacing to avoid cardiac enlargement (PACE) trial. Eur J Heart Fail 2014; 16:1016-25. [PMID: 25179592 DOI: 10.1002/ejhf.157] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 08/04/2014] [Accepted: 08/05/2014] [Indexed: 11/10/2022] Open
Abstract
AIMS We report the results of long-term follow-up of the Pacing to Avoid Cardiac Enlargement (PACE) trial, a prospective, double-blinded, randomized, multicentre study that confirmed the superiority of biventricular (BiV) pacing compared with right ventricular apical (RVA) pacing in prevention of LV adverse remodelling and deterioration of systolic function at 1 and 2 years. METHODS AND RESULTS Patients with bradycardia and preserved LVEF were randomized to receive RVA (n = 88) or BiV pacing (n = 89). Co-primary endpoints were LV end-systolic volume (LVESV) and LVEF measured by echocardiography. There were 149 patients who had extended follow-up, with a mean duration of 4.8 ± 1.5 years (2.5-7.8 years). The primary endpoint analyses were performed in 146 patients (74 in the RVA group and 72 in the BiV group). In the RVA pacing group, the LVEF decreased while the LVESV increased progressively at follow-up, but remained unchanged in the BiV pacing group. The differences in LVEF between the RVA and BiV groups were -6.3, -9.2, and -10.7% at 1-year, 2-year, and long-term follow-up, respectively (all P < 0.001). The corresponding differences in LVESV were +7.4, +9.9, and +13.1 mL, respectively (all P < 0.001). The deleterious effects of RVA pacing consistently occurred in all the pre-defined subgroups. Furthermore, patients with RVA pacing had a significantly higher prevalence of heart failure hospitalization than the BiV group (23.9% vs. 14.6%, log-rank χ² = 7.55, P = 0.006). CONCLUSION Left ventricular adverse remodelling and deterioration of systolic function continued at long-term follow-up in patients with RVA pacing; this deterioration was prevented by the use of BiV pacing. Also, heart failure hospitalization was more prevalent in the RVA pacing group.
Collapse
Affiliation(s)
- Cheuk-Man Yu
- Division of Cardiology, Department of Medicine and Therapeutics; Institute of Vascular Medicine; Institute of Innovative Medicine; Heart Education and Research Training (HEART) Center; and Li Ka Shing Institute of Health Sciences; Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | | | | | | | | | | |
Collapse
|