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González-Matos CE, Rodríguez-Queralto O, Záraket F, Jiménez J, Casteigt B, Vallès E. Conduction System Stimulation to Avoid Left Ventricle Dysfunction. Circ Arrhythm Electrophysiol 2024; 17:e012473. [PMID: 38284238 DOI: 10.1161/circep.123.012473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/03/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Right ventricular apical pacing (RVAP) can produce left ventricle dysfunction. Conduction system pacing (CSP) has been used successfully to reverse left ventricle dysfunction in patients with left bundle branch block. To date, data about CSP prevention of left ventricle dysfunction in patients with preserved left ventricular ejection fraction (LVEF) are scarce and limited mostly to nonrandomized studies. Our aim is to demonstrate that CSP can preserve normal ventricular function compared with RVAP in the setting of a high burden of ventricular pacing. METHODS Consecutive patients with a high-degree atrioventricular block and preserved or mildly deteriorated LVEF (>40%) were included in this prospective, randomized, parallel, controlled study, comparing conventional RVAP versus CSP. RESULTS Seventy-five patients were randomized, with no differences between basal characteristics in both groups. The stimulated QRS duration was significantly longer in the RVAP group compared with the CSP group (160.4±18.1 versus 124.2±20.2 ms; p<0.01). Seventy patients were included in the intention-to-treat analyses. LVEF showed a significant decrease in the RVAP group at 6 months compared with the CSP group (mean difference, -5.8% [95% CI, -9.6% to -2%]; P<0.01). Left ventricular end-diastolic diameter showed an increase in the RVAP group compared with the CSP group (mean difference, 3.2 [95% CI, 0.1-6.2] mm; P=0.04). Heart failure-related admissions were higher in the RVAP group (22.6% versus 5.1%; P=0.03). CONCLUSIONS Conduction system stimulation prevents LVEF deterioration and heart failure-related admissions in patients with normal or mildly deteriorated LVEF requiring a high burden of ventricular pacing. These results are only short term and need to be confirmed by further larger studies. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT06026683.
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Affiliation(s)
- Carlos E González-Matos
- Electrophysiology Unit, Cardiology Department, Hospital del Mar, Barcelona, Spain (C.E.G.-M., O.R.-Q., F.Z., J.J., B.C., E.V.)
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain (C.E.G.-M., E.V.)
- Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain (C.E.G.-M., O.R.-Q., F.Z., J.J., B.C., E.V.)
- Universitat Pompeu Fabra, Barcelona, Spain (C.E.G.-M., E.V.)
| | - Oriol Rodríguez-Queralto
- Electrophysiology Unit, Cardiology Department, Hospital del Mar, Barcelona, Spain (C.E.G.-M., O.R.-Q., F.Z., J.J., B.C., E.V.)
- Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain (C.E.G.-M., O.R.-Q., F.Z., J.J., B.C., E.V.)
| | - Fátima Záraket
- Electrophysiology Unit, Cardiology Department, Hospital del Mar, Barcelona, Spain (C.E.G.-M., O.R.-Q., F.Z., J.J., B.C., E.V.)
- Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain (C.E.G.-M., O.R.-Q., F.Z., J.J., B.C., E.V.)
| | - Jesús Jiménez
- Electrophysiology Unit, Cardiology Department, Hospital del Mar, Barcelona, Spain (C.E.G.-M., O.R.-Q., F.Z., J.J., B.C., E.V.)
- Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain (C.E.G.-M., O.R.-Q., F.Z., J.J., B.C., E.V.)
| | - Benjamín Casteigt
- Electrophysiology Unit, Cardiology Department, Hospital del Mar, Barcelona, Spain (C.E.G.-M., O.R.-Q., F.Z., J.J., B.C., E.V.)
- Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain (C.E.G.-M., O.R.-Q., F.Z., J.J., B.C., E.V.)
| | - Ermengol Vallès
- Electrophysiology Unit, Cardiology Department, Hospital del Mar, Barcelona, Spain (C.E.G.-M., O.R.-Q., F.Z., J.J., B.C., E.V.)
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain (C.E.G.-M., E.V.)
- Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain (C.E.G.-M., O.R.-Q., F.Z., J.J., B.C., E.V.)
- Universitat Pompeu Fabra, Barcelona, Spain (C.E.G.-M., E.V.)
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de Zuloaga C, Ferrari A. Electrophysiological demonstration of nonselective His-Purkinje system capture with para-Hisian pacing. J Electrocardiol 2023; 79:38-45. [PMID: 36934491 DOI: 10.1016/j.jelectrocard.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 02/24/2023] [Accepted: 03/02/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND The adverse effects of conventional right ventricular (RV) apical pacing prompted the search for more physiological pacing sites, such as selective and nonselective His bundle pacing (HBP), a variant of nonselective HBP (para-Hisian pacing), and mid-septal pacing. However, knowledge of their true benefit on the physiology of ventricular activation, lead stability, and pacing thresholds is limited. METHODS AND RESULTS We included 152 consecutive patients (mean age 61 ± 24, 63% men) in this retrospective study. Of these, 137 patients with different bradyarrhythmias underwent active fixation lead implantation at the RV apex (n = 54), para-Hisian region (n = 66), or mid interventricular septum (n = 17). Fifteen patients with ventricular preexcitation due to an accessory pathway not undergoing pacing were included as controls. A 12‑lead ECG was recorded in all patients, and cardiac electrical synchrony was assessed using the Synchromax® cross-correlation cardiac synchrony index (CSI). RESULTS QRS duration was prolonged in all pacing sites: from 114 ± 28 to 160 ± 29 (RV apex), from 110 ± 28 to 122 ± 29 (para-Hisian), and from 121 ± 24 to 154 ± 30 (mid interventricular septum). The CSI was significantly improved only in patients undergoing para-Hisian pacing, despite a slight widening of the QRS interval. There was no difference in pacing thresholds and sensed R-wave voltage between pacing sites. Only 1 lead, implanted at the para-Hisian region (1.5%), was dislodged towards the mid septum 48 h after implantation but did not require repositioning. CONCLUSIONS QRS duration was not associated with changes in CSI, meaning that QRS width does not significantly affect electrical synchrony.
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Affiliation(s)
- Claudio de Zuloaga
- Hospital Nacional Profesor Alejandro Posadas, Ecuador 1449 10ª "B" (CABA), Buenos Aires, Argentina.
| | - Andrés Ferrari
- Arrhythmias and Cardiac Pacing Unit, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Av. Ipiranga, Porto Alegre 6690, RS, Brazil
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Mizner J, Jurak P, Linkova H, Smisek R, Curila K. Ventricular Dyssynchrony and Pacing-induced Cardiomyopathy in Patients with Pacemakers, the Utility of Ultra-high-frequency ECG and Other Dyssynchrony Assessment Tools. Arrhythm Electrophysiol Rev 2022; 11:e17. [PMID: 35990106 PMCID: PMC9376832 DOI: 10.15420/aer.2022.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 04/09/2022] [Indexed: 11/23/2022] Open
Abstract
The majority of patients tolerate right ventricular pacing well; however, some patients manifest signs of heart failure after pacemaker implantation and develop pacing-induced cardiomyopathy. This is a consequence of non-physiological ventricular activation bypassing the conduction system. Ventricular dyssynchrony was identified as one of the main factors responsible for pacing-induced cardiomyopathy development. Currently, methods that would allow rapid and reliable ventricular dyssynchrony assessment, ideally during the implant procedure, are lacking. Paced QRS duration is an imperfect marker of dyssynchrony, and methods based on body surface mapping, electrocardiographic imaging or echocardiography are laborious and time-consuming, and can be difficult to use during the implantation procedure. However, the ventricular activation sequence can be readily displayed from the chest leads using an ultra-high-frequency ECG. It can be performed during the implantation procedure to visualise ventricular depolarisation and resultant ventricular dyssynchrony during pacing. This information can assist the electrophysiologist in selecting a pacing location that avoids dyssynchronous ventricular activation.
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Affiliation(s)
- Jan Mizner
- Department of Cardiology, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Pavel Jurak
- Institute of Scientific Instruments of the Czech Academy of Sciences, Brno, Czech Republic
| | - Hana Linkova
- Department of Cardiology, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Radovan Smisek
- Institute of Scientific Instruments of the Czech Academy of Sciences, Brno, Czech Republic
| | - Karol Curila
- Department of Cardiology, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
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Fan L, Yao J, Wang L, Xu D, Tang D. Optimization of Left Ventricle Pace Maker Location Using Echo-Based Fluid-Structure Interaction Models. Front Physiol 2022; 13:843421. [PMID: 35250642 PMCID: PMC8892190 DOI: 10.3389/fphys.2022.843421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 01/26/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Cardiac pacing has been an effective treatment in the management of patients with bradyarrhythmia and tachyarrhythmia. Different pacemaker location has different responses, and pacemaker effectiveness to each individual can also be different. A novel image-based ventricle animal modeling approach was proposed to optimize ventricular pacemaker site for better cardiac outcome. Method One health female adult pig (weight 42.5 kg) was used to make a pacing animal model with different ventricle pacing locations. Ventricle surface electric signal, blood pressure and echo image were acquired 15 min after the pacemaker was implanted. Echo-based left ventricle fluid-structure interaction models were constructed to perform ventricle function analysis and investigate impact of pacemaker location on cardiac outcome. With the measured electric signal map from the pig associated with the actual pacemaker site, electric potential conduction of myocardium was modeled by material stiffening and softening in our model, with stiffening simulating contraction and softening simulating relaxation. Ventricle model without pacemaker (NP model) and three ventricle models with the following pacemaker locations were simulated: right ventricular apex (RVA model), posterior interventricular septum (PIVS model) and right ventricular outflow tract (RVOT model). Since higher peak flow velocity, flow shear stress (FSS), ventricle stress and strain are linked to better cardiac function, those data were collected for model comparisons. Results At the peak of filling, velocity magnitude, FSS, stress and strain for RVOT and PIVS models were 13%, 45%, 18%, 13% and 5%, 30%, 10%, 5% higher than NP model, respectively. At the peak of ejection, velocity magnitude, FSS, stress and strain for RVOT and PIVS models were 50%, 44%, 54%, 59% and 23%, 36%, 39%, 53% higher than NP model, respectively. RVA model had lower velocity, FSS, stress and strain than NP model. RVOT model had higher peak flow velocity and stress/strain than PIVS model. It indicated RVOT pacemaker site may be the best location. Conclusion This preliminary study indicated that RVOT model had the best performance among the four models compared. This modeling approach could be used as “virtual surgery” to try various pacemaker locations and avoid risky and dangerous surgical experiments on real patients.
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Affiliation(s)
- Longling Fan
- Faculty of Science, Kunming University of Science and Technology, Kunming, China
- School of Mathematics, Southeast University, Nanjing, China
| | - Jing Yao
- Department of Ultrasound Medicine, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- *Correspondence: Jing Yao,
| | - Liang Wang
- School of Biological Science and Medical Engineering, Southeast University, Nanjing, China
| | - Di Xu
- Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Dalin Tang
- School of Biological Science and Medical Engineering, Southeast University, Nanjing, China
- Mathematical Sciences Department, Worcester Polytechnic Institute, Worcester, MA, United States
- Dalin Tang,
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Ferrari ADL, Gazzoni GF, Domingues LML, Willes JCF, Cabral GC, Ferreira FVC, Lodi LO, Reis G. Sincronia Ventricular na Estimulação Cardíaca Parahissiana: Alternativa por Ativação Cardíaca Fisiológica (Estimulação Indireta do Feixe de His)? Arq Bras Cardiol 2021; 118:488-502. [PMID: 35262586 PMCID: PMC8856677 DOI: 10.36660/abc.20201233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/24/2021] [Indexed: 11/23/2022] Open
Abstract
Fundamento A estimulação cardíaca artificial (ECA) por captura direta ou indireta do feixe de His resulta em contração ventricular sincrônica (ECA fisiológica). Objetivos Comparar sincronia cardíaca, características técnicas e resultados de parâmetros eletrônicos entre duas técnicas de ECA indireta do feixe de His: a não seletiva e a parahissiana. Métodos Intervenção experimental (novembro de 2019 a abril de 2020) com implante de marca-passo definitivo (MPd) DDD em pacientes com fração de ejeção ventricular esquerda > 35%. Foram comparadas a sincronia cardíaca resultante mediante algoritmo de análise eletrocardiográfica da variância espacial do QRS e as características técnicas associadas a cada método entre ECA hissiana não seletiva (DDD-His) e parahissiana (DDD-Var). Resultados De 51 pacientes (28 homens), 34 (66,7%) foram alocados no grupo DDD-Var e 17 (33,3%), no grupo DDD-His, com idade média de 74 e 79 anos, respectivamente. No grupo DDD-Var, a análise da variância espacial do QRS (índice de sincronia ventricular) mostrou melhora após o implante de MPd (p < 0,001). Ao ECG pós-implante, 91,2% dos pacientes do grupo DDD-Var mostraram padrão fisiológico de ECA, comprovando ativação similar à do DDD-His (88,2%; p = 0,999). O eixo do QRS estimulado também foi similar (fisiológico) para ambos os grupos. A mediana do tempo de fluoroscopia do implante foi de 7 minutos no grupo DDD-Var e de 21 minutos no DDD-His (p < 0,001), favorecendo a técnica parahissiana. A duração média do QRS aumentou nos pacientes do DDD-Var (114,7 ms pré-MPd e 128,2 ms pós-implante, p = 0,044). A detecção da onda R foi de 11,2 mV no grupo DDD-Var e de 6,0 mV no DDD-His (p = 0,001). Conclusão A ECA parahissiana comprova recrutamento indireto do feixe de His, mostrando-se uma estratégia eficaz e comparável à ECA fisiológica ao resultar em contração ventricular sincrônica similar à obtida por captura hissiana não seletiva.
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Abstract
Background: The detrimental outcomes of right ventricular pacing on left ventricular electromechanical function ultimately result in heart failure, a phenomenon termed pacing-induced cardiomyopathy (PICM) in clinical research. This study aimed to validate prognostic factors that can be used to identify patients with higher susceptibility to progress to the stage of cardiomyopathy before pacemaker implantation. Methods: This observational analysis enrolled 256 patients between January 2013 and June 2016, 23 (8.98%) of whom progressed to PICM after 1 year of follow-up. A Cox proportional hazard model was used to analyze the prognostic factors associated with PICM. Dose-response analysis was used to evaluate the relationship between significant indicators in multifactor analysis and PICM. Results: The mean values of left ventricular ejection fraction before and after pacemaker implantation in 23 patients diagnosed with PICM were 62.3% and 42.7%, respectively. Univariate analysis showed that sex, atrio-ventricular block, paced QRS duration, and ventricular pacing percentage were significantly associated with PICM. In the multivariate analysis, male sex (hazard ratio: 1.20, 95% confidence interval [CI]: 1.09–1.33, P < 0.005), paced QRS duration (hazard ratio: 1.95 per 1 ms increase, 95% CI: 1.80–2.12, P < 0.001), and ventricular pacing percentage (hazard ratio: 1.65 per 1% increase, 95% CI: 1.51–1.79, P < 0.001) were independent prognostic factors associated with the development of PICM. The ventricular pacing percentage and paced QRS duration level defined by the dose-response analysis were positively associated with PICM (P < 0.05). Conclusions: Our findings indicated that paced QRS duration and ventricular pacing percentage were the most sensitive prognostic factors for PICM.
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Liu P, Wang Q, Sun H, Qin X, Zheng Q. Left Bundle Branch Pacing: Current Knowledge and Future Prospects. Front Cardiovasc Med 2021; 8:630399. [PMID: 33834042 PMCID: PMC8021709 DOI: 10.3389/fcvm.2021.630399] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/05/2021] [Indexed: 12/16/2022] Open
Abstract
Cardiac pacing is an effective therapy for treating patients with bradycardia due to sinus node dysfunction or atrioventricular block. However, traditional right ventricular apical pacing (RVAP) causes electric and mechanical dyssynchrony, which is associated with increased risk for atrial arrhythmias and heart failure. Therefore, there is a need to develop a physiological pacing approach that activates the normal cardiac conduction and provides synchronized contraction of ventricles. Although His bundle pacing (HBP) has been widely used as a physiological pacing modality, it is limited by challenging implantation technique, unsatisfactory success rate in patients with wide QRS wave, high pacing capture threshold, and early battery depletion. Recently, the left bundle branch pacing (LBBP), defined as the capture of left bundle branch (LBB) via transventricular septal approach, has emerged as a newly physiological pacing modality. Results from early clinical studies have demonstrated LBBP's feasibility and safety, with rare complications and high success rate. Overall, this approach has been found to provide physiological pacing that guarantees electrical synchrony of the left ventricle with low pacing threshold. This was previously specifically characterized by narrow paced QRS duration, large R waves, fast synchronized left ventricular activation, and correction of left bundle branch block. Therefore, LBBP may be a potential alternative pacing modality for both RVAP and cardiac resynchronization therapy with HBP or biventricular pacing (BVP). However, the technique's widespread adaptation needs further validation to ascertain its safety and efficacy in randomized clinical trials. In this review, we discuss the current knowledge of LBBP.
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Affiliation(s)
- Peng Liu
- Department of Cardiology, The Second Affiliate Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Qiaozhu Wang
- Department of Cardiology, The Second Affiliate Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Hongke Sun
- Department of Cardiology, The Second Affiliate Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xinghua Qin
- School of Life Sciences, Northwestern Polytechnical University, Xi'an, China
| | - Qiangsun Zheng
- Department of Cardiology, The Second Affiliate Hospital of Xi'an Jiaotong University, Xi'an, China
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Chin JY, Kang KW, Park SH, Choi YJ, Jung KT, Lee S, Youn HJ. Pre-implant global longitudinal strain as an early sign of pacing-induced cardiomyopathy in patients with complete atrioventricular block. Echocardiography 2021; 38:175-182. [PMID: 33406280 PMCID: PMC7986095 DOI: 10.1111/echo.14942] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 10/22/2020] [Accepted: 11/11/2020] [Indexed: 11/29/2022] Open
Abstract
Introduction Long‐term right ventricular pacing is the only treatment for patients with a complete atrioventricular block (CAVB); however, it frequently triggers ventricular dys‐synchrony with left ventricular (LV) dysfunction. Previous studies showed that an early decline of LV global longitudinal strain (GLS) predicts pacing‐induced LV dysfunction. We aimed to investigate the potential ability of the initial LV strain to predict pacing‐induced cardiomyopathy (PICM) through long‐term follow‐ups. Methods We retrospectively enrolled 80 patients with CAVB with normal LV function who were implanted with dual‐chamber pacemakers between 2008 and 2018. Echocardiographic data and parameters (including longitudinal, radial, and circumferential strain based on speckle‐tracking) were analyzed for the pre‐implant (≤6 months) and post‐implant periods. PICM was defined as a ≥10% reduction in the left ventricular ejection fraction (LVEF) resulting in an LVEF of <50% during the post‐implant period. Predictors of PICM were identified using Cox proportional hazard models. Results Patients who developed PICM were more likely to exhibit lower baseline LV GLS, as well as wider native and pacing QRS durations, than those who did not develop PICM (P = .016, P = .011, and P = .026, respectively). In the multivariate analysis, pre‐implant LV GLS (hazard ratio: 1.27; 95% confidence interval 1.009–1.492; P = .004) was independently associated with the development of PICM. Conclusion A lower baseline LV GLS predicts an increased risk of PICM. Patients with CAVB exhibiting low GLS are at increased risk of PICM. More frequent follow‐up visits are warranted in these patients, who may also require de novo His‐bundle pacing or an upgrade to biventricular pacing.
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Affiliation(s)
- Jung Yeon Chin
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, College of Medicine, Eulji University Hospital, Eulji University of Korea, Daejeon, Korea
| | - Ki-Woon Kang
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, College of Medicine, Eulji University Hospital, Eulji University of Korea, Daejeon, Korea
| | - Sang Hyun Park
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, College of Medicine, Eulji University Hospital, Eulji University of Korea, Daejeon, Korea
| | - Yu Jeong Choi
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, College of Medicine, Eulji University Hospital, Eulji University of Korea, Daejeon, Korea
| | - Kyung Tae Jung
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, College of Medicine, Eulji University Hospital, Eulji University of Korea, Daejeon, Korea
| | - Soyoung Lee
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, College of Medicine, Eulji University Hospital, Eulji University of Korea, Daejeon, Korea
| | - Ho-Joong Youn
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
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Carpio EF, Gomez JF, Sebastian R, Lopez-Perez A, Castellanos E, Almendral J, Ferrero JM, Trenor B. Optimization of Lead Placement in the Right Ventricle During Cardiac Resynchronization Therapy. A Simulation Study. Front Physiol 2019; 10:74. [PMID: 30804805 PMCID: PMC6378298 DOI: 10.3389/fphys.2019.00074] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/22/2019] [Indexed: 12/18/2022] Open
Abstract
Patients suffering from heart failure and left bundle branch block show electrical ventricular dyssynchrony causing an abnormal blood pumping. Cardiac resynchronization therapy (CRT) is recommended for these patients. Patients with positive therapy response normally present QRS shortening and an increased left ventricle (LV) ejection fraction. However, around one third do not respond favorably. Therefore, optimal location of pacing leads, timing delays between leads and/or choosing related biomarkers is crucial to achieve the best possible degree of ventricular synchrony during CRT application. In this study, computational modeling is used to predict the optimal location and delay of pacing leads to improve CRT response. We use a 3D electrophysiological computational model of the heart and torso to get insight into the changes in the activation patterns obtained when the heart is paced from different regions and for different atrioventricular and interventricular delays. The model represents a heart with left bundle branch block and heart failure, and allows a detailed and accurate analysis of the electrical changes observed simultaneously in the myocardium and in the QRS complex computed in the precordial leads. Computational simulations were performed using a modified version of the O'Hara et al. action potential model, the most recent mathematical model developed for human ventricular electrophysiology. The optimal location for the pacing leads was determined by QRS maximal reduction. Additionally, the influence of Purkinje system on CRT response was assessed and correlation analysis between several parameters of the QRS was made. Simulation results showed that the right ventricle (RV) upper septum near the outflow tract is an alternative location to the RV apical lead. Furthermore, LV endocardial pacing provided better results as compared to epicardial stimulation. Finally, the time to reach the 90% of the QRS area was a good predictor of the instant at which 90% of the ventricular tissue was activated. Thus, the time to reach the 90% of the QRS area is suggested as an additional index to assess CRT effectiveness to improve biventricular synchrony.
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Affiliation(s)
- Edison F Carpio
- Centre for Research and Innovation in Bioengineering (Ci2B), Universitat Politècnica de València, Valencia, Spain
| | - Juan F Gomez
- Centre for Research and Innovation in Bioengineering (Ci2B), Universitat Politècnica de València, Valencia, Spain
| | - Rafael Sebastian
- Computational Multiscale Simulation Lab (CoMMLab), Department of Computer Science, Universitat de València, Valencia, Spain
| | - Alejandro Lopez-Perez
- Centre for Research and Innovation in Bioengineering (Ci2B), Universitat Politècnica de València, Valencia, Spain
| | - Eduardo Castellanos
- Electrophysiology Laboratory and Arrhythmia Unit, Grupo HM Hospitales, Hospital Monteprincipe, University CEU-San Pablo, Madrid, Spain
| | - Jesus Almendral
- Electrophysiology Laboratory and Arrhythmia Unit, Grupo HM Hospitales, Hospital Monteprincipe, University CEU-San Pablo, Madrid, Spain
| | - Jose M Ferrero
- Centre for Research and Innovation in Bioengineering (Ci2B), Universitat Politècnica de València, Valencia, Spain
| | - Beatriz Trenor
- Centre for Research and Innovation in Bioengineering (Ci2B), Universitat Politècnica de València, Valencia, Spain
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Chen K, Su H, Xie C, Wang Q, Yu F, Sun Q, Zhu H, Yang D, Xu J, Yan J. Prognostic Implications of QRS Duration in Third-Degree Atrioventricular Block Patients with Heart Failure Treated with Cardiac Resynchronization Therapy. Int Heart J 2018; 59:1320-1326. [PMID: 30369567 DOI: 10.1536/ihj.17-577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Cardiac resynchronization therapy (CRT) improves heart function and prognosis in third-degree atrioventricular block (AVB) patients with heart failure (HF). However, it is still unclear how to screen for appropriate patients before implantation. This study aimed to evaluate the value of using QRS duration to predict CRT efficacy.This study enrolled a total of 72 third-degree AVB patients with HF who received CRT implantation. The patients were divided into Groups A (QRS duration < 120 ms, 33 cases), B (120 ms ≤ QRS duration < 150 ms, 22 cases), and C (QRS duration ≥ 150 ms, 17 cases) according to their baseline QRS duration. The effects of different QRS durations on CRT efficacy were analyzed.The CRT response rate were 30.3%, 50.0%, and 76.5% in Groups A, B, and C, respectively (P = 0.008). The patients in the 3 groups showed significant changes in left ventricular (LV) end-diastolic volume, LV end-systolic volume, and LV ejection fraction over the baseline values at 12 months after the implantation (P < 0.05), with the greatest change observed in Group C. Survival analysis indicated statistically significant differences among Groups A, B, and C (P = 0.024). Multivariate logistic regression analysis suggested that QRS duration was an independent prognostic factor for CRT efficacy. Baseline QRS duration was associated with improved myocardial remodeling and reductions in the incidence rates of primary endpoint events.QRS ≥ 150 ms is an effective predictor of postoperative outcome in patients with third-degree AVB and HF treated with CRT.
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Affiliation(s)
- Kangyu Chen
- Department of Cardiology, The Provincial Hospital Affiliated to Anhui Medical University
| | - Hao Su
- Department of Cardiology, The Provincial Hospital Affiliated to Anhui Medical University
| | - Cuiping Xie
- Department of Cardiology, The Provincial Hospital Affiliated to Anhui Medical University
| | - Qi Wang
- Department of Cardiology, The Provincial Hospital Affiliated to Anhui Medical University
| | - Fei Yu
- Department of Cardiology, The Provincial Hospital Affiliated to Anhui Medical University
| | - Qi Sun
- Department of Cardiology, The Provincial Hospital Affiliated to Anhui Medical University
| | - Hongjun Zhu
- Department of Cardiology, The Provincial Hospital Affiliated to Anhui Medical University
| | - Dongmei Yang
- Echocardiography Laboratory, The Provincial Hospital Affiliated to Anhui Medical University
| | - Jian Xu
- Department of Cardiology, The Provincial Hospital Affiliated to Anhui Medical University
| | - Ji Yan
- Department of Cardiology, The Provincial Hospital Affiliated to Anhui Medical University
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Paton MF, Witte KK. Heart failure and right ventricular pacing - how to avoid the need for cardiac resynchronization therapy. Expert Rev Med Devices 2018; 16:35-43. [PMID: 30477355 DOI: 10.1080/17434440.2019.1552133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Heart failure (HF) is a common finding in patients with pacemakers implanted for bradycardia, with cross-sectional and longitudinal studies contributing to the growing consensus that right ventricular pacing can cause adverse cardiac remodeling and left ventricular systolic dysfunction increasing the risk of hospitalization and death. An unselected approach using cardiac resynchronization therapy from the time of first implant in patients with heart block has produced equivocal results. Contemporary research has therefore begun to focus on the stratification of patients' risk of pacemaker-associated impairment to permit focused, personalized management. AREAS COVERED The present review will describe the incidence and relevance of HF in the pacemaker population and discuss current management options for such patients. EXPERT COMMENTARY At present there are few contemporary data to guide the identification of patients with and at risk of pacemaker-associated cardiac remodeling and dysfunction. Emphasis must be placed on precise and personalized treatment approaches which currently remain under-investigated due to a number of challenges, for example, small sample sizes, limited clarity on programmed settings, and short follow-up periods.
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Affiliation(s)
- Maria F Paton
- a Leeds Institute of Cardiovascular and Metabolic Medicine , University of Leeds , Leeds , UK
| | - Klaus K Witte
- a Leeds Institute of Cardiovascular and Metabolic Medicine , University of Leeds , Leeds , UK
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Chen D, Wei H, Tang J, Liu L, Wu S, Lin C, Zhang Q, Liang Y, Chen S. A randomized comparison of fluoroscopic techniques for implanting pacemaker lead on the right ventricular outflow tract septum. Int J Cardiovasc Imaging 2016; 32:721-8. [PMID: 26797500 PMCID: PMC4853443 DOI: 10.1007/s10554-016-0840-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 01/10/2016] [Indexed: 01/21/2023]
Abstract
Right ventricular outflow tract (RVOT) septal pacing is commonly performed under the standard fluoroscopic positions during procedure. The aim of the prospective, randomized study was to evaluate the accuracy of the combination of standard fluoroscopic and left lateral (LL) fluoroscopic views for determination of RVOT septal position compared with standard fluoroscopic views alone. We prospectively enrolled patients who had indications for implantation of a permanent pacemaker. Patients were randomly assigned into two groups based on intraoperative fluoroscopic views as follows: LL group (three standard fluoroscopic views + LL fluoroscopic view) or standard group (three standard fluoroscopic views). Transthoracic echocardiography (TTE) determination of pacing sites was applied in all patients 3 days after pacemaker implantation. The implantation success rate of RVOT septal pacing was compared between groups. A total of 143 patients (59 males, mean age 57.6 ± 16.3 years) with symptomatic bradyarrhythmia were studied, of whom, 72 patients were randomized to LL group and 71 to standard group. TTE determination of pacing sites was compared with two groups. In the LL group, 60 patients (83 %) were achieved in RVOT septal position. In the standard group, however, the position of RVOT septum was only observed in 48 patients (68 %). The success rate of RVOT septal position in LL group was significantly higher than standard group (p = 0.029). Comparing to traditional views, combining LL view in the procedure will approve the accuracy of RVOT septal pacing site.
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Affiliation(s)
- Dongli Chen
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510000, Guangdong, China
| | - Huiqiang Wei
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510000, Guangdong, China
| | - Jiaojiao Tang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510000, Guangdong, China.
| | - Lie Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510000, Guangdong, China.
| | - Shulin Wu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510000, Guangdong, China
| | - Chunying Lin
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510000, Guangdong, China
| | - Qianhuan Zhang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510000, Guangdong, China
| | - Yuanhong Liang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510000, Guangdong, China
| | - Silin Chen
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510000, Guangdong, China
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Zou C, Song J, Li H, Huang X, Liu Y, Zhao C, Shi X, Yang X. Right ventricular outflow tract septal pacing is superior to right ventricular apical pacing. J Am Heart Assoc 2015; 4:jah3942. [PMID: 25896891 PMCID: PMC4579934 DOI: 10.1161/jaha.115.001777] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background The effects of right ventricular apical pacing (RVAP) and right ventricular outflow tract (RVOT) septal pacing on atrial and ventricular electrophysiology have not been thoroughly compared. Methods and Results To identify a more favorable pacing strategy with fewer adverse effects, 80 patients who had complete atrioventricular block with normal cardiac function and who were treated with either RVAP (n=42) or RVOT septal pacing (n=38) were recruited after an average of 2 years of follow‐up. The data from electrocardiography and echocardiography performed before pacemaker implantation and at the end of follow‐up were collected. The patients in the RVOT septal pacing and RVAP groups showed similar demographic and clinical characteristics before pacing treatments. After a mean follow‐up of 2 years, the final maximum P‐wave duration; P‐wave dispersion; Q‐, R‐, and S‐wave complex duration; left atrial volume index; left ventricular end‐systolic diameter; ratio of transmitral early diastolic filling velocity to mitral annular early diastolic velocity; and interventricular mechanical delay in the RVOT septal pacing group were significantly less than those in the RVAP group (P<0.05). The final left ventricular ejection fraction of the RVOT septal pacing group was significantly higher than that of the RVAP group (P<0.05). Conclusions Compared with RVAP, RVOT septal pacing has fewer adverse effects regarding atrial electrical activity and structure in patients with normal cardiac function.
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Affiliation(s)
- Cao Zou
- Department of Cardiology, First Affiliated Hospital of Soochow University, Suzhou, China (C.Z., J.S., H.L., X.Y.)
| | - Jianping Song
- Department of Cardiology, First Affiliated Hospital of Soochow University, Suzhou, China (C.Z., J.S., H.L., X.Y.)
| | - Hui Li
- Department of Cardiology, First Affiliated Hospital of Soochow University, Suzhou, China (C.Z., J.S., H.L., X.Y.)
| | - Xingmei Huang
- Department of Electrocardiography, First Affiliated Hospital of Soochow University, Suzhou, China (X.H., Y.L.)
| | - Yuping Liu
- Department of Electrocardiography, First Affiliated Hospital of Soochow University, Suzhou, China (X.H., Y.L.)
| | - Caiming Zhao
- Department of Echocardiography, First Affiliated Hospital of Soochow University, Suzhou, China (C.Z., X.S.)
| | - Xin Shi
- Department of Echocardiography, First Affiliated Hospital of Soochow University, Suzhou, China (C.Z., X.S.)
| | - Xiangjun Yang
- Department of Cardiology, First Affiliated Hospital of Soochow University, Suzhou, China (C.Z., J.S., H.L., X.Y.)
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Zhou W, Benharash P, Chua JH, Nakahara S, Ho JK, Mahajan A. Acute Effects of Pacing at Different Ventricular Sites on Left Ventricular Rotational Mechanics in a Porcine Model. J Cardiothorac Vasc Anesth 2014; 29:1148-54. [PMID: 25824449 DOI: 10.1053/j.jvca.2014.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose of this study was to examine the acute effects of pacing at different ventricular sites on hemodynamics and left ventricular (LV) rotational mechanics using speckle-tracking echocardiography (STE) in a porcine model. DESIGN A prospective laboratory investigation. SETTING University research laboratory. PARTICIPANTS Yorkshire pigs. INTERVENTIONS In 9 pigs, after midline sternotomy, epicardial pacing was performed from the right ventricular outflow tract (RVOT), right ventricular apex (RVA), and LV free wall. MEASUREMENTS AND MAIN RESULTS Two-dimensional STE and conductance catheter-derived LV pressure-volume measurements were made to determine the impact of pacing from various sites on LV rotational parameters (twist/untwist) and hemodynamics. RVOT pacing caused the least decrease in end-systolic pressure from baseline (-9.5%), when compared with RVA (-19.1%) and LV (-23.4%). Systolic and diastolic parameters (Emax, Tau) also were different among RVOT (4.7±0.8 mmHg/mL, 32±4 ms), RVA (3.9±0.7 mmHg/mL, 37±6 ms), and LV sites (3.6±0.8 mmHg/mL, 42±7 ms). Similar to the effects of pacing on hemodynamics, RVOT pacing better preserved LV twist (11.1±1.8 v 8.6±1.7, 5.9±0.7 °) and untwisting rate (64.6±8.5 v 56.2±5.3, 48.2±8.5 °/s) when compared with RV apical pacing and LV pacing. Furthermore, prolongation of conduction from LV lateral to anteroseptal at LV base (26.5±3.8 v 13.8±3.3 ms, p<0.05) and LV midpapillary muscle level (35.6±5.6 v 14.1±2.4 ms, p<0.05) was observed with LV pacing compared with RVOT pacing. CONCLUSIONS The present data showed that the LV twist/untwist and cardiac systolic and diastolic function were least affected by RVOT pacing. This finding may be explained by the proximity of this location to the native ventricular conduction system.
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Affiliation(s)
| | - Peyman Benharash
- Cardiovascular Surgery, University of California Los Angeles, Los Angeles, CA
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