1
|
Ghossein MA, Zanon F, Salden F, van Stipdonk A, Marcantoni L, Engels E, Luermans J, Westra S, Prinzen F, Vernooy K. Left Ventricular Lead Placement Guided by Reduction in QRS Area. J Clin Med 2021; 10:jcm10245935. [PMID: 34945236 PMCID: PMC8707800 DOI: 10.3390/jcm10245935] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/07/2021] [Accepted: 12/14/2021] [Indexed: 12/07/2022] Open
Abstract
Background: Reduction in QRS area after cardiac resynchronization therapy (CRT) is associated with improved long-term clinical outcome. The aim of this study was to investigate whether the reduction in QRS area is associated with hemodynamic improvement by pacing different LV sites and can be used to guide LV lead placement. Methods: Patients with a class Ia/IIa CRT indication were prospectively included from three hospitals. Acute hemodynamic response was assessed as the relative change in maximum rate of rise of left ventricular (LV) pressure (%∆LVdP/dtmax). Change in QRS area (∆QRS area), in QRS duration (∆QRS duration), and %∆LVdP/dtmax were studied in relation to different LV pacing locations within a patient. Results: Data from 52 patients paced at 188 different LV pacing sites were investigated. Lateral LV pacing resulted in a larger %∆LVdP/dtmax than anterior or posterior pacing (p = 0.0007). A similar trend was found for ∆QRS area (p = 0.001) but not for ∆QRS duration (p = 0.23). Pacing from the proximal electrode pair resulted in a larger %∆LVdP/dtmax (p = 0.004), and ∆QRS area (p = 0.003) but not ∆QRS duration (p = 0.77). Within patients, correlation between ∆QRS area and %∆LVdP/dtmax was 0.76 (median, IQR 0.35; 0,89). Conclusion: Within patients, ∆QRS area is associated with %∆LVdP/dtmax at different LV pacing locations. Therefore, QRS area, which is an easily, noninvasively obtainable and objective parameter, may be useful to guide LV lead placement in CRT.
Collapse
Affiliation(s)
- Mohammed Ali Ghossein
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 ER Maastricht, The Netherlands;
- Correspondence:
| | - Francesco Zanon
- Santa Maria Della Misericordia General Hospital, 45100 Rovigo, Italy; (F.Z.); (L.M.)
| | - Floor Salden
- Maastricht University Medical Center, Department of Cardiology, Maastricht University, 6229 HX Maastricht, The Netherlands; (F.S.); (A.v.S.); (J.L.); (K.V.)
| | - Antonius van Stipdonk
- Maastricht University Medical Center, Department of Cardiology, Maastricht University, 6229 HX Maastricht, The Netherlands; (F.S.); (A.v.S.); (J.L.); (K.V.)
| | - Lina Marcantoni
- Santa Maria Della Misericordia General Hospital, 45100 Rovigo, Italy; (F.Z.); (L.M.)
| | - Elien Engels
- Yale New Haven Hospital, New Haven, CT 06510, USA;
| | - Justin Luermans
- Maastricht University Medical Center, Department of Cardiology, Maastricht University, 6229 HX Maastricht, The Netherlands; (F.S.); (A.v.S.); (J.L.); (K.V.)
| | - Sjoerd Westra
- Radboud University Medical Center, Radboud University Nijmegen, 6525 GA Nijmegen, The Netherlands;
| | - Frits Prinzen
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 ER Maastricht, The Netherlands;
| | - Kevin Vernooy
- Maastricht University Medical Center, Department of Cardiology, Maastricht University, 6229 HX Maastricht, The Netherlands; (F.S.); (A.v.S.); (J.L.); (K.V.)
- Radboud University Medical Center, Radboud University Nijmegen, 6525 GA Nijmegen, The Netherlands;
| |
Collapse
|
2
|
Borgmann M, Ivanda M, Hadizamani Y, Mohaupt M, Bals R, Lucas R, Hamacher J, Köllner V. Does the 6-minute walk test in hospitalized COPD patients exclusively correlate with lung function parameters or should psychological factors also be taken into account? PLoS One 2020; 15:e0232587. [PMID: 32365134 PMCID: PMC7197854 DOI: 10.1371/journal.pone.0232587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 04/18/2020] [Indexed: 11/29/2022] Open
Abstract
The 6-minute walk test is generally considered a standard test for the evaluation of short-term maximal physical performance. It has not been evaluated whether psychological factors, such as anxiety or depression, affect the performance or the results of the test. The main aim of this study was to investigate whether a correlation exists between psychological factors and the data from the 6-minute walking test. The study cohort consisted of 85 (♀ = 34 and ♂ = 51) 66 ± 10 (mean ± SD) year-old patients with chronic obstructive pulmonary disease (COPD) hospitalized for disease exacerbation. Forced Expiratory Volume in the first second (FEV1) (% predicted) as predictor for lung function, as well as anxiety and depression symptoms assessed using the Hospital Anxiety and Depression Scale (HADS) as psychological predictors were collected. Bivariate correlations and hierarchical linear regression models were used to analyse the correlations. Walking distance was on average 260m ± 107m and ranged from 64m to 480m. HADS was negatively correlated with 6-min walking distance (r = 0.441, p = .0009, r = -.523, p = 00006). Hierarchical linear regression showed that FEV1 alone explained 33%, and together with the psychological variables anxiety and depression explained 42% of the variance of results from the 6-minute walking test. These findings demonstrated that 11% of the data correlated with the psychological variables alone (p = .011). The effect size for lung function (f2 = .717) and psychological variables (f2 = .352) were high, whereas the socio-demographic variables sex, age, educational level and BMI could not explain any additional variance in our cohort. In conclusion, our study indicates that psychological factors such as symptoms of depression and anxiety are associated with lower physical functional performance in the 6-minute walking test. As such, these factors should also be assessed. Future research is needed to show if treatments of anxiety and depression can improve the walking distance in COPD patients.
Collapse
Affiliation(s)
- Michèle Borgmann
- Internal Medicine and Pneumology, Lindenhofspital, Bern, Switzerland
- Lungen- und Atmungsstiftung Bern, Bern, Switzerland
| | | | - Yalda Hadizamani
- Internal Medicine and Pneumology, Lindenhofspital, Bern, Switzerland
- Lungen- und Atmungsstiftung Bern, Bern, Switzerland
| | - Markus Mohaupt
- Internal Medicine, Sonnenhofspital Bern, Bern, Switzerland
| | - Robert Bals
- Internal Medicine V—Pneumology, Allergology, Respiratory and Environmental Medicine, Faculty of Medicine, Saarland University, Homburg/Saar, Germany
| | - Rudolf Lucas
- Lungen- und Atmungsstiftung Bern, Bern, Switzerland
- Division of Pulmonary Medicine, Vascular Biology Center, Medical College of Georgia, Georgia Regents University, Augusta, GA, United States of America
| | - Jürg Hamacher
- Internal Medicine and Pneumology, Lindenhofspital, Bern, Switzerland
- Lungen- und Atmungsstiftung Bern, Bern, Switzerland
- * E-mail:
| | - Volker Köllner
- Department of Behavioral Therapy and Psychosomatic Medicine, Rehabilitation Center Seehof, Federal German Pension Agency, Teltow, Germany
- Department of Psychosomatic Medicine, Psychosomatic Rehabilitation Research Group, Center for Internal Medicine and Dermatology, Charité—Universitätsmedizin, Berlin, Germany
| |
Collapse
|
3
|
Crozier A, Blazevic B, Lamata P, Plank G, Ginks M, Duckett S, Sohal M, Shetty A, Rinaldi CA, Razavi R, Niederer SA, Smith NP. Analysis of lead placement optimization metrics in cardiac resynchronization therapy with computational modelling. Europace 2017; 18:iv113-iv120. [PMID: 28011838 DOI: 10.1093/europace/euw366] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 09/07/2016] [Indexed: 11/14/2022] Open
Abstract
AIMS The efficacy of cardiac resynchronization therapy (CRT) is known to vary considerably with pacing location, however the most effective set of metrics by which to select the optimal pacing site is not yet well understood. Computational modelling offers a powerful methodology to comprehensively test the effect of pacing location in silico and investigate how to best optimize therapy using clinically available metrics for the individual patient. METHODS AND RESULTS Personalized computational models of cardiac electromechanics were used to perform an in silico left ventricle (LV) pacing site optimization study as part of biventricular CRT in three patient cases. Maps of response to therapy according to changes in total activation time (ΔTAT) and acute haemodynamic response (AHR) were generated and compared with preclinical metrics of electrical function, strain, stress, and mechanical work to assess their suitability for selecting the optimal pacing site. In all three patients, response to therapy was highly sensitive to pacing location, with laterobasal locations being optimal. ΔTAT and AHR were found to be correlated (ρ < -0.80), as were AHR and the preclinical activation time at the pacing site (ρ ≥ 0.73), however pacing in the last activated site did not result in the optimal response to therapy in all cases. CONCLUSION This computational modelling study supports pacing in laterobasal locations, optimizing pacing site by minimizing paced QRS duration and pacing in regions activated late at sinus rhythm. Results demonstrate information content is redundant using multiple preclinical metrics. Of significance, the correlation of AHR with ΔTAT indicates that minimization of QRSd is a promising metric for optimization of lead placement.
Collapse
Affiliation(s)
- Andrew Crozier
- Division of Imaging Sciences and Biomedical Engineering, King's College London, St Thomas Hospital, London SE1 7EH, UK.,Institute of Biophysics, Medical University of Graz, Harrachgasse 21/IV, 8010 Graz, Austria
| | - Bojan Blazevic
- Division of Imaging Sciences and Biomedical Engineering, King's College London, St Thomas Hospital, London SE1 7EH, UK
| | - Pablo Lamata
- Division of Imaging Sciences and Biomedical Engineering, King's College London, St Thomas Hospital, London SE1 7EH, UK
| | - Gernot Plank
- Institute of Biophysics, Medical University of Graz, Harrachgasse 21/IV, 8010 Graz, Austria
| | - Matthew Ginks
- Department of Cardiology, Guy's and St. Thomas' Hospital, London SE1 7EH, London, UK
| | - Simon Duckett
- Department of Cardiology, Guy's and St. Thomas' Hospital, London SE1 7EH, London, UK
| | - Manav Sohal
- Department of Cardiology, Guy's and St. Thomas' Hospital, London SE1 7EH, London, UK
| | - Anoop Shetty
- Department of Cardiology, Guy's and St. Thomas' Hospital, London SE1 7EH, London, UK
| | - Christopher A Rinaldi
- Department of Cardiology, Guy's and St. Thomas' Hospital, London SE1 7EH, London, UK
| | - Reza Razavi
- Division of Imaging Sciences and Biomedical Engineering, King's College London, St Thomas Hospital, London SE1 7EH, UK
| | - Steven A Niederer
- Division of Imaging Sciences and Biomedical Engineering, King's College London, St Thomas Hospital, London SE1 7EH, UK
| | - Nicolas P Smith
- Division of Imaging Sciences and Biomedical Engineering, King's College London, St Thomas Hospital, London SE1 7EH, UK .,Faculty of Engineering, University of Auckland, 20 Symonds St, Auckland 1010, New Zealand
| |
Collapse
|
4
|
Furniss GO, Liang M, Jimenez A, Harding S. Wire Externalisation for Left Ventricular Lead Placement in Cardiac Resynchronisation Therapy: A Step-by-step Guide. Heart Lung Circ 2015; 24:1094-103. [PMID: 26162936 DOI: 10.1016/j.hlc.2015.04.173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 03/07/2015] [Accepted: 04/14/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Left ventricular (LV) lead implantation for CRT can be challenging. We describe the technique of wire externalisation to enable posterolateral (PL) LV lead placement and give case examples to illustrate its use. METHODS The technique includes: The externalised guidewire provides excellent support for antegrade or retrograde advancement of the LV lead. RESULTS Wire externalisation has been used to overcome PL branch tortuosity, persistent left SVC or acute angulation of the CS ostium. Antegrade delivery or retrograde delivery is possible but there may be an additional need for balloon angioplasty to facilitate lead advancement. There have been no complications at implant or 30-day follow-up. CONCLUSIONS The wire externalisation technique can facilitate optimal LV lead placement in difficult CRT cases.
Collapse
Affiliation(s)
- Guy O Furniss
- Wellington Regional Hospital, Wellington, New Zealand; Derriford Hospital, Plymouth, UK.
| | - Michael Liang
- Wellington Regional Hospital, Wellington, New Zealand
| | | | - Scott Harding
- Wellington Regional Hospital, Wellington, New Zealand
| |
Collapse
|
5
|
A detailed assessment of the human coronary venous system using contrast computed tomography of perfusion-fixed specimens. Heart Rhythm 2013; 11:282-8. [PMID: 24144884 DOI: 10.1016/j.hrthm.2013.10.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Access to the coronary venous system is required for the delivery of several cardiac therapies including cardiac resynchronization therapy, coronary sinus ablation, and coronary drug delivery. Therefore, characterization of the coronary venous anatomy will provide insights to gain improved access to these vessels and subsequently improved therapies. For example, cardiac resynchronization therapy has a 30% nonresponder rate, partially due to suboptimal lead placement within the coronary veins. OBJECTIVE To understand the implications of coronary venous anatomy for the development of devices deployed within these vessels. METHODS We cannulated the coronary sinus of 121 perfusion-fixed human hearts with a venogram balloon catheter and injected contrast into the venous system while obtaining computed tomographic images. For each major coronary vein, distance to the coronary sinus, branching angle, arc length, tortuosity, number of branches, and ostial diameter were assessed from the reconstructed anatomy. RESULTS Twenty-nine percent (35/121) specimens did not have a venous branch overlying the inferolateral side of the heart large enough to fit a 5F pacing lead. No significant differences in anatomy were found between subgroups with varying cardiac medical histories. CONCLUSION The anatomical approach employed in this study has allowed for the development of a unique database of human coronary venous anatomy that can be used for the optimization of design and delivery of cardiac devices.
Collapse
|
6
|
Biffi M, Zanon F, Bertaglia E, Padeletti L, Varbaro A, De Santo T, Boriani G, Yang Z. Short-spaced dipole for managing phrenic nerve stimulation in patients with CRT: The “phrenic nerve mapping and stimulation EP” catheter study. Heart Rhythm 2013; 10:39-45. [DOI: 10.1016/j.hrthm.2012.08.045] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Indexed: 10/27/2022]
|
7
|
García-Bolao I, Calvo N, Gavira JJ, Moreno-Galdós L, Arguedas-Jiménez H, Canepa JP, García-De-Yébenes M. [Current status of cardiac resynchronization therapy]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2012; 82:235-42. [PMID: 23021361 DOI: 10.1016/j.acmx.2012.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 02/27/2012] [Accepted: 04/02/2012] [Indexed: 10/27/2022] Open
Abstract
The present document reviews various aspects of the current status of cardiac resynchronization therapy: mechanisms of action, current indications and implantation technique.
Collapse
Affiliation(s)
- Ignacio García-Bolao
- Unidad de Electrofisiología y Arritmias, Departamento de Cardiología y Cirugía Cardiaca, Clínica Universidad de Navarra, Pamplona, España.
| | | | | | | | | | | | | |
Collapse
|
8
|
Biffi M, Exner DV, Crossley GH, Ramza B, Coutu B, Tomassoni G, Kranig W, Li S, Kristiansen N, Voss F. Occurrence of phrenic nerve stimulation in cardiac resynchronization therapy patients: the role of left ventricular lead type and placement site. Europace 2012; 15:77-82. [PMID: 22848075 DOI: 10.1093/europace/eus237] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
AIMS Unwanted phrenic nerve stimulation (PNS) has been reported in ∼1 in 4 patients undergoing left ventricular (LV) pacing. The occurrence of PNS over mid-term follow-up and the significance of PNS are less certain. METHODS AND RESULTS Data from 1307 patients enrolled in pre-market studies of LV leads manufactured by Medtronic (models 4193 and 4195 unipolar, 4194, 4196, 4296, and 4396 bipolar) were pooled. Left ventricular lead location was recorded at implant using a common classification scheme. Phrenic nerve stimulation symptoms were either spontaneously reported or identified at scheduled follow-up visits. A PNS-related complication was defined as PNS resulting in invasive intervention or the termination of LV pacing. Average follow-up was 14.9 months (range 0.0-46.6). Phrenic nerve stimulation symptoms occurred in 169 patients (12.9%). Phrenic nerve stimulation-related complications occurred in 21 of 1307 patients (1.6%); 16 of 738 (2.2%) in the unipolar lead studies, and 5 of 569 (0.9%) in the bipolar lead studies (P = 0.08). Phrenic nerve stimulation was more frequent at middle-lateral/posterior, and apical LV sites (139/1010) vs. basal-posterior/lateral/anterior, and middle-anterior sites (20/297; P= 0.01). As compared with an anterior LV lead position, a lateral LV pacing site was associated with over a four-fold higher risk of PNS (P= 0.005) and an apical LV pacing site was associated with over six-fold higher risk of PNS (P= 0.001). CONCLUSION Phrenic nerve stimulation occurred in 13% of patients undergoing LV lead placement and was more common at mid-lateral/posterior, and LV apical sites. Most cases (123/139; 88%) of PNS were mitigated via electrical reprogramming, without the need for invasive intervention.
Collapse
Affiliation(s)
- Mauro Biffi
- Institute of Cardiology, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Biffi M, Foerster L, Eastman W, Eggen M, Grenz NA, Sommer J, De Santo T, Haddad T, Varbaro A, Yang Z. Effect of bipolar electrode spacing on phrenic nerve stimulation and left ventricular pacing thresholds: an acute canine study. Circ Arrhythm Electrophysiol 2012; 5:815-20. [PMID: 22787012 DOI: 10.1161/circep.112.971317] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Phrenic nerve stimulation (PNS) is a common complication of cardiac resynchronization therapy when left ventricular (LV) pacing occurs via a coronary vein. The purpose of this study was to evaluate the effects of bipolar electrode spacing on PNS and LV pacing thresholds. METHODS AND RESULTS Electrophysiology catheters with standard (2 mm-5 mm-2 mm) or modified (1 mm-5 mm-1 mm) interelectrode spacing was, respectively, inserted in a posterior/lateral cardiac vein in a randomized order in 6 anesthetized dogs via jugular access. The phrenic nerve was dissected via a left minithoracotomy and repositioned over the vein as close as possible to one of the electrodes. The presence of PNS was verified (ie, PNS threshold <2 V at 0.5 ms in unipolar configuration). Bipolar pacing was delivered using the electrode closest to the phrenic nerve as the cathode, and multiple bipolar electrode spacing configurations were tested. During bipolar pacing, PNS threshold increased as bipolar electrode spacing was reduced (P<0.05), whereas LV pacing thresholds did not change significantly (P>0.05). Compared with a standard bipolar electrode spacing of 20 mm for LV leads, 1 and 2 mm bipolar electrode spacing resulted in a PNS threshold increase of 5.5±2.2 V (P=0.003) and 2.8±1.7 V (P<0.001), respectively. Similarly, PNS threshold increased by 6.5±3.7 V with 1 mm and by 3.8±1.9 V with 2 mm bipolar pacing (both P<0.001), compared with unipolar pacing. CONCLUSIONS This study suggests that reducing LV bipolar electrode spacing from the standard 20 mm to 1 or 2 mm may significantly increase the PNS threshold without compromising LV pacing thresholds.
Collapse
Affiliation(s)
- Mauro Biffi
- Institute of Cardiology, University of Bologna, Bologna, Italy.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Dong YX, Powell BD, Asirvatham SJ, Friedman PA, Rea RF, Webster TL, Brooke KL, Hodge DO, Wiste HJ, Yang YZ, Hayes DL, Cha YM. Left ventricular lead position for cardiac resynchronization: a comprehensive cinegraphic, echocardiographic, clinical, and survival analysis. Europace 2012; 14:1139-47. [PMID: 22467754 DOI: 10.1093/europace/eus045] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
AIMS We sought to determine the clinical and survival outcomes of cardiac resynchronization therapy (CRT) associated with left ventricular (LV) lead location. The lateral left ventricle has been considered the optimal LV lead location for CRT. METHODS AND RESULTS Left ventricular lead cinegrams taken in 30° right and left anterior oblique views were evaluated in 457 recipients of CRT with a pacemaker or a defibrillator from 1 January 2002 to 31 December 2008 in this retrospective study. Left ventricular lead placement was prioritized at implantation into posterolateral (PL), anterolateral (AL), middle cardiac, and anterointerventricular coronary veins. Using echocardiographic LV 16-segment analysis, we grouped the leads as anterior, AL, PL, and posterior locations. New York Heart Association (NYHA) class and echocardiography were assessed before and after CRT. Clinical and survival outcomes after CRT were compared among the four LV lead locations. Patient baseline demographic characteristics were similar among these four groups. Improvement in NYHA class was significantly greater in the AL (P= 0.04) and PL (P= 0.03) locations than in the anterior location. There was a tendency for greater improvement in LV ejection fraction among the AL (P= 0.11) and PL (P= 0.08) locations than the anterior location. Kaplan-Meier survival estimate at 4 years varied for location: AL, 72%; anterior, 48%; PL, 62%; and posterior, 72% (P= 0.003). CONCLUSION Cardiac resynchronization therapy recipients are profiting from all lead positions. However, LV lead placed in the AL and PL positions is more preferential for achieving optimal CRT benefit than leads placed in the anterior position.
Collapse
Affiliation(s)
- Ying-Xue Dong
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Thébault C, Donal E, Meunier C, Gervais R, Gerritse B, Gold MR, Abraham WT, Linde C, Daubert JC. Sites of left and right ventricular lead implantation and response to cardiac resynchronization therapy observations from the REVERSE trial. Eur Heart J 2012; 33:2662-71. [PMID: 22285578 DOI: 10.1093/eurheartj/ehr505] [Citation(s) in RCA: 129] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES The objective of this study is to ascertain the effects of the left (LV) and right (RV) ventricular lead tip position in response to cardiac resynchronization therapy (CRT). BACKGROUND The REVERSE randomized trial examined the effects of CRT in patients with asymptomatic or mildly symptomatic heart failure (HF). METHODS We analysed data collected from the active group (CRT-ON) of REVERSE in whom the precise locations of the LV and RV ventricular lead tips were determined from postoperative chest roentgenograms as part of a prespecified sub-study. LV position was classified as lateral or non-lateral, and apical or non-apical. RV position was classified as apical or non-apical. Echocardiographic LV end-systolic volume index (LVESVi), QRS duration, and clinical outcomes at 12-24 months of follow-up were evaluated with respect to the lead tip position. The primary trial endpoint was the proportion of patients with a worsened HF clinical composite response, scored as improved, unchanged, or worsened. RESULTS Totally 346 patients included in this analysis were followed for a median of 12.6 months (interquartile range: 11.9-23.9 months). The proportion of worsened HF clinical composite response did not correlate with lead position, whereas a significantly greater decrease in the powered secondary endpoint of LVESVi was observed with the non-apical vs. the apical LV lead positions. CRT-paced QRS duration was significantly shorter than at baseline in patients with lateral vs. non-lateral LV position, as well non-apical vs. apical LV position. The incidence of composite endpoint of death and first hospitalization for HF was lower in the LV lateral than in the non-lateral (HR 0.44; 95% CI 0.19-0.99; P= 0.04), and in the LV non-apical than in the apical group (HR 0.27; 95% CI 0.11-0.63; P= 0.001). No significant differences were observed between RV apical and non-apical positions of the lead tip. CONCLUSIONS A more favourable outcome of CRT with regard to LV reverse remodelling and the composite of time to death or first HF hospitalization was observed when the LV lead tip was implanted in the lateral wall, away from the apex, while the position of the RV lead tip was indifferent. The long-term change in QRS duration was significantly associated with the position of the LV lead tip. ClinicalTrials.gov Identifier: NCT00271154.
Collapse
Affiliation(s)
- Christophe Thébault
- Department of Cardiology, University Hospital, CIC IT, INSERM 642, Rennes, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
de Roest GJ, Allaart CP, de Haan S, Hendriks ML, Bronzwaer JG, van Rossum AC, de Cock CC. Effects of QRS duration and pacing location on pressure-volume loop evaluation of cardiac resynchronization therapy in end-stage heart failure. Am J Cardiol 2011; 108:1581-8. [PMID: 21890082 DOI: 10.1016/j.amjcard.2011.07.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 07/06/2011] [Accepted: 07/06/2011] [Indexed: 10/17/2022]
Abstract
Cardiac resynchronization therapy (CRT) decreases the morbidity and mortality in patients with end-stage heart failure. However, patient selection remains challenging, because a considerable 30% to 50% do not respond. Controversy exists on the cutoff values for the QRS duration and the optimal lead location. The present study relates these parameters on an individual basis to acute pump function improvement using invasively obtained pressure-volume loops. Fifty-seven patients with symptomatic end-stage heart failure were included in our temporary biventricular stimulation study and were grouped according to the QRS duration (QRS <20 ms, QRS ≥120 ms but <150 ms, and QRS ≥150 ms). All patients underwent pressure-volume loop assessment of the response to biventricular pacing, comparing the baseline measurements to both right ventricular apex pacing combined with a left ventricular lead in the posterolateral and anterolateral region of the LV. Group analysis during conventional (posterolateral and right ventricular apex) CRT did not show improvement in stroke work and dP/dt(max) (-2%, p = NS; and -7%; p <0.001) in the narrow QRS group but a significant increase in the intermediate (+27%, p = 0.020, and +5%, p = 0.044) and wide (+48%, p = 0.002, and +18%, p <0.001) QRS groups. CRT using the anterolateral and right ventricular apex configuration evoked a consistently lower response compared to posterolateral and right ventricular apex, resulting in a significant hemodynamic deterioration in the narrow QRS group. However, analysis on an individual basis identified 25% of patients with narrow QRS duration showing possible hemodynamic benefit from CRT compared to 83% of patients with intermediate and wide QRS combined. In contrast, 15% of patients had deterioration by conventional (posterolateral right ventricular apex) CRT in the intermediate and wide QRS groups compared to 31% in the narrow QRS group; 19% of patients could be improved by lead placement in the anterolateral rather than the posterolateral region. In conclusion, the acute hemodynamic response to CRT is generally in line with the long-term results from large randomized trials; however, the individual variation is large. The temporary biventricular stimulation protocol might aid in individual patient selection and in research aiming at a reduction of nonresponders and improvement in lead positioning.
Collapse
|
13
|
Durante A, Cianflone D, Camici PG. A Critical Reappraisal of Differences in Cardiac Resynchronization Therapy Defibrillator Effectiveness Between Men and Women in the MADIT-CRT Trial. J Am Coll Cardiol 2011; 58:442-3; author reply 443-4. [PMID: 21757127 DOI: 10.1016/j.jacc.2011.02.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 02/15/2011] [Indexed: 11/16/2022]
|
14
|
BIFFI MAURO, BERTINI MATTEO, ZIACCHI MATTEO, GARDINI BEATRICE, MAZZOTTI ANDREA, MASSARO GIULIA, DIEMBERGER IGOR, MARTIGNANI CRISTIAN, VALZANIA CINZIA, BORIANI GIUSEPPE. Management of Phrenic Stimulation in CRT Patients over the Long Term: Still an Unmet Need ? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 34:1201-8. [DOI: 10.1111/j.1540-8159.2011.03147.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
15
|
Kautzner J, Peichl P, Sedláček K. Imaging to improve the results of cardiac resynchronization therapy. Interv Cardiol 2011. [DOI: 10.2217/ica.11.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
16
|
Minden HH. [Technical innovations and limitation in cardiac electrotherapy]. Herzschrittmacherther Elektrophysiol 2011; 22:11-5. [PMID: 21344233 DOI: 10.1007/s00399-011-0117-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Coronary sinus (CS) lead positioning is one of the main determinants of cardiac resynchronization therapy (CRT). The implantation of the CS lead is faced with several technical difficulties that may prevent the achievement of a stable position and good performance of the CS lead without phrenic nerve stimulation (PNS). New developments in catheter and lead technology to overcome these difficulties are presented.
Collapse
Affiliation(s)
- H-H Minden
- Klinik für Innere Medizin/Kardiologie, Oberhavel-Kliniken, Marwitzer Str. 91, 16761, Hennigsdorf, Deutschland.
| |
Collapse
|
17
|
Sung RK, Foster E. Assessment of Systolic Dyssynchrony for Cardiac Resynchronization Therapy Is Not Clinically Useful. Circulation 2011; 123:656-62. [DOI: 10.1161/circulationaha.110.954420] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Raphael K. Sung
- From the Division of Cardiology, University of California, San Francisco
| | - Elyse Foster
- From the Division of Cardiology, University of California, San Francisco
| |
Collapse
|
18
|
|
19
|
Biffi M, Moschini C, Bertini M, Saporito D, Ziacchi M, Diemberger I, Valzania C, Domenichini G, Cervi E, Martignani C, Sangiorgi D, Branzi A, Boriani G. Phrenic Stimulation. Circ Arrhythm Electrophysiol 2009; 2:402-10. [PMID: 19808496 DOI: 10.1161/circep.108.836254] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Phrenic stimulation (PS) may hinder left ventricular (LV) pacing. We prospectively observed its prevalence in consecutive patients with cardiac resynchronization therapy (CRT) devices.
Methods and Results—
In the years 2003 to 2006, 197 patients received a CRT device. PS and LV threshold measurements were carried out at implantation and at 6-month follow-up. LV reverse remodeling was assessed by echocardiography before implantation and at follow-up. LV lead placement was lateral/posterolateral in 86% of patients. Both PS and LV reverse remodeling occurred most frequently at the lateral/posterolateral LV pacing sites (
P
<0.001). PS was detected in 73 (37%) of patients and was clinically relevant in 41 (22%). The detection of PS at implantation had a poor sensitivity, as it occurred only in left lateral or sitting position in 27 patients. Ten patients (5%) underwent repeated surgery and 4 (2%) had their CRT turned off because of PS. At follow-up, we could manage PS noninvasively in 32 patients with a small PS-LV threshold difference: in 20 by cathode programmability (3 also thanks to automatic management of LV output) and in 12 (without cathode programmability) by programming the LV output as threshold +1 V.
Conclusions—
PS may seriously hinder CRT. A bipolar LV lead and cathode programmability are mandatory to avoid PS by changing the LV pacing vector at target sites for CRT. LV stability at target sites despite PS should also be pursued by these means. The automatic adjustment of LV pacing output is complementary in patients with a small PS-LV threshold difference.
Collapse
Affiliation(s)
- Mauro Biffi
- From the Institute of Cardiology, Policlinico S. Orsola-Malpighi, University of Bologna, Italy
| | - Carlotta Moschini
- From the Institute of Cardiology, Policlinico S. Orsola-Malpighi, University of Bologna, Italy
| | - Matteo Bertini
- From the Institute of Cardiology, Policlinico S. Orsola-Malpighi, University of Bologna, Italy
| | - Davide Saporito
- From the Institute of Cardiology, Policlinico S. Orsola-Malpighi, University of Bologna, Italy
| | - Matteo Ziacchi
- From the Institute of Cardiology, Policlinico S. Orsola-Malpighi, University of Bologna, Italy
| | - Igor Diemberger
- From the Institute of Cardiology, Policlinico S. Orsola-Malpighi, University of Bologna, Italy
| | - Cinzia Valzania
- From the Institute of Cardiology, Policlinico S. Orsola-Malpighi, University of Bologna, Italy
| | - Giulia Domenichini
- From the Institute of Cardiology, Policlinico S. Orsola-Malpighi, University of Bologna, Italy
| | - Elena Cervi
- From the Institute of Cardiology, Policlinico S. Orsola-Malpighi, University of Bologna, Italy
| | - Cristian Martignani
- From the Institute of Cardiology, Policlinico S. Orsola-Malpighi, University of Bologna, Italy
| | - Diego Sangiorgi
- From the Institute of Cardiology, Policlinico S. Orsola-Malpighi, University of Bologna, Italy
| | - Angelo Branzi
- From the Institute of Cardiology, Policlinico S. Orsola-Malpighi, University of Bologna, Italy
| | - Giuseppe Boriani
- From the Institute of Cardiology, Policlinico S. Orsola-Malpighi, University of Bologna, Italy
| |
Collapse
|
20
|
Hawkins NM, Petrie MC, Burgess MI, McMurray JJ. Selecting Patients for Cardiac Resynchronization Therapy. J Am Coll Cardiol 2009; 53:1944-59. [DOI: 10.1016/j.jacc.2008.11.062] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Revised: 10/14/2008] [Accepted: 11/02/2008] [Indexed: 10/20/2022]
|
21
|
Arenal Maíz A, Castel MA, López Gil M, Merino Llorens JL. [Update on arrhythmias and cardiac electrophysiology]. Rev Esp Cardiol 2009; 62 Suppl 1:67-79. [PMID: 19174051 DOI: 10.1016/s0300-8932(09)70042-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This article contains a review of the most important developments in clinical arrhythmology and interventional cardiac electrophysiology that have been reported during the past year. Special emphasis has been placed on clinical conditions that are most prevalent in the general population as well as on progress that has been achieved using the main therapeutic approaches, whether pharmacologic or interventional.
Collapse
|
22
|
Dou J, Xia L, Zhang Y, Shou G, Wei Q, Liu F, Crozier S. Mechanical analysis of congestive heart failure caused by bundle branch block based on an electromechanical canine heart model. Phys Med Biol 2008; 54:353-71. [PMID: 19098354 DOI: 10.1088/0031-9155/54/2/012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Asynchronous electrical activation, induced by bundle branch block (BBB), can cause reduced ventricular function. However, the effects of BBB on the mechanical function of heart are difficult to assess experimentally. Many heart models have been developed to investigate cardiac properties during BBB but have mainly focused on the electrophysiological properties. To date, the mechanical function of BBB has not been well investigated. Based on a three-dimensional electromechanical canine heart model, the mechanical properties of complete left and right bundle branch block (LBBB and RBBB) were simulated. The anatomical model as well as the fiber orientations of a dog heart was reconstructed from magnetic resonance imaging (MRI) and diffusion tensor MRI (DT-MRI). Using the solutions of reaction-diffusion equations and with a strategy of parallel computation, the asynchronous excitation propagation and intraventricular conduction in BBB was simulated. The mechanics of myocardial tissues were computed with time-, sarcomere length-dependent uniaxial active stress initiated at the time of depolarization. The quantification of mechanical intra- and interventricular asynchrony of BBB was then investigated using the finite-element method with an eight-node isoparametric element. The simulation results show that (1) there exists inter- and intraventricular systolic dyssynchrony during BBB; (2) RBBB may have more mechanical synchrony and better systolic function of the left ventricle (LV) than LBBB; (3) the ventricles always move toward the early-activated ventricle; and (4) the septum experiences higher stress than left and right ventricular free walls in BBB. The simulation results validate clinical and experimental recordings of heart deformation and provide regional quantitative estimates of ventricular wall strain and stress. The present work suggests that an electromechanical heart model, incorporating real geometry and fiber orientations, may be helpful for better understanding of the mechanical implications of congestive heart failure (CHF) caused by BBB.
Collapse
Affiliation(s)
- Jianhong Dou
- Department of Biomedical Engineering, Zhejiang University, Hangzhou 310027, People's Republic of China. Guangzhou General Army Hospital, Guangzhou 510010, People's Republic of China
| | | | | | | | | | | | | |
Collapse
|