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Jin W, Yu C, Wang L, Ma Y, He D, Zhu T. Abnormal inter-ventricular diastolic mechanical delay in patients with ST-segment elevation myocardial infarction. BMC Cardiovasc Disord 2023; 23:494. [PMID: 37803312 PMCID: PMC10559586 DOI: 10.1186/s12872-023-03531-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 09/24/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND This study aimed to investigate the ventricular mechanical relaxation pattern and its clinical influence in patients with ST-segment elevation myocardial infarction (STEMI). METHODS Echocardiography was performed to measure mitral and tricuspid diastolic opening times. Left ventricular diastolic mechanical delay (LVMDd) was defined as diastolic filling of the right ventricle earlier than that of the left ventricle, and right ventricular diastolic mechanical delay (RVMDd) was defined as the right ventricular diastolic filling later than left ventricular filling. RESULTS Among 152 patients with STEMI, 100 (65.8%) had LVMDd, and 47 (30.9%) had RVMDd. In-hospital complications were significantly increased in patients with RVMDd (61.6% vs. 41.0%, P = 0.017). Those with RVMDd exhibited significantly lower left ventricular global longitudinal strain (11.7 ± 4.1% vs. 13.2 ± 4.0%, P = 0.035), global work index (913.8 ± 365.9 vs. 1098.9 ± 358.8 mmHg%, P = 0.005) and global constructive work (1218.6 ± 392.8 vs. 1393.7 ± 432.7 mmHg%, P = 0.021). Mitral deceleration time significantly decreased (127.4 ± 33.5 vs. 145.6 ± 41.7 ms, P = 0.012), and the ratio of early mitral inflow to early mitral annular velocity (E/E') significantly increased [13.0(11.0-20.0) vs. 11.9(9.3-14.3), P = 0.006] in the RVMDd group. Logistic regression analysis showed that age (odds ratio [OR]:0.920; P = 0.001), brain natriuretic peptide level (OR: 1.1002; P = 0.036) and mitral E/E' (OR: 1.187; P = 0.003) were independently associated with RVMDd. CONCLUSIONS Delayed right ventricular filling is related to more severe left ventricular systolic and diastolic dysfunction in STEMI patients. More attention should be paid to patients with RVMDd to prevent adverse events during hospitalization.
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Affiliation(s)
- Wenying Jin
- Department of Cardiology, Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| | - Chao Yu
- Department of Cardiology, Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| | - Lan Wang
- Department of Cardiology, Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| | - Yuliang Ma
- Department of Cardiology, Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| | - Dan He
- Department of Cardiology, Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| | - Tiangang Zhu
- Department of Cardiology, Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China.
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Miyazawa AA, Francis DP, Whinnett ZI. Basic Principles of Hemodynamics in Pacing. Card Electrophysiol Clin 2022; 14:133-140. [PMID: 35715072 DOI: 10.1016/j.ccep.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Pacing therapy aims to improve overall cardiac function by normalizing cardiac electrical activation. Although hemodynamic measurements allow the impact of cardiac pacing on cardiac function to be quantified, the protocol is crucial to minimize the effect of noise and achieve greater precision. Multiple steps can be undertaken to optimize accuracy of hemodynamic measurements. These include comparing with a reference state, using an average of a set number of beats, making repeated measurements, ensuring all beats are included, and pacing at faster heart rates. These measurements can aid comparison between different pacing modalities and guide optimal programming.
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Affiliation(s)
- Alejandra A Miyazawa
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK.
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Corbisiero R, Schmidt J, Muller D, Sookhu S, Shah M, Ochman A, Kazemain P. Paced or sensed conduction time to determine programming with cardiac resynchronization therapy: The PASED-CRT Trial. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:967-972. [PMID: 33665812 DOI: 10.1111/pace.14212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/12/2021] [Accepted: 02/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is a well-established treatment for patients with drug refractory heart failure. OBJECTIVES This study sought to compare the longest RVsense to LVsense activation time (sLAT) versus the longest RVpace to LVsense activation time (pLAT) as the programmed site for left ventricular (LV) pacing in CRT patients with quadripolar LV leads at 3 months. METHODS This single site, double-blinded, prospective trial, randomized patients 1:1 into the sLAT or pLAT group to determine response. LV pacing was programmed at implant and maintained through 3 months of follow-up. The 6-minute hall walk (6MHW) test, NYHA, Minnesota living with heart failure, and clinical composite score (CCS) at the 3 months was compared. RESULTS N = 92 patients (73M:19F age 66 ± 11.3 years) were randomized implanted and programmed per protocol. Baseline characteristics were comparable. N = 39 sLAT and N = 34 pLAT completed the 3-month visit for final analysis. Significant improvement from baseline to 3 months was seen in the sLAT group from 253.9 (+/-11.5) to 323.1 (+/-11.9) P = .001. Similarly, the pLAT group improved from 274.9 (+/-16.15) to 343.9 (+/-15.9) P = .003. The difference between these groups, however, did not reach significance (P = .86). The pLAT group demonstrated a higher responder rate of (71%) versus the sLAT group (64%) based on the CCS although not reaching significance (P = .56). CONCLUSIONS Use of both the pLAT and sLAT method of programming demonstrated significant improvement in 6MHW distance at 3 months with pLAT demonstrating a slightly higher responder rate based on CCS (P = .56). pLAT should be considered at minimum as equivalent in patients with no intrinsic conduction.
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Affiliation(s)
| | | | - David Muller
- Abbott Laboratories, Sicklerville, New Jersey, USA
| | - Sanjay Sookhu
- Deborah Heart & Lung Center, Browns Mills, New Jersey, USA
| | - Meet Shah
- Deborah Heart & Lung Center, Browns Mills, New Jersey, USA
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Zhang Y, Xing Q, Zhang JH, Jiang WF, Qin M, Liu X. Long-Term Effect of Different Optimizing Methods for Cardiac Resynchronization Therapy in Patients with Heart Failure: A Randomized and Controlled Pilot Study. Cardiology 2019; 142:158-166. [PMID: 31189165 DOI: 10.1159/000499502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 03/10/2019] [Indexed: 11/19/2022]
Abstract
AIM During cardiac resynchronization therapy (CRT), optimized programming of the atrioventricular (AV) delay and ventricular-to-ventricular (VV) interval can lead to improved hemodynamics, symptomatic response, and left ventricular systolic function. Currently, however, there is no recommendation for the best optimization method. This study aimed to compare the long-term clinical outcomes of 4 different CRT optimization methods. METHODS One hundred and twenty-four consecutive CRT patients with severe heart failure and left bundle-branch block configuration were randomly assigned into four groups to undergo AV/VV delay optimization through echocardiogram (ECHO; n = 30), electrocardiogram (ECG; n = 32), QuickOpt algorithm (n = 28), and nominal AV/VV (n = 36) groups. Patients were followed up and underwent examinations, including New York Heart Association (NYHA) cardiac functional classification, 6-min walking distance (6MWD), and echocardiography, at 6, 12, 24, 36, and 48 months, respectively. The patients' survival and clinical outcomes were compared among the four groups. RESULTS Kaplan-Meier survival analyses showed that the median survival was the same in the 4 groups: ECHO, 43 months; ECG, 44 months; QuickOpt, 44 months, and nominal, 41 months. At the 6-month follow-up, the reduction in left ventricular end diastolic diameter (LVEDD) was significantly less in the nominal group (-1.91 ± 2.58 mm) than that in the other three groups (ECHO: -3.70 ± 2.78 mm, p = 0.012; ECG: -3.53 ± 3.14 mm, p = 0.020; QuickOpt: -3.46 ± 2.65 mm, p = 0.032); 6MWD was significantly shorter in the nominal group (87.88 ± 34.76 m) than that in the other three groups (ECHO: 120.63 ± 56.93 m, p = 0.006; ECG: 114.97 ± 54.95 m, p = 0.020; QuickOpt: 114.57 ± 35.41 m, p = 0.027). Left ventricular ejection fraction (LVEF) significantly increased in ECHO (7.23 ± 2.76%, p = 0.010), ECG (8.50 ± 3.17%, p < 0.001), and QuickOpt (8.39 ± 2.90%, p < 0.001) compared with the nominal group (5.35 ± 2.59%). There were no significant differences among the groups in the aforementioned parameters at 24, 36, and 48 months, respectively. CONCLUSION While LVEDD, LVEF, 6MWD, and NYHA were significantly improved in ECHO, ECG, and QuickOpt at 6 months, there were no significant improvements in any of the groups at 12, 24, and 48 months. These findings suggested that the long-term effect of the four CRT methods for heart failure was not significantly different.
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Affiliation(s)
- Yu Zhang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China,
| | - Qiang Xing
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, China
| | - Jiang-Hua Zhang
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, China
| | - Wei-Feng Jiang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Mu Qin
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xu Liu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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Urbanek B, Kaczmarek K, Klimczak A, Ruta J, Chudzik M, Piestrzeniewicz K, Ptaszynski P, Wranicz JK. Potential benefit of optimizing atrioventricular & interventricular delays in patients with cardiac resynchronization therapy. Indian J Med Res 2018; 146:71-77. [PMID: 29168462 PMCID: PMC5719610 DOI: 10.4103/ijmr.ijmr_1560_14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background & objectives: The clinical benefit of optimization (OPT) of atrioventricular delay (AVD) and interventricular delay (VVD) in cardiac resynchronization therapy (CRT) remains debatable. This study was aimed to determine the influence of AVD and VVD OPT on selected parameters in patients early after CRT implantation and at mid-term follow up (FU). Methods: Fifty two patients (61±10 yr, 23 males) with left bundle branch block, left ventricular ejection fraction (LVEF) ≤35 per cent and heart failure were selected for CRT implantation. Early on the second day (2DFU) after CRT implantation, the patients were assigned to the OPT or the factory setting (FS) group. Haemodynamic and electrical parameters were evaluated at baseline, on 2DFU after CRT and mid-term FU [three-month FU (3MFU)]. Echocardiographic measures were assessed before implantation and at 3MFU. The AVD/VVD was deemed optimal for the highest cardiac output (CO) with impedance cardiography (ICG) monitoring. Results: On 2DFU, the AVD was shorter in the OPT group, LV was paced earlier than in FS group and CO was insignificantly higher in OPT group. At 3MFU, improvement of CO was observed only in OPT patients, but the intergroup difference was not significant. At 3MFU in OPT group, reduction of LV in terms of LV end-diastolic diameter (LVeDD), LV end-systolic diameter, LV end-diastolic and systolic volume with the improvement in LVEF was observed. In FS group, only a reduction in LVeDD was present. In OPT group, the paced QRS duration was shorter than in FS group patients. Interpretation & conclusions: CRT OPT of AVD and VVD with ICG was associated with a higher CO and better reverse LV remodelling. CO monitoring with ICG is a simple, non-invasive tool to optimize CRT devices.
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Affiliation(s)
- Bozena Urbanek
- Department of Electrocardiology, Medical University of Lodz, Lodz, Poland
| | | | - Artur Klimczak
- Department of Electrocardiology, Medical University of Lodz, Lodz, Poland
| | - Jan Ruta
- Department of Electrocardiology, Medical University of Lodz, Lodz, Poland
| | - Michal Chudzik
- Department of Electrocardiology, Medical University of Lodz, Lodz, Poland
| | | | - Pawel Ptaszynski
- Department of Electrocardiology, Medical University of Lodz, Lodz, Poland
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Friedberg MK, Schwartz SM, Zhang H, Chiu-Man C, Manlhiot C, Ilina MV, Arsdell GV, Kirsh JA, McCrindle BW, Stephenson EA. Hemodynamic effects of sustained postoperative cardiac resynchronization therapy in infants after repair of congenital heart disease: Results of a randomized clinical trial. Heart Rhythm 2017; 14:240-247. [DOI: 10.1016/j.hrthm.2016.09.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Indexed: 10/20/2022]
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Conraads VMA, Vanderheyden M, Paelinck B, Verstreken S, Blankoff I, Miljoen H, De Sutter J, Beckers P. The effect of endurance training on exercise capacity following cardiac resynchronization therapy in chronic heart failure patients: a pilot trial. ACTA ACUST UNITED AC 2016; 14:99-106. [PMID: 17301634 DOI: 10.1097/hjr.0b013e32801164b3] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Both endurance training (ET) and cardiac resynchronization therapy (CRT) improve quality of life (QOL) and exercise tolerance in patients with advanced chronic heart failure (CHF). DESIGN A randomized intervention trial to study the effect on exercise capacity of ET in addition to CRT in patients with CHF and dyssynchrony. METHODS Seventeen patients (eight men, aged 59+/-9 years) with CHF and dyssynchrony were randomized to CRT with (n=8) or without (n=9) ET and compared with two matched control CHF groups (standard care with ET: n=9, standard care only: n=10). At baseline and after 5 months, exercise tolerance, left ventricular (LV) remodelling, QOL and NT-pro brain natriuretic peptide (NT-proBNP) levels were assessed. RESULTS Peak oxygen consumption (VO2peak), maximal workload (Wattmax), circulatory power, LV ejection fraction, dyssynchrony and QOL improved in both CRT groups. However, the increase in VO2peak (+40% versus +16%, P=0.005), Wattmax (+43% versus +13%, P=0.0005), and circulatory power (+74% versus +32%, P=0.01), was significantly greater in the trained versus the untrained CRT patients. Comparison of the four patient groups confirmed the cumulative effects of CRT plus ET. CONCLUSIONS ET in resynchronized CHF patients is feasible and further enhances exercise tolerance. Patients with severe CHF should be prescribed an exercise training programme after implantation in order to maximize the expected benefit.
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Doi K, Noda T, Yoshida K, Yamasaki H, Sekiguchi Y, Kamakura S, Shimizu W, Aonuma K. Current status of cardiac resynchronization therapy device optimization in Japan. J Arrhythm 2013. [DOI: 10.1016/j.joa.2013.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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10
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Cobb V, Thomas M, Ellery S, Jewell S, Lee L, James R, O'Nunain S, Hildick-Smith D. Cardiac resynchronisation therapy: a randomised trial of factory or echocardiographic settings for optimum response. Heart Lung Circ 2013; 22:717-23. [PMID: 23499523 DOI: 10.1016/j.hlc.2013.01.009] [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: 04/05/2012] [Revised: 12/21/2012] [Accepted: 01/08/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND We aimed to assess whether echocardiographically-optimised atrioventricular (AV) and interventricular (VV) delay programming provided any additional benefit over standard settings following biventricular pacemaker implantation in patients with advanced heart failure. METHODS Paired data were collected on 22 patients (aged 67.5 ± 8.3 years, 16 male) with refractory heart failure, NYHA class III/IV symptoms, sinus rhythm, LBBB and a broad QRS complex >120 ms. All patients underwent implantation of a biventricular pacemaker and were randomised to eight weeks of factory pacing mode (Mode 1) or echocardiographically-guided pacing mode (Mode 2), followed by eight weeks in the alternate mode, in a randomised blinded crossover design. RESULTS Peak oxygen consumption, 6 min walk distance, NYHA class and quality of life scores improved after biventricular pacing, but no significant difference was found between the two modes, with the exception of peak oxygen consumption score (baseline: 14.8 ± 0.9, Mode 1: 14.6 ± 1.2, Mode 2: 16.1 ± 1.2 mL/kg/min), which was better in Mode 2 than Mode 1 (p 0.003). CONCLUSION Transthoracic echocardiographic optimisation of AV and VV delays following biventricular pacing may offer additional clinical benefit in an unselected group of patients when compared with factory settings.
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Affiliation(s)
- Vanessa Cobb
- Cardiology Department, The Heart Hospital, University College London Hospitals NHS Trust, 16-18 Westmoreland Street, London W1G 8PH, United Kingdom.
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Wang D, Yu H, Yun T, Zang H, Yang G, Wang S, Wang Z, Jing Q, Han Y. Long-term clinical effects of programmer-guided atrioventricular and interventricular delay optimization: Intracardiac electrography versus echocardiography for cardiac resynchronization therapy in patients with heart failure. J Int Med Res 2013; 41:115-22. [PMID: 23569136 DOI: 10.1177/0300060512474570] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives To compare the haemodynamic results and long-term clinical outcomes of intracardiac electrography (QuickOpt®; St Jude Medical, St Paul, MN, USA) and echocardiography for optimization of atrioventricular (AV) and interventricular (VV) delays in cardiac resynchronization therapy (CRT). Methods Patients with CRT devices were prospectively enrolled; AV/VV delays were optimized by either QuickOpt® or echocardiography. Patients in the QuickOpt® group underwent both echocardiography and QuickOpt® optimization, and QuickOpt® AV/VV delays were used to program the CRT. All patients were followed-up for 12 months. Results In total, 44 patients were enrolled. There was good correlation between AV/VV delays determined by QuickOpt® ( n = 20) and echocardiography ( n = 24). QuickOpt® was significantly faster than echocardiography-guided optimization. Cardiac function, 6-min walking distance and left ventricular ejection fraction were significantly and similarly improved in both groups at 6 and 12 months compared with baseline. In the QuickOpt® group, left ventricular end diastolic diameters were significantly smaller at 6 and 12 months compared with baseline. Conclusions QuickOpt® is a quick, convenient and easy to perform method for optimization of AV and VV delays, with a similar long-term clinical outcome to echocardiography-guided optimization.
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Affiliation(s)
- Dongmei Wang
- Department of Cardiology, Bethune International Peace Hospital, Shijiazhuang, China
- Department of Cardiology, Shenyang Northern Hospital, Shenyang, China
| | - Haibo Yu
- Department of Cardiology, Shenyang Northern Hospital, Shenyang, China
| | - Tian Yun
- Department of Cardiology, Shenyang Northern Hospital, Shenyang, China
| | - Hongyun Zang
- Department of Cardiology, Shenyang Northern Hospital, Shenyang, China
| | - Guitang Yang
- Department of Cardiology, Shenyang Northern Hospital, Shenyang, China
| | - Shouli Wang
- Department of Cardiology, Shenyang Northern Hospital, Shenyang, China
- Department of Cardiology, the 306 Hospital of PLA, Beijing, China
| | - Zulu Wang
- Department of Cardiology, Shenyang Northern Hospital, Shenyang, China
| | - Quanmin Jing
- Department of Cardiology, Shenyang Northern Hospital, Shenyang, China
| | - Yaling Han
- Department of Cardiology, Shenyang Northern Hospital, Shenyang, China
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Abraham WT, León AR, St. John Sutton MG, Keteyian SJ, Fieberg AM, Chinchoy E, Haas G. Randomized controlled trial comparing simultaneous versus optimized sequential interventricular stimulation during cardiac resynchronization therapy. Am Heart J 2012; 164:735-41. [PMID: 23137504 DOI: 10.1016/j.ahj.2012.07.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2008] [Accepted: 07/10/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) reduces morbidity and mortality and improves symptoms in patients with systolic heart failure (HF) and ventricular dyssynchrony. This randomized, double-blind, controlled study evaluated whether optimizing the interventricular stimulating interval (V-V) to sequentially activate the ventricles is clinically better than simultaneous V-V stimulation during CRT. METHODS Patients with New York Heart Association (NYHA) III or IV HF, meeting both CRT and implantable cardioverter-defibrillator indications, randomly received either simultaneous CRT or CRT with optimized V-V settings for 6 months. Patients also underwent echocardiography-guided atrioventricular delay optimization to maximize left ventricular filling. The V-V optimization involved minimizing the left ventricular septal to posterior wall motion delay during CRT. The primary objective was to demonstrate noninferiority using a clinical composite end point that included mortality, HF hospitalization, NYHA functional class, and patient global assessment. Secondary end points included changes in NYHA classification, 6-minute hall walk distance, quality of life, peak VO(2), and event-free survival. RESULTS The composite score improved in 75 (64.7%) of 116 simultaneous patients and in 92 (75.4%) of 122 optimized patients (P < .001, for noninferiority). A prespecified test of superiority showed that more optimized patients improved (P = .03). New York Heart Association functional class improved in 58.0% of simultaneous patients versus 75.0% of optimized patients (P = .01). No significant differences in exercise capacity, quality of life, peak VO(2), or HF-related event rate between the 2 groups were observed. CONCLUSIONS These findings demonstrate modest clinical benefit with optimized sequential V-V stimulation during CRT in patients with NYHA class III and IV HF. Optimizing V-V timing may provide an additional tool for increasing the proportion of patients who respond to CRT.
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Nawar A, El-Hoseiny R, Ragab D, Al-Aziz AA. V–V delay interval optimization in CRT using echocardiography compared to QRS width in surface ECG. Egypt Heart J 2012. [DOI: 10.1016/j.ehj.2011.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Xu GJ, Gan TY, Tang BP, Ma YT, Zhang Y, Li JX, Zhang YY, Wang J, Tang Q, Wang CM, Li YD, Zhang JH. Predictive factors and clinical effect of optimized cardiac resynchronization therapy. Exp Ther Med 2012; 5:355-361. [PMID: 23251298 PMCID: PMC3524119 DOI: 10.3892/etm.2012.802] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 10/29/2012] [Indexed: 11/21/2022] Open
Abstract
The aim of this study was to assess the effectiveness of cardiac resynchronization therapy (CRT) by intracardiac delay optimization using echocardiography. Sixty-five patients were implanted with a CRT device randomly assigned to receive simultaneous biventricular pacing or echo-optimized sequential CRT. Forty-two patients were defined as responders and 23 patients were classified as non-responders. During a 12-month follow-up period, the positive response rate, QRS duration, New York Heart Association class, mitral insufficiency grade, left ventricular end-systolic volume and LV end-diastolic volume were similar in the optimized and non-optimized groups (P>0.05), whereas 6-minute walking distance, quality-of-life score, left ventricular (LV) ejection fraction and aortic velocity time integral were significantly improved in the optimized group (P<0.05). The baseline QRS durations of the responders and non-responders were similar (P>0.05), whereas heart failure aetiology, clinical and echocardiographic measurements showed significant differences (P<0.05). The mean decrease in QRS duration after 12 months of CRT used for separating responders and non-responders was significantly different (P<0.05), and significant differences were observed in the mean decrease of QRS duration between responders and non-responders (P<0.05). Echocardiographic optimization may further improve the effectiveness of CRT. Moreover, severe mitral regurgitation and greater LV volume are likely to indicate a poor response to CRT.
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Affiliation(s)
- Guo-Jun Xu
- Department of Cardiology, First Affiliated Hospital, Xinjiang Medical University, Urumqi 830054, P.R. China
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Cheng CM, Huang JL, Wu TJ, Su CS, Pai HY, Liao MF, Ting CT, Chen SA. Comparison of quick optimization of interventricular delay between simple methods: intracardiac electrogram and surface electrocardiogram after cardiac resynchronization therapy. Europace 2012; 14:1317-23. [DOI: 10.1093/europace/eus061] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Kandala J, Altman RK, Park MY, Singh JP. Clinical, laboratory, and pacing predictors of CRT response. J Cardiovasc Transl Res 2012; 5:196-212. [PMID: 22362181 DOI: 10.1007/s12265-012-9352-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 02/08/2012] [Indexed: 01/21/2023]
Abstract
A decade of research has established the role of cardiac resynchronization therapy (CRT) in medically refractory, moderate to severe systolic heart failure (HF) with intraventricular conduction delay. CRT is an electrical therapy instituted to reestablish ventricular synchronization in order to improve cardiac function and favorably modulate the neurohormonal system. CRT confers a mortality benefit, improved HF hospitalizations, and functional outcome in this population, but not all patients consistently demonstrate a positive CRT response. The nonresponder rate varies from 20% to 40%, depending on the defined response criteria. Efforts to improve response to CRT have focused on a number of fronts. Methods to optimize the correction of electrical and mechanical dyssynchrony, which is the primary target of CRT, has been the focus of research, in addition to improving patient selection and optimizing post-implant care. However, a major issue in dealing with improving nonresponse rates has been finding an accurate and generally accepted definition of "response" itself. The availability of a standard consensus definition of CRT response would enable the estimation of nonresponder burden accurately and permit the development of strategies to improve CRT response. In this review, we define various aspects of "response" to CRT and outline variability in the definition criteria and the problems with its inconsistencies. We describe clinical, laboratory, and pacing predictors that influence CRT response and outcome and how to optimize response.
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Affiliation(s)
- Jagdesh Kandala
- Cardiac Arrhythmia Service, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Houthuizen P, Bracke FALE, van Gelder BM. Atrioventricular and interventricular delay optimization in cardiac resynchronization therapy: physiological principles and overview of available methods. Heart Fail Rev 2011; 16:263-76. [PMID: 21431901 PMCID: PMC3074065 DOI: 10.1007/s10741-010-9215-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
In this review, the physiological rationale for atrioventricular and interventricular delay optimization of cardiac resynchronization therapy is discussed including the influence of exercise and long-term cardiac resynchronization therapy. The broad spectrum of both invasive and non-invasive optimization methods is reviewed with critical appraisal of the literature. Although the spectrum of both invasive and non-invasive optimization methods is broad, no single method can be recommend for standard practice as large-scale studies using hard endpoints are lacking. Current efforts mainly investigate optimization during resting conditions; however, there is a need to develop automated algorithms to implement dynamic optimization in order to adapt to physiological alterations during exercise and after anatomical remodeling.
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Affiliation(s)
- Patrick Houthuizen
- Department of Cardiology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands.
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Brignole M, Botto G, Mont L, Iacopino S, De Marchi G, Oddone D, Luzi M, Tolosana JM, Navazio A, Menozzi C. Cardiac resynchronization therapy in patients undergoing atrioventricular junction ablation for permanent atrial fibrillation: a randomized trial. Eur Heart J 2011; 32:2420-9. [PMID: 21606084 DOI: 10.1093/eurheartj/ehr162] [Citation(s) in RCA: 240] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AIMS On the basis of the current knowledge, cardiac resynchronization therapy (CRT) cannot be recommended as a first-line treatment for patients with severely symptomatic permanent atrial fibrillation undergoing atrioventricular (AV) junction ablation. We examined whether CRT was superior to conventional right ventricular (RV) pacing in reducing heart failure (HF) events. METHODS AND RESULTS In this prospective, multi-centre study, we randomly assigned 186 patients, in whom AV junction ablation and CRT device implantation had been successfully performed, to receive optimized echo-guided CRT (97 patients) or RV apical pacing (89 patients). The data were analysed according to the intention-to-treat principle. During a median follow-up of 20 months (interquartile range 11-24), the primary composite endpoint of death from HF, hospitalization due to HF, or worsening HF occurred in 11 (11%) patients in the CRT group and 23 (26%) patients in the RV group [CRT vs. RV group: sub-hazard ratio (SHR) 0.37 ( 95% CI 0.18-0.73), P = 0.005]. In the CRT group, compared with the RV group, fewer patients had worsening HF [SHR 0.27 (95% CI 0.12-0.58), P = 0.001] and hospitalizations for HF [SHR 0.20 (95% CI 0.06-0.72), P = 0.013]. Total mortality was similar in both groups [hazard ratio (HR) 1.57 (95% CI 0.58-4.27), P = 0.372]. The beneficial effects of CRT were consistent in patients who had ejection fraction ≤35%, New York Heart Association Class ≥III and QRS width ≥120 and in those who did not. At multi-variable Cox regression, only CRT mode remained an independent predictor of absence of clinical failure during the follow-up [HR = 0.23 (95% CI 0.08-0.66), P = 0.007]. CONCLUSIONS In patients undergoing 'Ablate and Pace' therapy for severely symptomatic permanent atrial fibrillation, CRT is superior to RV apical pacing in reducing the clinical manifestations of HF. (ClinicalTrials.gov number: NCT00111527).
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Affiliation(s)
- Michele Brignole
- Arrhythmologic Centre, Department of Cardiology, Ospedali del Tigullio, 16033 Lavagna, Italy.
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Perzanowski C. Is echo-guided optimization of biventricular devices time practical? Int J Cardiol 2011; 148:114-5. [PMID: 21316115 DOI: 10.1016/j.ijcard.2011.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 01/08/2011] [Accepted: 01/13/2011] [Indexed: 10/18/2022]
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Higuchi R, Tada H, Okaniwa H, Nakajima T, Takemura N, Fuke E, Sato C, Hayashi T, Miki Y, Sakamoto T, Fukasawa R, Kumagai K, Naito S, Oshima S. Utility and Validation of Corrected Left Ventricular Filling Time for Determining the Optimal AV Delay in Patients Receiving Cardiac Resynchronization Therapy. J Arrhythm 2011. [DOI: 10.1016/s1880-4276(11)80019-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Ho JK, Mahajan A. Cardiac Resynchronization Therapy for Treatment of Heart Failure. Anesth Analg 2010; 111:1353-61. [DOI: 10.1213/ane.0b013e3181fa3408] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Spotnitz ME, Richmond ME, Quinn TA, Cabreriza SE, Wang DY, Albright CM, Weinberg AD, Dizon JM, Spotnitz HM. Relation of QRS shortening to cardiac output during temporary resynchronization therapy after cardiac surgery. ASAIO J 2010; 56:434-40. [PMID: 20592584 PMCID: PMC3086767 DOI: 10.1097/mat.0b013e3181e88ac6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) can improve cardiac function in heart failure without increasing myocardial oxygen consumption. However, CRT optimization based on hemodynamics or echocardiography is difficult. QRS duration (QRSd) is a possible alternative optimization parameter. Accordingly, we assessed QRSd optimization of CRT during cardiac surgery. We hypothesized that QRSd shortening during changes in interventricular pacing delay (VVD) would increase cardiac output (CO). Seven patients undergoing coronary artery bypass, aortic or mitral valve surgery with left ventricular (LV) ejection fraction < or =40%, and QRSd > or =100 msec were studied. CRT was implemented at epicardial pacing sites in the left and right ventricle and right atrium during VVD variation after cardiopulmonary bypass. QRSd was correlated with CO from an electromagnetic aortic flow probe. Both positive and negative correlations were observed. Correlation coefficients ranged from 0.70 to -0.74 during VVD testing. Clear minima in QRSd were observed in four patients and were within 40 msec of maximum CO in two. We conclude that QRSd is not useful for routine optimization of VVD after cardiac surgery but may be useful in selected patients. Decreasing QRSd is associated with decreasing CO in some patients, suggesting that CRT can affect determinants of QRSd and ventricular function independently.
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Affiliation(s)
- Matthew E Spotnitz
- Departments of Surgery, Columbia University, New York City, New York 10032, USA
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Szulik M, Tillekaerts M, Vangeel V, Ganame J, Willems R, Lenarczyk R, Rademakers F, Kalarus Z, Kukulski T, Voigt JU. Assessment of apical rocking: a new, integrative approach for selection of candidates for cardiac resynchronization therapy. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2010; 11:863-9. [PMID: 20615904 DOI: 10.1093/ejechocard/jeq081] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
AIMS Current attempts of improving patient selection in cardiac resynchronization therapy (CRT) are mainly based on echocardiographic timing of myocardial velocity peaks. Regional myocardial function is neglected. Apical transverse motion (ATM) is a new parameter to quantify apical rocking as an integrative surrogate of both temporal and functional inhomogeneities within the left ventricle. In this study, we tested the predictive value of apical rocking for response to CRT. METHODS AND RESULTS Sixty-nine patients eligible for CRT were assessed by echocardiography before and 11 ± 5 months after pacemaker implantation. Response was defined as left ventricular (LV) end-systolic volume decrease >15%. Rocking was quantified (ATM) and visually assessed by four blinded readers. Predictive value for CRT response of both assessments was compared with conventional dyssynchrony parameters. ATM in the four-chamber view plane differentiated best between responders and non-responders (2.2 ± 1.5 vs. 0.06 ± 1.9 mm, P< 0.0001). Quantified ATM predicted reverse remodelling with a sensitivity, specificity, and accuracy of 75, 96, and 83% whereas visual rocking assessment resulted in 89, 75, and 83%, respectively. The accuracy of conventional parameters was significantly lower. CONCLUSION Apical rocking is a new marker to assess LV dyssynchrony and predict CRT response. It is superior to conventional parameters. Even its simple visual assessment may be sufficiently accurate in the clinical setting.
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Affiliation(s)
- Mariola Szulik
- Department of Cardiovascular Diseases, University Hospital Gasthuisberg, Catholic University Leuven, Herestraat 49, 3000 Leuven, Belgium
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Bogaard MD, Doevendans PA, Leenders GE, Loh P, Hauer RNW, van Wessel H, Meine M. Can optimization of pacing settings compensate for a non-optimal left ventricular pacing site? Europace 2010; 12:1262-9. [PMID: 20562112 DOI: 10.1093/europace/euq167] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
AIMS Optimal left ventricular (LV) lead position improves the response to cardiac resynchronization therapy (CRT). However, in some patients it is not possible to position the LV lead at an optimal pacing site. The aim of this study was to determine whether optimization of the pacing settings atrioventricular delay (AVD) and interventricular delay (VVD) can compensate for a non-optimal LV pacing site. METHODS AND RESULTS In 16 patients with heart failure [New York Heart Association class III (13) or IV (3), median QRS duration of 172 ms and median LV ejection fraction of 20%] the acute haemodynamic effect of biventricular pacing was assessed at > or =2 pacing sites by the increase in maximum rate of LV pressure rise (%dP/dt(max)). At each site the AVD and VVD were optimized. Biventricular pacing with nominal settings at a non-optimal LV pacing site improved dP/dt(max) by 12.8% (-0.5 to 23.2%). This could be further improved by 6.5 percentage points (1.2-13.9) by optimization of pacing settings (P = 0.001) and by 9.9 percentage points (3.7-13.3, P = 0.004) by optimization of pacing site. Optimization of the LV pacing site and pacing settings together improved %dP/dt(max) by 16.2 per cent points (10.0-21.8, P < 0.001). CONCLUSION Optimization of the AVD and VVD can partly compensate for a non-optimal LV pacing site. However, a combination of an optimal LV pacing site and optimized pacing settings gives the best acute haemodynamic response.
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Affiliation(s)
- Margot D Bogaard
- Department of Cardiology, University Medical Center Utrecht, CX Utrecht, The Netherlands.
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DUVALL WLANE, HANSALIA RIPLE, WIJETUNGA MELANIEN, BUCKLEY SAMANTHA, FISCHER AVI. Advantage of Optimizing V-V Timing in Cardiac Resynchronization Therapy Devices. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 33:1161-8. [DOI: 10.1111/j.1540-8159.2010.02806.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Taha N, Zhang J, Ranjan R, Daneshvar S, Castillo E, Guillen E, Montoya MC, Velasquez G, Naqvi TZ. Biventricular pacemaker optimization guided by comprehensive echocardiography-preliminary observations regarding the effects on systolic and diastolic ventricular function and third heart sound. J Am Soc Echocardiogr 2010; 23:857-66. [PMID: 20510584 DOI: 10.1016/j.echo.2010.04.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Doppler echocardiography of mitral inflow or aortic outflow or both has been validated and advocated to guide biventricular (Biv) pacemaker optimization. A comprehensive and tailored Doppler echocardiographic evaluation may be required in patients with heart failure to assist with Biv pacemaker optimization. The third heart sound (S(3)), an acoustic cardiographic parameter, has been demonstrated to be a highly specific finding for hemodynamic evaluation in patients with heart failure. The aims of this study were to evaluate the use of comprehensive Doppler echocardiography as a guide during Biv pacemaker optimization in patients after cardiac resynchronization therapy and to evaluate the feasibility of S(3) intensity to be a cost-efficient parameter for Biv pacemaker optimization compared with Doppler echocardiography. METHODS Comprehensive Doppler echocardiographic evaluations were performed during Biv pacemaker optimization in 44 patients referred for pacemaker optimization (mean age, 71 + or - 12 years; mean left ventricular ejection fraction, 34 + or - 11%). Blinded assessment of S(3) intensity was performed simultaneously using acoustic cardiography. The correlation and improvement in cardiac hemodynamics were analyzed between the methods. RESULTS Echocardiographically guided optimization resulted in significant improvements in the left ventricular outflow velocity-time integral (15.92 + or - 4.77 to 18.51 + or - 5.19 cm, P < .001), ejection time (278 + or - 40 to 293 + or - 40 ms, P < .001), myocardial performance index (0.57 + or - 0.19 to 0.44 + or - 0.14, P < .002), and peak pulmonary artery systolic pressure (42 + or - 13 to 36 + or - 11 mm Hg, P < .04) and decreased S(3) intensity from 4.81 + or - 1.84 at baseline to 3.96 + or - 1.22 after optimization (P < .02) for the overall study group and from 6.63 + or - 1.37 to 4.85 + or - 1.13 (P < .001) in the 18 patients with baseline S(3) intensity > 5.0. The correlation between echocardiographic and acoustic cardiographic S(3) intensity for optimal atrioventricular delay was 0.86 (P < .001) and for optimal interventricular delay was 0.64 (P < .001). Optimal atrioventricular delay was identical by echocardiographic and acoustic cardiographic S(3) intensity in 56%, and optimal interventricular delay was identical in 75% of patients. Pacemakers were permanently programmed on the basis of echocardiographic evaluation. In 35 patients available for follow up, the mean New York Heart Association class reduced from 2.55 + or - 0.81 to 1.77 + or - 0.90 (P < .001) and the mean quality-of-life score as assessed by Minnesota Living With Heart Failure Questionnaire improved from 45 + or - 28 to 32 + or - 28 (P = .08) at 2.5 + or - 2.1 months. CONCLUSION Comprehensive echocardiographically guided Biv pacemaker optimization produces significant improvement in Doppler echocardiographic hemodynamics, a reduction in S(3) intensity, and an improvement in functional class in patients after cardiac resynchronization therapy.
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Affiliation(s)
- Nima Taha
- Non Invasive Diagnostic Services and Echocardiography Laboratory, Cardiovascular and Thoracic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Sleep apnea in patients with heart failure: Could cardiac resynchronization therapy be the first line treatment? Int J Cardiol 2010; 140:128-30; author reply 130-1. [DOI: 10.1016/j.ijcard.2008.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Accepted: 11/08/2008] [Indexed: 11/18/2022]
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Kamdar R, Frain E, Warburton F, Richmond L, Mullan V, Berriman T, Thomas G, Tenkorang J, Dhinoja M, Earley M, Sporton S, Schilling R. A prospective comparison of echocardiography and device algorithms for atrioventricular and interventricular interval optimization in cardiac resynchronization therapy. Europace 2010; 12:84-91. [PMID: 19892713 DOI: 10.1093/europace/eup337] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
AIMS Echocardiographic optimization of atrioventricular (AV) and interventricular (VV) intervals in cardiac resynchronization therapy (CRT) is costly, time-consuming, and requires skill and expertise so is usually undertaken only in 'non-responder' patients. An algorithm in St Jude Medical CRT devices (QuickOpt) claims to optimize these settings automatically. The aim of this study was to compare the two optimization techniques. METHODS AND RESULTS Optimization of AV and VV intervals was performed a month after CRT device implantation in 26 patients with heart failure, first by echocardiography then by QuickOpt. The left ventricular outflow tract (LVOT) velocity-time integral (VTI) was measured after optimization by each method. Agreement between the optimization methods was assessed by the Bland-Altman analysis and correlation by Pearson's correlation coefficient. There was good correlation between the LVOT VTI following optimization by both methods (R2 = 0.77, P < 0.001). However, agreement between the two methods was poor, with 15 of 26 and 10 of 26 patients having a >20 ms difference in the optimal AV and VV interval values, respectively. Left ventricular outflow tract VTI was significantly better (22 of 26 patients; P < 0.001) in patients optimized by echocardiography than by QuickOpt. CONCLUSION There is a poor agreement in optimal AV and VV intervals determined by echocardiography and QuickOpt, with echocardiographic optimization giving a superior haemodynamic outcome.
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Affiliation(s)
- Ravindu Kamdar
- Department of Cardiology, St Bartholomew's Hospital, Barts and the London NHS Trust, Dominion House, 60 Bartholomew Close, West Smithfield, EC1A 7BE London, UK
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Bertini M, Valzania C, Biffi M, Martignani C, Ziacchi M, Pedri S, Domenichini G, Diemberger I, Saporito D, Rocchi G, Rapezzi C, Branzi A, Boriani G. Interventricular Delay Optimization: A Comparison among Three Different Echocardiographic Methods. Echocardiography 2010; 27:38-43. [DOI: 10.1111/j.1540-8175.2009.00975.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Recent advances in cardiac resynchronization therapy: echocardiographic modalities, patient selection, optimization, non-responders—all you need to know for more efficient CRT. Int J Cardiovasc Imaging 2009; 26:177-91. [DOI: 10.1007/s10554-009-9523-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2009] [Accepted: 10/16/2009] [Indexed: 12/24/2022]
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Khan FZ, Virdee MS, Pugh PJ, Read PA, Fynn SP, Dutka DP. Non-invasive cardiac output measurements based on bioreactance for optimization of atrio- and interventricular delays. Europace 2009; 11:1666-74. [PMID: 19910316 DOI: 10.1093/europace/eup358] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Marsan NA, Bleeker GB, Van Bommel RJ, Borleffs CJW, Bertini M, Holman ER, van der Wall EE, Schalij MJ, Bax JJ. Cardiac resynchronization therapy in patients with ischemic versus non-ischemic heart failure: Differential effect of optimizing interventricular pacing interval. Am Heart J 2009; 158:769-76. [PMID: 19853696 DOI: 10.1016/j.ahj.2009.09.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Accepted: 09/03/2009] [Indexed: 11/28/2022]
Abstract
BACKGROUND Whether sequential biventricular pacing provides substantial benefits over conventional simultaneous stimulation remains unclear, particularly regarding the differences between ischemic and non-ischemic patients. The purpose of this study was to evaluate the acute effect of interventricular pacing interval (V-V) optimization on left ventricular (LV) systolic performance and dyssynchrony in ischemic versus non-ischemic patients. METHODS Sixty-nine consecutive patients underwent cardiac resynchronization therapy. Within 3 days after implantation, V-V was optimized by measuring (every 20-millisecond interval) LV systolic performance (LV outflow-tract velocity-time-integral, LVOT VTI) and LV dyssynchrony (using tissue Doppler imaging). Optimal pacing configuration was the one achieving maximal increase in LVOT VTI. RESULTS Optimized sequential pacing provided a significant improvement in LVOT VTI compared to simultaneous stimulation (from 138 +/- 42 to 163 +/- 38 mm, P < .001) and was associated with a significant reduction in LV dyssynchrony (from 33 +/- 31 to 19 +/- 24 milliseconds, P < .001). The increase in LVOT VTI and LV ejection fraction after implantation was greater in non-ischemic as compared to ischemic patients (P < .001). However, V-V optimization yielded a larger improvement in LV systolic performance in ischemic patients (P = .03). Consequently, the 2 groups showed comparable response after V-V optimization. A significant correlation was observed between LV scar tissue and optimal V-V interval (r = 0.58, P < .001), with a larger extent of scar related to a larger level of LV preactivation, probably reflecting slow intra-LV conduction. CONCLUSIONS Optimized sequential biventricular pacing further increased LV systolic performance as compared to simultaneous stimulation, particularly in ischemic patients where the presence of a large scar was correlated with a larger LV preactivation.
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Affiliation(s)
- Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, The Netherlands
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[Pacemaker optimization guided by echocardiography in cardiac resynchronization therapy]. SRP ARK CELOK LEK 2009; 137:416-22. [PMID: 19764597 DOI: 10.2298/sarh0908416t] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Cardiac resynchronization therapy (CRT) or biventricular pacing is a contemporary treatment in the management of advanced heart failure. Echocardiography plays an evolving and important role in patient selection for CRT, follow-up of acute and chronic CRT effects and optimization of device settings after biventricular pacemaker implantation. In this paper we illustrate usefulness of echocardiography for successful AV and VV timing optimization in patients with CRT. A review of up-to-date literature concerning rationale for AV and VV delay optimization, echocardiographic protocols and current recommendations for AV and VV optimization after CRT are also presented. OUTLINE OF CASES The first case is of successful AV delay optimization guided by echocardiography in a patient with dilated cardiomyopathy treated with CRT is presented. Pulsed blood flow Doppler was used to detect mitral inflow while programming different duration of AV delay. The AV delay with optimal transmittal flow was established. The optimal mitral flow was the one with clearly defined E and A waves and maximal velocity time integral (VTI) of the mitral flow. Improvement in clinical status and reverse left ventricle remodelling with improvement of ejection fraction was registered in our patient after a month. The second case presents a patient with heart failure caused by dilated cardiomyopathy; six months after CRT implantation the patient was still NYHA class III and with a significantly depressed left ventricular ejection fraction. Optimization of VV interval guided by echocardiography was undertaken measuring VTI of the left ventricular outflow tract (LVOT) during programming of different VV intervals. The optimal VV interval was determined using a maximal LVOT VTI. A month after VV optimization our patient showed improvement in LV ejection fraction. CONCLUSION Optimal management of patients treated with CRT integrate both clinical and echocardiographic follow-up with, if needed, echocardiographically guided optimization of AV and VV delays, which offers the possibility of additional clinical improvement in such patients.
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Singh JP, Rosenthal LS, Hranitzky PM, Berg KC, Mullin CM, Thackeray L, Kaplan A. Device diagnostics and long-term clinical outcome in patients receiving cardiac resynchronization therapy. Europace 2009; 11:1647-53. [PMID: 19752011 DOI: 10.1093/europace/eup250] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS This retrospective analysis sought to develop and validate a model using the measured diagnostic variables in cardiac resynchronization therapy (CRT) devices to predict mortality. METHODS AND RESULTS Data used in this analysis came from two CRT studies: Cardiac Resynchronization Therapy Registry Evaluating Patient Response with RENEWAL Family Devices (CRT RENEWAL) (n = 436) and Heart Failure-Heart Rate Variability (HF-HRV) (n = 838). Patients from CRT RENEWAL were used to create a model for risk of death using logistic regression and to create a scoring system that could be used to predict mortality. Results of both the logistic regression and the clinical risk score were validated in a cohort of patients from the HF-HRV study. Diagnostics significantly improved over time post-CRT implant (all P < 0.001) and were correlated with a trend of decreased risk of death. The regression model classified CRT RENEWAL patients into low (2.8%), moderate (6.9%), and high (13.8%) risk of death based on tertiles of their model predicted risk. The clinical risk score classified CRT RENEWAL patients into low (2.8%), moderate (10.1%), and high (13.4%) risk of death based on tertiles of their score. When both the regression model and the clinical risk score were applied to the HF-HRV study, each was able to classify patients into appropriate levels of risk. CONCLUSION Device diagnostics may be used to create models that predict the risk of death.
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Affiliation(s)
- Jagmeet P Singh
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114-2696, USA.
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Fischer A, Hansalia R, Buckley S, Goldberg R, Goldman M, Muntner P, Mehta D, Duvall WL. Lack of clinical predictors of optimal V-V delay in patients with cardiac resynchronization devices. J Interv Card Electrophysiol 2009; 25:153-8. [PMID: 19148728 DOI: 10.1007/s10840-008-9336-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Accepted: 10/15/2008] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Cardiac resynchronization therapy (CRT) is a well-established therapy for patients with moderate-to-severe heart failure (HF), left ventricular dysfunction with an ejection fraction <or= 35% and a QRS on the surface electrocardiogram of >or=130 msec. Device optimization is often performed, adjusting the timing of RV and LV stimulation to produce a pacing sequence that yields the best global cardiac performance. However, no standard guidelines exist for optimization and many invasive and non-invasive techniques have been employed with mixed results. The aim of the present study was to determine whether there are any clinical predictors of the optimal V-V settings in patients implanted with CRT devices. METHODS AND RESULTS We prospectively evaluated 47 consecutive patients with HF who were referred to our device optimization clinic. The mean patient age was 64.9 +/- 12.7 years. Patients were in both sinus rhythm (83%) and atrial fibrillation. Prior to device implant, 51% of patients had left bundle branch block (LBBB), 17% had intra-ventricular conduction delay (IVCD) and 21% were RV paced. Sixty-two percent were male, the mean QRS duration was 152 +/- 29 ms, mean LVEF 26 +/- 8% and 60% had a non-ischemic cardiomyopathy. Overall, 82% of patients required sequential pacing with 69% requiring LV pre-excitation to produce the best global cardiac function as determined by aortic velocity time integrals (VTI). In our cohort, none of the clinical characteristics evaluated, including etiology of the cardiomyopathy, QRS duration, LVEF, pre-implant rhythm or AV delay were predictive of an optimal simultaneous or sequential V-V setting. CONCLUSIONS None of the clinical variables tested in our analysis predicted optimal RV-LV settings. Our results suggest that individual optimization and programming of V-V settings is necessary. The inability to predict optimal settings likely reflects the unique characteristics of each patient and supports the need for individualized programming of each device.
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Affiliation(s)
- Avi Fischer
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, NY 10029, USA.
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SAKSENA SANJEEV, SIMON ANNMARIE, MATHEW PHILIP, NAGARAKANTI RANGADHAM. Intracardiac Echocardiography-Guided Cardiac Resynchronization Therapy: Technique and Clinical Application. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:1030-9. [DOI: 10.1111/j.1540-8159.2009.02435.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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LENARCZYK RADOSŁAW, KOWALSKI OSKAR, SREDNIAWA BEATA, PRUSZKOWSKA-SKRZEP PATRYCJA, PLUTA SŁAWOMIR, SOKAL ADAM, KUKULSKI TOMASZ, STABRYŁA-DESKA JOANNA, WOŹNIAK ALEKSANDRA, KOWALCZYK JACEK, ZIELIŃSKA TERESA, MAZUREK MICHAŁ, STREB WITOLD, ZEMBALA MARIAN, KALARUS ZBIGNIEW. Triple-Site Versus Standard Cardiac Resynchronization Therapy Study (TRUST CRT): Clinical Rationale, Design, and Implementation. J Cardiovasc Electrophysiol 2009; 20:658-62. [DOI: 10.1111/j.1540-8167.2008.01394.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Albertsen AE, Poulsen SH, Andersen K, Mortensen PT, Egeblad H. Simple Preimplant Identification of Optimum VV Timing before Cardiac Resynchronization Therapy: Tissue Doppler Imaging versus Conventional 2D Echocardiography. Echocardiography 2009; 26:412-9. [DOI: 10.1111/j.1540-8175.2008.00811.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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GRAS DANIEL, GUPTA MANISHS, BOULOGNE ERIC, GUZZO LISA, ABRAHAM WILLIAMT. Optimization of AV and VV Delays in the Real-World CRT Patient Population: An International Survey on Current Clinical Practice. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32 Suppl 1:S236-9. [DOI: 10.1111/j.1540-8159.2008.02294.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Mid-term outcomes of triple-site vs. conventional cardiac resynchronization therapy: A preliminary study. Int J Cardiol 2009; 133:87-94. [DOI: 10.1016/j.ijcard.2007.12.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2007] [Revised: 10/28/2007] [Accepted: 12/11/2007] [Indexed: 11/22/2022]
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Barold SS, Ilercil A, Herweg B. Echocardiographic optimization of the atrioventricular and interventricular intervals during cardiac resynchronization. Europace 2009; 10 Suppl 3:iii88-95. [PMID: 18955406 DOI: 10.1093/europace/eun220] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
An optimized atrioventricular (AV) interval can maximize the benefits of cardiac resynchronization therapy (CRT). If programmed poorly, it may curtail beneficial effects of CRT. AV optimization will not convert non-responder to responder, but may convert under-responder to improved status. There are many echocardiographic techniques for AV optimization but there is no universally accepted gold standard. The optimal AV delay varies with time, necessitating periodic re-evaluation. As the optimal AV delay may lengthen on exercise, a rate-adaptive AV delay should not be routinely programmed. Intra- and interatrial conduction delays may require AV junctional ablation when AV optimization is impossible in patients with a poor clinical response. Fusion with the spontaneous QRS complex may be acceptable on a trial basis to seek a better clinical response or with a short PR interval. Routine VV optimization is presently controversial but programming may prove beneficial in some patients with a suboptimal CRT response where no cause is found. It may partially compensate for less than optimal left ventricular (LV) lead position and may correct for heterogeneous ventricular activation including a prolonged LV latency interval and slow conduction (scarring) near the LV pacing site. VV timing is generally programmed using the aortic velocity-time integral, and long-term variations of the optimal value necessitate periodic re-evaluation.
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Affiliation(s)
- S Serge Barold
- Cardiology Division, University of South Florida College of Medicine and Tampa General Hospital, Tampa, FL, USA.
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Anselmino M, Antolini M, Amellone C, Piovano E, Massa R, Trevi G. Optimization of Cardiac Resynchronization Therapy: Echocardiographic vs Semiautomatic Device Algorithms. ACTA ACUST UNITED AC 2009; 15:14-8. [DOI: 10.1111/j.1751-7133.2008.00036.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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YPENBURG CLAUDIA, VAN DE VEIRE NICO, WESTENBERG JOSJ, BLEEKER GABEB, MARSAN NINAAJMONE, HENNEMAN MAUREENM, VAN DER WALL ERNSTE, SCHALIJ MARTINJ, ABRAHAM THEODOREP, BAROLD SSERGE, BAX JEROENJ. Noninvasive Imaging in Cardiac Resynchronization Therapy-Part 2: Follow-up and Optimization of Settings. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:1628-39. [DOI: 10.1111/j.1540-8159.2008.01237.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Interventricular delay interval optimization in cardiac resynchronization therapy guided by echocardiography versus guided by electrocardiographic QRS interval width. Am J Cardiol 2008; 102:1373-7. [PMID: 18993158 DOI: 10.1016/j.amjcard.2008.07.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Revised: 07/13/2008] [Accepted: 07/13/2008] [Indexed: 11/22/2022]
Abstract
Present devices for cardiac resynchronization therapy offer the possibility of tailoring the hemodynamic effect of biventricular pacing by optimization of the interventricular delay (VV) beyond atrioventricular (AV)-interval optimization. It was not yet defined whether a QRS width-based strategy may be a helpful tool for echocardiography for device programming. The aim of the study was to investigate the relation between VV-interval optimization guided by echocardiography and guided by QRS interval width. One hundred six patients with a cardiac resynchronization therapy device for > or =3 months were enrolled. All patients underwent echocardiographic AV and VV delay optimization. The AV interval was optimized according to the E wave-A wave (EA) interval and left ventricular filling time. At the optimal AV delay, VV optimization was performed by measuring the aortic velocity time integral at 5 different settings: simultaneous right and left ventricle output, left ventricle pre-excitation (left ventricle + 40 and 80 ms, respectively), and right ventricle pre-excitation (right ventricle + 40 and 80 ms, respectively). A 12-lead electrocardiogram was recorded and QRS duration was measured in the lead with the greatest QRS width. The electrocardiographic (ECG)-optimized VV interval was defined according to the narrowest achievable QRS interval among 5 VV intervals. The echocardiographic-optimized VV interval was left ventricle + 40 ms in 28 patients, left ventricle + 80 ms in 15 patients, simultaneous in 46 patients, right ventricle + 40 ms in 14 patients, and right ventricle + 80 ms in 3 patients. Significant concordance (kappa = 0.69, p <0.001) was found between the echocardiographic- and ECG-optimized VV interval. In conclusion, significant concordance appeared to exist during biventricular pacing between VV programming based on the shortest QRS interval at 12-lead ECG pacing and echocardiographic-guided VV-interval optimization. A combined ECG- and echocardiographic approach could be a less time-consuming solution in performing this operation.
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Bartunek J, Vanderheyden M. Cardiac dyssynchrony in congestive heart failure and atrial fibrillation: integrating regularization and resynchronization. J Am Coll Cardiol 2008; 52:1247-9. [PMID: 18926328 DOI: 10.1016/j.jacc.2008.07.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Accepted: 07/02/2008] [Indexed: 11/24/2022]
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Bhan A, Kapetanakis S, Monaghan MJ. Optimization of Cardiac Resynchronization Therapy. Echocardiography 2008; 25:1031-9. [DOI: 10.1111/j.1540-8175.2008.00789.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Brignole M, Menozzi C, Botto GL, Mont L, Osca Asensi J, García Medina D, Oddone D, Navazio A, Luzi M, Iacopino S, De Fabrizio G, Proclemer A, Vardas P. Usefulness of echo-guided cardiac resynchronization pacing in patients undergoing "ablate and pace" therapy for permanent atrial fibrillation and effects of heart rate regularization and left ventricular resynchronization. Am J Cardiol 2008; 102:854-60. [PMID: 18805110 DOI: 10.1016/j.amjcard.2008.05.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Revised: 05/14/2008] [Accepted: 05/14/2008] [Indexed: 11/30/2022]
Abstract
An acute comparative study of right ventricular (RV) pacing and echocardiographically guided cardiac resynchronization pacing (CRP) was performed in patients who underwent "ablate and pace" therapy for permanent atrial fibrillation. It was hypothesized that optimized CRP guided by tissue Doppler echocardiography would exert an additive beneficial hemodynamic effect to that of rate regularization achieved through atrioventricular junction ablation. An acute intrapatient comparison of echocardiographic parameters was performed between baseline preablation values and RV pacing and CRP (performed <24 hours after ablation) in 50 patients. Optimized CRP configuration was defined as the modality of pacing corresponding to that of the shortest intra-left ventricular (LV) delay among simultaneous biventricular pacing, sequential biventricular pacing, and single-chamber pacing. The intra-LV delay was defined as the difference between the longest and the shortest activation time in the six basal segments of the left ventricle. Compared with preablation measures, the ejection fraction increased by 10.8% during RV pacing (19% in patients with intra-LV delays <47.5 ms and 3% in those with intra-LV delays >47.5 ms). Compared with RV pacing, CRP caused a 9.2% increase in the ejection fraction, a 6.8% decrease in LV systolic diameter, and a 17.3% decrease in mitral regurgitation area; LV dyssynchrony was reduced from 52 +/- 27 to 21 +/- 12 ms. Similar results were observed in patients with and without depressed systolic function and in patients with and without left bundle branch block. In conclusion, rate regularization achieved through atrioventricular junction ablation and RV pacing provides a favorable hemodynamic effect that is inversely related to the level of LV dyssynchrony. Minimizing LV dyssynchrony by means of optimized CRP yields an additional important benefit.
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Affiliation(s)
- Michele Brignole
- Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy.
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Evonich RF, Stephens JC, Merhi W, Dukkipati S, Tepe N, Shannon F, Altshuler J, Sakwa M, Bassett J, Hanson E, Boura J, O'Neill WW, Haines DE. The role of temporary biventricular pacing in the cardiac surgical patient with severely reduced left ventricular systolic function. J Thorac Cardiovasc Surg 2008; 136:915-21. [DOI: 10.1016/j.jtcvs.2007.11.048] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Revised: 11/16/2007] [Accepted: 11/26/2007] [Indexed: 11/29/2022]
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van Gelder BM, Meijer A, Bracke FA. The Optimized V-V Interval Determined by Interventricular Conduction Times Versus Invasive Measurement by LVdP/dtMAX. J Cardiovasc Electrophysiol 2008; 19:939-44. [PMID: 18399968 DOI: 10.1111/j.1540-8167.2008.01160.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Berry M van Gelder
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands.
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Valzania C, Eriksson MJ, Boriani G, Gadler F. Cardiac resynchronization therapy during rest and exercise: comparison of two optimization methods. Europace 2008; 10:1161-9. [PMID: 18753213 PMCID: PMC2552406 DOI: 10.1093/europace/eun216] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Aims Optimal exercise programming of cardiac resynchronization therapy (CRT) devices is unknown. We aimed to: (i) investigate variations in optimal atrioventricular (AV) and interventricular (VV) delays from rest to exercise, assessed by both echocardiography and an automated intracardiac electrogram (IEGM) method; (ii) evaluate the acute haemodynamic impact of CRT optimization performed during exercise. Methods and results Twenty-four heart failure patients, previously implanted with a CRT defibrillator, underwent AV and VV delay optimization, by echocardiography and IEGM methods, both at rest and during supine bicycle exercise. Rest-to-exercise variations in optimal VV delay were observed in 58% of patients. Conversely, optimal AV delay did not change during exercise compared with rest. Substantial agreement of AV and VV delays was observed between both the optimization methods. Exercise optimization of VV delay by either method improved intraventricular dyssynchrony and increased aortic velocity time integral compared with the resting setting (P < 0.001). Conclusion In patients implanted with a CRT device, optimal VV delay varied considerably from rest to exercise, while AV delay did not change. Re-assessment of the optimal pacing configuration during supine exercise, by echocardiography as well as IEGM methods, yielded an additional haemodynamic benefit to that provided by resting optimization.
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Affiliation(s)
- Cinzia Valzania
- Department of Medicine, Division of Cardiology, Karolinska Institutet, Stockholm, Sweden.
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