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Manuel L. Temporary epicardial pacing wires post-cardiac surgery: a literature review. Gen Thorac Cardiovasc Surg 2022; 70:595-601. [PMID: 35653000 DOI: 10.1007/s11748-022-01831-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 05/13/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although epicardial pacing wires are routinely inserted after cardiac surgical procedures, there is little in the medical literature to help standardise their use and identify associated risks and benefits. Much of the decision-making surrounding pacing wires are based on the surgeon's preference and vary highly between centers. METHODS A literature review was conducted exploring the evidence, indications, and current practice for temporary pacing wires. Risk factors for developing post-operative arrhythmias necessitating use of temporary pacing wires and complications were also reviewed. CONCLUSIONS Although temporary epicardial pacing wires have a crucial role to play in the post-operative recovery period, the current literature suggests that they should be considered on an individual basis in all high-risk patients including increased age, low ejection fraction, diabetes mellitus, elevated pulmonary artery pressures, prolonged cross clamp time, pacing required to wean from bypass, pre-operative arrhythmia, and multiple valvular and transplant operations. Although complications from pacing wires are low, this figure is likely underreported and further studies are required to focus on the risks and benefits of insertion.
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Affiliation(s)
- Lucy Manuel
- Cardiothoracic Surgery Department, Royal North Shore Hospital, St Leonards, Australia.
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Monaco F, Di Prima AL, Kim JH, Plamondon MJ, Yavorovskiy A, Likhvantsev V, Lomivorotov V, Hajjar LA, Landoni G, Riha H, Farag A, Gazivoda G, Silva F, Lei C, Bradic N, El-Tahan M, Bukamal N, Sun L, Wang C. Management of Challenging Cardiopulmonary Bypass Separation. J Cardiothorac Vasc Anesth 2020; 34:1622-1635. [DOI: 10.1053/j.jvca.2020.02.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 11/11/2022]
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3
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Gielgens R, Herold I, van Straten A, van Gelder B, Bracke F, Korsten H, Soliman Hamad M, Bouwman R. The Hemodynamic Effects of Different Pacing Modalities After Cardiopulmonary Bypass in Patients With Reduced Left Ventricular Function. J Cardiothorac Vasc Anesth 2018; 32:259-266. [DOI: 10.1053/j.jvca.2017.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Indexed: 11/11/2022]
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4
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Varma PK, Namboodiri N, Raman SP, Pappu UK, Gadhinglajkar SV, Ho J, Owais K, Mahmood F. CASE 10—2015: Cardiac Resynchronization Therapy: Role of Intraoperative Real-Time Three-Dimensional Transesophageal Echocardiography. J Cardiothorac Vasc Anesth 2015; 29:1365-75. [PMID: 26159744 DOI: 10.1053/j.jvca.2015.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Suneel Puthuvassery Raman
- Department of Anesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | | | | | - Jonathan Ho
- Department of Anesthesiology, University of California, Los Angeles, Los Angeles, CA
| | - Khurram Owais
- Department of Anaesthesia, Beth Israel Deaconess Medical Center, Boston, MA
| | - Feroze Mahmood
- Department of Anaesthesia, Beth Israel Deaconess Medical Center, Boston, MA
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Brusen RM, Hahn R, Cabreriza SE, Cheng B, Wang DY, Truong W, Spotnitz HM. Wall Thickness, Pulmonary Hypertension, and Diastolic Filling Abnormalities Predict Response to Postoperative Biventricular Pacing. J Cardiothorac Vasc Anesth 2015; 29:1155-61. [PMID: 25998068 DOI: 10.1053/j.jvca.2015.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Post-cardiopulmonary bypass biventricular pacing improves hemodynamics but without clearly defined predictors of response. Based on preclinical studies and prior observations, it was suspected that diastolic dysfunction or pulmonary hypertension is predictive of hemodynamic benefit. DESIGN Randomized controlled study of temporary biventricular pacing after cardiopulmonary bypass. SETTING Single-center study at university-affiliated tertiary care hospital. INTERVENTIONS Patients who underwent bypass with preoperative ejection fraction ≤40% and QRS duration ≥100 ms or double-valve surgery were enrolled. At 3 time points between separation from bypass and postoperative day 1, pacing delays were varied to optimize hemodynamics. PARTICIPANTS Data from 43 patients were analyzed. MEASUREMENTS AND MAIN RESULTS Cardiac output and arterial pressure were measured under no pacing, atrial pacing, and biventricular pacing. Preoperative echocardiograms and pulmonary artery catheterizations were reviewed, and measures of both systolic and diastolic function were compared to hemodynamic response. Early after separation, improvement in cardiac output was positively correlated with pulmonary vascular resistance (R(2) = 0.97, p<0.001), ventricle wall thickness (R(2) = 0.72, p = 0.002)), and E/e', a measure of abnormal diastolic ventricular filling velocity (R(2) = 0.56, p = 0.04). Similar trends were seen with mean arterial pressure. QRS duration and ejection fraction did not correlate significantly with improvements in hemodynamics. CONCLUSIONS There may be an effect of biventricular pacing related to amelioration of abnormal diastolic filling patterns rather than electrical resynchronization in the postoperative state.
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Affiliation(s)
| | | | | | - Bin Cheng
- Biostatistics, Columbia University, New York, NY
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6
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Sagara K. Ventriculoventricular delay optimization of a cardiac resynchronization device. J Arrhythm 2014. [DOI: 10.1016/j.joa.2014.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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Havalad V, Cabreriza SE, Cheung EW, Aponte-Patel L, Wang A, Cheng B, Wang DY, Silver E, Bacha EA, Spotnitz HM. Optimized multisite ventricular pacing in postoperative single-ventricle patients. Pediatr Cardiol 2014; 35:1213-9. [PMID: 24827078 PMCID: PMC5706648 DOI: 10.1007/s00246-014-0918-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 04/25/2014] [Indexed: 11/28/2022]
Abstract
Ventricular dyssynchrony is associated with morbidity and mortality after palliation of a single ventricle. The authors hypothesized that resynchronization with optimized temporary multisite pacing postoperatively would be safe, feasible, and effective. Pacing was assessed in the intensive care unit within the first 24 h after surgery. Two unipolar atrial pacing leads and four bipolar ventricular pacing leads were placed at standardized sites intraoperatively. Pacing was optimized to maximize mean arterial pressure. The protocol tested 11 combinations of the 4 different ventricular lead sites, 6 atrioventricular delays (50-150 ms), and 14 intraventricular delays. Optimal pacing settings were thus determined and ultimately compared in four configurations: bipolar, unipolar, single-site atrioventricular pacing, and intrinsic rhythm. Each patient was his or her own control, and all pacing comparisons were implemented in random sequence. Single-ventricle palliation was performed for 17 children ages 0-21 years. Pacing increased mean arterial pressure (MAP) versus intrinsic rhythm, with the following configurations: bipolar multisite pacing increased MAP by 2.2 % (67.7 ± 2.4 to 69.2 ± 2.4 mmHg; p = 0.013) and unipolar multisite pacing increased MAP by 2.8 % (67.7 ± 2.4 to 69.6 ± 2.7 mmHg; p = 0.002). Atrioventricular single-site pacing increased MAP by 2.1 % (67.7 ± 2.4 to 69.1 ± 2.5 mmHg: p = 0.02, insignificant difference under Bonferroni correction). The echocardiographic fractional area change in nine patients increased significantly only with unipolar pacing (32 ± 3.1 to 36 ± 4.2 %; p = 0.02). No study-related adverse events occurred. Multisite pacing optimization is safe and feasible in the early postoperative period after single-ventricle palliation, with improvements in mean arterial pressure and fractional area shortening. Further study to evaluate clinical benefits is required.
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Affiliation(s)
- Vinod Havalad
- Department of Pediatrics, Advocate Children's Hospital, 1775 Dempster Street, Park Ridge, IL, USA,
| | | | - Eva W. Cheung
- Department of Pediatrics, Columbia University, New York, NY, USA
| | | | - Alice Wang
- Department of Surgery, Columbia University, New York, NY, USA
| | - Bin Cheng
- Department of Biostatistics, Columbia University, New York, NY, USA
| | - Daniel Y. Wang
- Department of Medicine, Columbia University, New York, NY, USA
| | - Eric Silver
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - Emile A. Bacha
- Department of Surgery, Columbia University, New York, NY, USA
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BOSE ABHISHEK, UPADHYAY GAURAVA, KANDALA JAGDESH, HEIST EDWINK, MELA THEOFANIE, PARKS KIMBERLYA, SINGH JAGMEETP. Does Prior Valve Surgery Change Outcome in Patients Treated with Cardiac Resynchronization Therapy? J Cardiovasc Electrophysiol 2014; 25:1206-13. [DOI: 10.1111/jce.12469] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 05/21/2014] [Accepted: 05/27/2014] [Indexed: 12/31/2022]
Affiliation(s)
- ABHISHEK BOSE
- Cardiac Arrhythmia Service; Corrigan Minehan Institute Heart Center; Massachusetts General Hospital; Boston Massachusetts USA
| | - GAURAV A. UPADHYAY
- Cardiac Arrhythmia Service; Corrigan Minehan Institute Heart Center; Massachusetts General Hospital; Boston Massachusetts USA
| | - JAGDESH KANDALA
- Cardiac Arrhythmia Service; Corrigan Minehan Institute Heart Center; Massachusetts General Hospital; Boston Massachusetts USA
| | - EDWIN K. HEIST
- Cardiac Arrhythmia Service; Corrigan Minehan Institute Heart Center; Massachusetts General Hospital; Boston Massachusetts USA
| | - THEOFANIE MELA
- Cardiac Arrhythmia Service; Corrigan Minehan Institute Heart Center; Massachusetts General Hospital; Boston Massachusetts USA
| | - KIMBERLY A. PARKS
- Heart Failure and Cardiac Transplant Program; Corrigan Minehan Institute Heart Center; Massachusetts General Hospital; Boston Massachusetts USA
| | - JAGMEET P. SINGH
- Cardiac Arrhythmia Service; Corrigan Minehan Institute Heart Center; Massachusetts General Hospital; Boston Massachusetts USA
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Lazarescu C, Kara-Mostefa S, Parlanti JM, Clavey M, Mertes PM, Longrois D. Reassessment of the Natural Evolution and Complications of Temporary Epicardial Wires After Cardiac Surgery. J Cardiothorac Vasc Anesth 2014; 28:506-11. [DOI: 10.1053/j.jvca.2013.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Indexed: 11/11/2022]
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10
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Spotnitz HM. Invited commentary. Ann Thorac Surg 2014; 97:609. [PMID: 24484799 DOI: 10.1016/j.athoracsur.2013.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 10/01/2013] [Accepted: 10/11/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Henry M Spotnitz
- Department of Surgery, Columbia University Medical Center, 622 W 168th St, 10th Flr, Vanderbilt Clinic, Rm 1010, New York, NY10032.
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11
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Wang A, Cabreriza SE, Cheng B, Shanewise JS, Spotnitz HM. Feasibility of speckle-tracking echocardiography for assessment of left ventricular dysfunction after cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2014; 28:31-35. [PMID: 24055281 PMCID: PMC5706645 DOI: 10.1053/j.jvca.2013.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Effects of temporary biventricular pacing after cardiopulmonary bypass are unpredictable, and the utility of speckle-tracking echocardiography in this setting is unclear. Accordingly, speckle-tracking analysis of transgastric echocardiograms taken during cardiac surgery was assessed as a potential tool to measure strain, synchrony, and twist as indices to predict response. DESIGN Prospective observational study, in part, with a randomized controlled study of temporary permanent biventricular pacing after cardiopulmonary bypass. SETTING Single-center study at university-affiliated tertiary care hospital. PARTICIPANTS Twenty-one cardiac surgery candidates with ejection fraction ≤40% and QRS duration ≥100 ms or who were undergoing double-valve surgery. INTERVENTIONS Transgastric views of the basal, midpapillary, and apical levels of the left ventricle were acquired before and after bypass. MEASUREMENTS AND MAIN RESULTS Midpapillary sections were analyzable in 38% of patients. The remainder had epicardial borders extending beyond the field of view (24%) or inadequate image quality (38%). Only 9% of basal or apical sections were analyzable. Midpapillary radial strain and synchrony changed insignificantly after bypass. Variation in fractional area change correlated with changes in radial strain (p = 0.041) but not with synchrony. CONCLUSIONS Intraoperative transgastric echocardiography is inadequate for speckle-tracking analysis with current techniques. Intraoperative predictors of temporary biventricular pacing response are lacking.
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Affiliation(s)
- Alice Wang
- Department of Surgery, Columbia Presbyterian Medical Center, New York, NY; Duke University School of Medicine, Durham, NC
| | - Santos E Cabreriza
- Department of Surgery, Columbia Presbyterian Medical Center, New York, NY
| | - Bin Cheng
- Department of Biostatistics, Mailman School of Public Health of Columbia University, New York, NY
| | - Jack S Shanewise
- Division of Cardiothoracic Anesthesiology, Columbia Presbyterian Medical Center, New York, NY
| | - Henry M Spotnitz
- Department of Surgery, Columbia Presbyterian Medical Center, New York, NY.
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12
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Sohaib SMA, Whinnett ZI, Ellenbogen KA, Stellbrink C, Quinn TA, Bogaard MD, Bordachar P, van Gelder BM, van Geldorp IE, Linde C, Meine M, Prinzen FW, Turcott RG, Spotnitz HM, Wichterle D, Francis DP. Cardiac resynchronisation therapy optimisation strategies: systematic classification, detailed analysis, minimum standards and a roadmap for development and testing. Int J Cardiol 2013; 170:118-31. [PMID: 24239155 DOI: 10.1016/j.ijcard.2013.10.069] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 09/19/2013] [Accepted: 10/19/2013] [Indexed: 01/23/2023]
Abstract
In this article an international group of CRT specialists presents a comprehensive classification system for present and future schemes for optimising CRT. This system is neutral to the measurement technology used, but focuses on little-discussed quantitative physiological requirements. We then present a rational roadmap for reliable cost-effective development and evaluation of schemes. A widely recommended approach for AV optimisation is to visually select the ideal pattern of transmitral Doppler flow. Alternatively, one could measure a variable (such as Doppler velocity time integral) and "pick the highest". More complex would be to make measurements across a range of settings and "fit a curve". In this report we provide clinicians with a critical approach to address any recommendations presented to them, as they may be many, indistinct and conflicting. We present a neutral scientific analysis of each scheme, and equip the reader with simple tools for critical evaluation. Optimisation protocols should deliver: (a) singularity, with only one region of optimality rather than several; (b) blinded test-retest reproducibility; (c) plausibility; (d) concordance between independent methods; and (e) transparency, with all steps open to scrutiny. This simple information is still not available for many optimisation schemes. Clinicians developing the habit of asking about each property in turn will find it easier to win now down the broad range of protocols currently promoted. Expectation of a sophisticated enquiry from the clinical community will encourage optimisation protocol-designers to focus on testing early (and cheaply) the basic properties that are vital for any chance of long term efficacy.
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Affiliation(s)
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- National Heart & Lung Institute, Imperial College London, UK.
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Lu JG, Pensiero A, Aponte-Patel L, Velez de Villa B, Rusanov A, Cheng B, Cabreriza SE, Spotnitz HM. Short-term reduction in intrinsic heart rate during biventricular pacing after cardiac surgery: a substudy of a randomized clinical trial. J Thorac Cardiovasc Surg 2013; 146:1494-500. [PMID: 24075465 DOI: 10.1016/j.jtcvs.2013.06.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 03/29/2013] [Accepted: 06/27/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND The Biventricular Pacing After Cardiac Surgery trial investigates hemodynamics of temporary pacing in selected patients at risk of left ventricular dysfunction. This trial demonstrates improved hemodynamics during optimized biventricular pacing compared with atrial pacing at the same heart rate 1 and 2 hours after bypass and reduced vasoactive-inotropic score over the first 4 hours after bypass. However, this advantage of biventricular versus atrial pacing disappears 12 to 24 hours later. We hypothesized that changes in intrinsic heart rate can explain variable effects of atrial pacing in this setting. METHODS Heart rate, mean arterial pressure, cardiac output, and medications depressing heart rate were analyzed in patients randomized to continuous biventricular pacing (n = 16) or standard of care (n = 18). RESULTS During 30-second testing periods without pacing, intrinsic heart rate was lower in the paced group 12 to 24 hours after bypass (76.5 ± 17.5 vs 91.7 ± 13.0 beats per minute; P = .040) but not 1 or 2 hours after bypass. Cardiac output (4.4 ± 1.2 vs 3.6 ± 1.9 L/min; P = .054) and stroke volume (53 ± 2 vs 42 ± 2 mL; P = .051) increased overnight in the paced group. Vasoactive medication doses were not different between groups, whereas dexmedetomidine administration was prolonged over postoperative hours 12 to 24 in the paced group (793 ± 528 vs 478 ± 295 minutes; P = .013). CONCLUSIONS These observations suggest that hemodynamic benefits of biventricular pacing 12 to 24 hours after cardiopulmonary bypass lead to withdrawal of sympathetic drive and decreased intrinsic heart rate. Depression of intrinsic rate increases the apparent benefit of atrial pacing in the chronically paced group but not in the control group. Additional study is needed to define clinical benefits of these effects.
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Affiliation(s)
- Jiajie G Lu
- Department of Surgery, Columbia University, New York, NY
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14
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Lazarescu C, Mertes PM, Longrois D. [Temporary epicardial pacing following cardiac surgery: practical aspects]. ACTA ACUST UNITED AC 2013; 32:592-601. [PMID: 23972516 DOI: 10.1016/j.annfar.2013.07.805] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 07/17/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To review the practical aspects of temporary epicardial pacing following open heart surgery. METHODS Review of articles published in English or French within the last five years and investigating temporary epicardial pacing (indications, pacing modes, epicardial wires and temporary generators). The studies were extracted from the databases ScienceDirect and Pubmed. RESULTS Temporary epicardial pacing is used to treat severe conduction and/or rhythm disorders, but also to improve hemodynamics by optimizing selected temporary pacing settings. Temporary epicardial pacing consists in choosing the most suitable pacing mode according to the situation (surgery, patient, conduction and/or rhythm abnormalities) and setting its parameters that ensure : i) optimal pacemaker functioning; ii) epicardial electrodes longevity; iii) the most favorable hemodynamic profiles. Management of temporary pacing settings and their regular adjustment, at least daily and based on thresholds, are part of good clinical practices. Nevertheless, the French literature lacks official recommendations for temporary epicardial pacing. CONCLUSION Temporary epicardial pacing following cardiac surgery is a simple method, more effective than transcutaneous pacing and easier to implement than transvenous pacing. Its practical management should be known by all physicians (anesthetists, cardiac surgeons) as well as paramedical personnel in order to avoid the risks of suboptimal functioning. A good practice protocol is proposed at the end of the manuscript.
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Affiliation(s)
- C Lazarescu
- Service d'anesthésie-réanimation cardiovasculaire, CHR de Metz, 1, allée du Château, 57085 Metz cedex, France.
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Spotnitz HM, Cabreriza SE, Wang DY, Quinn TA, Cheng B, Bedrosian LN, Aponte-Patel L, Smith CR. Primary endpoints of the biventricular pacing after cardiac surgery trial. Ann Thorac Surg 2013; 96:808-15. [PMID: 23866800 DOI: 10.1016/j.athoracsur.2013.04.101] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 04/18/2013] [Accepted: 04/23/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND This study sought to determine whether optimized biventricular pacing increases cardiac index in patients at risk of left ventricular dysfunction after cardiopulmonary bypass. Procedures included coronary artery bypass, aortic or mitral surgery and combinations. This trial was approved by the Columbia University Institutional Review Board and was conducted under an Investigational Device Exemption. METHODS Screening of 6,346 patients yielded 47 endpoints. With informed consent, 61 patients were randomized to pacing or control groups. Atrioventricular and interventricular delays were optimized 1 (phase I), 2 (phase II), and 12 to 24 hours (phase III) after bypass in all patients. Cardiac index was measured by thermal dilution in triplicate. A 2-sample t test assessed differences between groups and subgroups. RESULTS Cardiac index was 12% higher (2.83±0.16 [standard error of the mean] vs 2.52±0.13 liters/minute/square meter) in the paced group, less than predicted and not statistically significant (p=0.14). However, when aortic and aortic-mitral surgery groups were combined, cardiac index increased 29% in the paced group (2.90±0.19, n=14) versus controls (2.24±0.15, n=11) (p=0.0138). Using a linear mixed effects model, t-test revealed that mean arterial pressure increased with pacing versus no pacing at all optimization points (phase I 79.2±1.7 vs 74.5±1.6 mm Hg, p=0.008; phase II 75.9±1.5 vs 73.6±1.8, p=0.006; phase III 81.9±2.8 vs 79.5±2.7, p=0.002). CONCLUSIONS Cardiac index did not increase significantly overall but increased 29% after aortic valve surgery. Mean arterial pressure increased with pacing at 3 time points. Additional studies are needed to distinguish rate from resynchronization effects, emphasize atrioventricular delay optimization, and examine clinical benefits of temporary postoperative pacing.
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Affiliation(s)
- Henry M Spotnitz
- Department of Surgery, Columbia Presbyterian Medical Center, New York, New York 10032, USA.
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16
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Wang A, Cabreriza SE, Quinn TA, Richmond ME, Cheng B, Spotnitz HM. Regional and global strain changes during biventricular pacing in a porcine model of acute left ventricular volume overload. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2013; 32:675-682. [PMID: 23525394 DOI: 10.7863/jum.2013.32.4.675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES Biventricular pacing may ameliorate symptoms of acute heart failure. Speckle-tracking echocardiography can assess cardiac function to elucidate mechanisms of benefit. Accordingly, radial and circumferential strain and radial and circumferential strain synchrony were measured with speckle-tracking echocardiography during biventricular pacing in a model of left ventricular (LV) volume overload. METHODS Heart block was established in 4 open-chest anesthetized pigs. Left ventricular volume overload was induced with an ascending aorta-LV apex conduit. Measurements included cardiac output by an aortic flow probe, the maximum derivative of LV pressure versus time (dP/dtmax), and transseptal pressure synchrony. Biventricular pacing was performed for combinations of 3 interventricular delays and 3 LV pacing sites. Speckle-tracking echocardiographic analysis was applied to short-axis images at the midpapillary LV for 9 pacing combinations. Strain and synchrony parameters were correlated with hemodynamics. RESULTS Increased cardiac output correlated with improved global circumferential strain (P = .002) but not changes in global radial strain or radial strain synchrony. Increased LV dP/dtmax was associated with improved circumferential strain in the septum (P < .001) and radial strain in the lateral wall (P = .046). Improved transseptal pressure synchrony was associated with improved global circumferential strain, but primarily in the septum (P < .001). Aortic valve closure occurred before peak radial strain in 62% of beats and before peak circumferential strain in 6%. CONCLUSIONS During acute LV volume overload, hemodynamic improvement with biventricular pacing was associated with improved circumferential strain primarily in the septum. Radial strain and radial strain synchrony did not correlate with improvement, possibly due to delayed systolic contraction. An increase in circumferential strain in the septum associated with optimum transseptal pressure synchrony suggested improvement by interventricular assist from the right ventricle.
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Affiliation(s)
- Alice Wang
- Department of Surgery, Columbia Presbyterian Medical Center, New York, NY 10032, USA
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Havalad V, Bacchetta M, Wang DY, Cabreriza SE, Aponte-Patel L, Cheng B, Spotnitz HM. Cardiac pacing: a novel approach to right ventricle failure during pulmonary thromboendarterectomy. J Thorac Cardiovasc Surg 2013; 145:1141-1143. [PMID: 23321544 DOI: 10.1016/j.jtcvs.2012.12.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 12/12/2012] [Accepted: 12/18/2012] [Indexed: 11/18/2022]
Affiliation(s)
- Vinod Havalad
- Department of Pediatrics, Advocate Children's Hospital, Park Ridge, Ill
| | | | - Daniel Y Wang
- Department of Medicine, Columbia University, New York, NY
| | | | | | - Bin Cheng
- Mailman School of Public Health, Columbia University, New York, NY
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Wang DY, Kelly LA, Richmond ME, Quinn TA, Cheng B, Spotnitz MD, Cabreriza SE, Naka Y, Stewart AS, Smith CR, Spotnitz HM. Feasibility of temporary biventricular pacing after off-pump coronary artery bypass grafting in patients with reduced left ventricular function. Tex Heart Inst J 2013; 40:403-409. [PMID: 24082369 PMCID: PMC3783126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
In selected patients undergoing cardiac surgery, our research group previously showed that optimized temporary biventricular pacing can increase cardiac output one hour after weaning from cardiopulmonary bypass. Whether pacing is effective after beating-heart surgery is unknown. Accordingly, in this study we examined the feasibility of temporary biventricular pacing after off-pump coronary artery bypass grafting. The effects of optimized pacing on cardiac output were measured with an electromagnetic aortic flow probe at the conclusion of surgery in 5 patients with a preoperative mean left ventricular ejection fraction of 0.26 (range, 0.15-0.35). Atrioventricular (7) and interventricular (9) delay settings were optimized in randomized order. Cardiac output with optimized biventricular pacing was 4.2 ± 0.7 L/min; in sinus rhythm, it was 3.8 ± 0.5 L/min. Atrial pacing at a matched heart rate resulted in cardiac output intermediate to that of sinus rhythm and biventricular pacing (4 ± 0.6 L/min). Optimization of atrioventricular and interventricular delay, in comparison with nominal settings, trended toward increased flow. This study shows that temporary biventricular pacing is feasible in patients with preoperative left ventricular dysfunction who are undergoing off-pump coronary artery bypass grafting. Further study of the possible clinical benefits of this intervention is warranted.
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Affiliation(s)
- Daniel Y Wang
- Departments of Medicine (Dr. Wang), Surgery (Drs. Naka, Smith, H. Spotnitz, M. Spotnitz, and Stewart, and Mr. Cabreriza and Ms Kelly), Pediatrics (Dr. Richmond), and Biostatistics (Dr. Cheng), Columbia University, New York, NY 10032; and National Heart and Lung Institute (Dr. Quinn), Imperial College London, Harefield Heart Science Centre, Harefield UB9 6JH, United Kingdom
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Hajj-Chahine J, Jayle C, Tomasi J, Corbi P. eComment. Cardiac resynchronization therapy in cardiac surgery. Interact Cardiovasc Thorac Surg 2012; 15:923-4. [PMID: 23100557 PMCID: PMC3480625 DOI: 10.1093/icvts/ivs407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jamil Hajj-Chahine
- Department of Cardio-Thoracic Surgery, University Hospital of Poitiers, Poitiers, France
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García-Bengochea JB, Fernández AL, Calvelo DS, Escudero JA, Gude F, Juanatey JRG. Temporary epicardial left ventricular and biventricular pacing improves cardiac output after cardiopulmonary bypass. J Cardiothorac Surg 2012; 7:113. [PMID: 23088393 PMCID: PMC3539891 DOI: 10.1186/1749-8090-7-113] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Accepted: 09/17/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate, with different pacing modes, acute changes in left ventricular systolic function, obtained by continuous cardiac output thermodilution in various subsets of patients undergoing cardiopulmonary bypass surgery. Increments of mean arterial pressure and cardiac output were considered the end point. METHODS Fifty cases electively submitted to cardiac surgery were analyzed. Isolated valve surgery 62%, coronary revascularization 30% and 8% mixed disease. Left ventricular ejection fraction was preserved in 50%,36% had moderate depression,(EF 36%-50%) whereas 14% had severe depression (EF < 35%). Left bundle branch block occurred in 18%. Preoperatively 84% were in sinus rhythm and 16% in atrial fibrillation. The different subgroups were analyzed for comparisons. Right atrial-right ventricular and right atrial-left ventricular pacing were employed in sinus rhytm. Biventricular pacing was also used in atrial fibrillation. RESULTS Right atrium-right ventricular pacing, decreased significantly mean arterial pressure and cardiac output (2.3%) in the overall population and in the subgroups studied. Right atrium-left ventricle, increased mean arterial pressure and cardiac output in 79% of patients and yielded cardiac output increments of 7.5% (0.40 l/m) in the low ejection fraction subgroup and 7.3% (0.43 l/m) in the left bundle branch block subset. In atrial fibrillation patients, left ventricular and biventricular pacing produced a significant increase in cardiac output 8.5% (0.39 l/min) and 11.6% (0.53 l/min) respectively. The dP/dt max increased significantly with both modes (p = 0.021,p = 0.028). CONCLUSION Right atrial-right ventricular pacing generated adverse hemodynamic effects. Right atrium-left ventricular pacing produced significant CO improvement particularly in cases with depressed ventricular function and left bundle branch block. The greatest increments were observed with left ventricular or biventricular pacing in atrial fibrillation with depressed ejection fraction.
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Affiliation(s)
- Jose B García-Bengochea
- Cardiac Surgical Division, Department of Surgery, Hospital Clínico Universitario, 15706, Santiago de Compostela, Spain.
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Markewitz A. Temporäre Schrittmachertherapie bei herzchirurgischen Operationen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2012. [DOI: 10.1007/s00398-012-0955-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Response of mean arterial pressure to temporary biventricular pacing after chest closure during cardiac surgery. J Thorac Cardiovasc Surg 2012; 144:1445-52. [PMID: 22920599 DOI: 10.1016/j.jtcvs.2012.04.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 03/06/2012] [Accepted: 04/04/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVES We have previously demonstrated that biventricular pacing increased cardiac output within 1 hour of weaning from cardiopulmonary bypass in selected patients. To assess the possible sustained benefit, we reviewed in the present study the effects of biventricular pacing on the mean arterial pressure after chest closure. METHODS A total of 30 patients (mean ejection fraction 35% ± 15%, mean QRS 119 ± 24 ms) underwent coronary bypass and/or valve surgery. The mean arterial pressure was maximized during biventricular pacing using atrioventricular delays of 90 to 270 ms and interventricular delays of +80 to -80 ms during 20-second intervals in random sequence. Optimized biventricular pacing was finally compared with atrial pacing at a matched heart rate and to a sinus rhythm during 30-second intervals. Vasoactive medication and fluid infusion rates were held constant. The arterial pressure was digitized, recorded, and integrated. Statistical significance was assessed using linear mixed effects models and Bonferroni's correction. RESULTS Optimized atrioventricular delay, ranging from 90 to 270 ms, increased the mean arterial pressure 4% versus nominal and 7% versus the worst (P < .001). Optimized interventricular delay increased pressure 3% versus nominal and 7% versus the worst. Optimized biventricular pacing increased the mean arterial pressure 4% versus sinus rhythm (78.5 ± 2.4 vs 75.1 ± 2.4 mm Hg; P = .002) and 3% versus atrial pacing (76.4 ± 2.7 mm Hg; P = .017). CONCLUSIONS Temporary biventricular pacing improves the hemodynamics after chest closure, with effects similar to those within 1 hour of bypass. Individualized optimization of atrioventricular delay is warranted, because the optimal delay was longer in 80% of our patients than the current recommendations for temporary postoperative pacing.
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Nguyen HV, Havalad V, Aponte-Patel L, Murata AY, Wang DY, Rusanov A, Cheng B, Cabreriza SE, Spotnitz HM. Temporary biventricular pacing decreases the vasoactive-inotropic score after cardiac surgery: a substudy of a randomized clinical trial. J Thorac Cardiovasc Surg 2012; 146:296-301. [PMID: 22841906 DOI: 10.1016/j.jtcvs.2012.07.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 06/05/2012] [Accepted: 07/10/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Vasoactive medications improve hemodynamics after cardiac surgery but are associated with high metabolic and arrhythmic burdens. The vasoactive-inotropic score was developed to quantify vasoactive and inotropic support after cardiac surgery in pediatric patients but may be useful in adults as well. Accordingly, we examined the time course of this score in a substudy of the Biventricular Pacing After Cardiac Surgery trial. We hypothesized that the score would be lower in patients randomized to biventricular pacing. METHODS Fifty patients selected for increased risk of left ventricular dysfunction after cardiac surgery and randomized to temporary biventricular pacing or standard of care (no pacing) after cardiopulmonary bypass were studied in a clinical trial between April 2007 and June 2011. Vasoactive agents were assessed after cardiopulmonary bypass, after sternal closure, and 0 to 7 hours after admission to the intensive care unit. RESULTS Over the initial 3 collection points after cardiopulmonary bypass (mean duration, 131 minutes), the mean vasoactive-inotropic score decreased in the biventricular pacing group from 12.0 ± 1.5 to 10.5 ± 2.0 and increased in the standard of care group from 12.5 ± 1.9 to 15.5 ± 2.9. By using a linear mixed-effects model, the slopes of the time courses were significantly different (P = .02) and remained so for the first hour in the intensive care unit. However, the difference was no longer significant beyond this point (P = .26). CONCLUSIONS The vasoactive-inotropic score decreases in patients undergoing temporary biventricular pacing in the early postoperative period. Future studies are required to assess the impact of this effect on arrhythmogenesis, morbidity, mortality, and hospital costs.
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Affiliation(s)
- Huy V Nguyen
- Columbia University College of Physicians and Surgeons, New York, NY, USA
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Biventricular pacing improves left ventricular function by 2-D strain in right ventricular failure. J Surg Res 2012; 178:571-7. [PMID: 22748597 DOI: 10.1016/j.jss.2012.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 04/24/2012] [Accepted: 06/01/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND We used speckle-tracking echocardiography to test the hypothesis that regional left ventricular (LV) strain would improve during optimized biventricular pacing (BiVP) in acute right ventricular (RV) pressure overload (PO). MATERIALS AND METHODS Complete heart block and RVPO were induced in five open-chest fully anesthetized pigs. BiVP was optimized by adjusting atrioventricular and interventricular delays to maximize cardiac output derived from an aortic flow probe. LV short axis views were obtained during atrio-RV pacing (RVP), atrio-LV pacing (LVP), and BiVP. Intraventricular synchrony was assessed by comparing speckle-tracking echocardiography-derived time to peak (TTP) strain in the anterior septal (AS) and posterior wall segments. Segmental function was assessed using radial strain. RESULTS Cardiac output was higher with optimized (RV first) BiVP than with LVP (0.96 ± 0.26 L/min versus 0.89 ± 0.27 L/min; P = 0.05). AS TTP strain (502 ± 19 ms) during LVP was prolonged versus BiVP (392 ± 58 ms) and versus RVP (390 ± 53 ms) (P = 0.0018). AS TTP strain during LVP was prolonged versus posterior (502 ± 19 ms versus 396 ± 72 ms, P = 0.0011). No significant difference in TTP strain in these segments was seen with BiVP or RVP. Posterior strain (20% ± 5%) increased 66% versus AS strain (12% ± 6%) during BiVP (P = 0.0029). A similar increase occurred during RVP (posterior 20% ± 3% versus AS 12% ± 7%, P = 0.0002). Posterior strain did not increase during LVP. CONCLUSIONS BiVP and RVP restore intraventricular LV synchrony and increase regional function versus LVP during RVPO. RV pre-excitation unloads the RV and reduces the duration of AS contraction, facilitating synchrony of all LV segments and increasing free wall LV contraction.
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Clinical validation of a real-time data processing system for cardiac output and arterial pressure measurement during intraoperative biventricular pacing optimization. ASAIO J 2012; 58:191-6. [PMID: 22395120 DOI: 10.1097/mat.0b013e31824aefce] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Biventricular pacing (BiVP) improves cardiac output (CO) and mean arterial pressure (MAP) after cardiopulmonary bypass (CPB) in selected patients at risk for acute left heart failure after cardiac surgery. Optimization of atrioventricular delay (AVD) and interventricular delay (VVD) to maximize the hemodynamic effect of pacing requires rapid and accurate data processing. Conventional post hoc data processing (PP) is accurate but time-consuming, and infeasible in the intraoperative setting. We created a customized, real-time data processing (RTP) system to improve data processing efficiency, while maintaining accuracy. Biventricular pacing optimization was performed within 1 hour of the conclusion of CPB in 10 patients enrolled in the Biventricular Pacing After Cardiac Surgery trial. Cardiac output, measured by an electromagnetic flow meter, and arterial pressure were recorded as AVD was randomly varied across seven settings and VVD across nine settings. Post hoc data processing values calculated by two observers were compared to RTP-generated outputs for CO and MAP. Interexaminer reliability coefficients were generated to access the dependability of RTP. Interexaminer reliability coefficient values ranged from 0.997 to 0.999, indicating RTP is as reliable as PP for optimization. Real-time data processing is instantaneous and therefore is more practical in a clinical setting than the PP method. Real-time data processing is useful for guiding intraoperative BiVP optimization and merits further development.
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STRAKA F, PIRK J, PINĎÁK M, SKALSKÝ I, VANČURA V, ČIHÁK R, MAREK T, LUPÍNEK P, SCHORNÍK D, MAŠÍN J, ZEMAN M, ŠKROBÁKOVÁ J, DORAZILOVÁ Z, SKIBOVÁ J. Biventricular Pacing in the Early Postoperative Period After Cardiac Surgery. Physiol Res 2011; 60:877-85. [PMID: 21995901 DOI: 10.33549/physiolres.932060] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cardiac resynchronization therapy is not commonly used in the early postoperative period in patients undergoing cardiac surgery who have left ventricular (LV) dysfunction and a history of heart failure. We performed a prospective randomized clinical trial to compare atrial synchronous right ventricular (DDD RV) and biventricular (DDD BIV) pacing within 72 hours after cardiac surgery in patients with an EF ≤35 %, a QRS interval longer than 120 msec and who had LV dyssynchrony detected by real-time three-dimensional echocardiography (RT3DE). Epicardial pacing was provided by a modified Medtronic INSYNC III pacemaker. An LV epicardial pacing lead was implanted on the latest activated segment of the LV based on RT3DE. The study included 18 patients with ischemic heart disease, with or without valvular heart disease (14 men, 4 women, average age 71 years). Patients undergoing DDD BIV pacing had a statistically significant greater CO and CI (CO 6.7±1.8 l/min, CI 3.4±0.7 l/min/m²) than patients undergoing DDD RV pacing (CO 5.5±1.4 l/min, CI 2.8±0.7 l/min/m²), p<0.001. DDD BIV pacing in the early postoperative period after cardiac surgery corrects LV dyssynchrony and has better hemodynamic results than DDD RV pacing.
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Affiliation(s)
- F. STRAKA
- Heart Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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WANG DANIELY, SPOTNITZ HENRYM. To the Editor:. Pacing Clin Electrophysiol 2011; 34:1705; author reply 1705-6. [DOI: 10.1111/j.1540-8159.2011.03232.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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STRAKA FRANTISEK, SCHORNIK DAVID. Reply:. Pacing Clin Electrophysiol 2011. [DOI: 10.1111/j.1540-8159.2011.03238.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Rusanov A, Wang DY, Cabreriza SE, Bedrosian LN, Karl SR, Richmond ME, Quinn TA, Cheng B, Spotnitz HM. Effect of atrioventricular conduction prolongation on optimization of paced atrioventricular delay for biventricular pacing after cardiac surgery. J Cardiothorac Vasc Anesth 2011; 26:209-16. [PMID: 22000982 DOI: 10.1053/j.jvca.2011.07.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Atrioventricular conduction prolongation (AVCP) in cardiac pacing is measurable and results primarily from delayed atrial conduction. Noninvasive methods for measuring atrial conduction are lacking. Accordingly, AVCP was used to estimate atrial conduction and investigate its role on the paced atrioventricular delay (pAVD) during biventricular pacing (BiVP) optimization. DESIGN Retrospective analysis of data collected as part of a randomized controlled study of temporary BiVP after cardiopulmonary bypass. SETTING Single-center study at university-affiliated tertiary care hospital. PARTICIPANTS Cardiac surgical patients at risk of left ventricular failure after cardiopulmonary bypass. INTERVENTIONS Temporary BiVP was optimized immediately after cardiopulmonary bypass. Vasoactive medication and fluid infusion rates were held constant during optimization. MEASUREMENTS AND MAIN RESULTS For each patient the AVCP and the pAVD producing the optimum (highest) cardiac output (OptCO) and mean arterial pressure (OptMAP) were determined. Patients were stratified into long- and short-AVCP groups. Overall AVCP (mean ± standard deviation) was 64 ± 28 ms. For the short-AVCP group (<64 ms, n = 3), AVCP, OptCO, and OptMAP were 40 ± 11, 120 ± 0, and 150 ± 30 ms, respectively, and for the long-AVCP group (>64 ms, n = 4), these same parameters were 89 ± 10, 218 ± 44, and 218 ± 29 ms. OptCO and OptMAP were significantly less in the short-AVCP group (p = 0.015 and p = 0.029, respectively). CONCLUSIONS AVCP varies widely after cardiopulmonary bypass, affecting optimum pAVD. Failure to correct for this can result in the selection of inappropriately short and potentially deleterious pAVDs, especially when nominal pAVD is used, causing BiVP to appear ineffective.
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Affiliation(s)
- Alexander Rusanov
- Department of Anesthesiology, Columbia University Medical Center, New York, NY 10032, USA.
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Validation of automated monitoring of cardiac output for biventricular pacing optimization. ASAIO J 2010; 56:265-9. [PMID: 20335801 DOI: 10.1097/mat.0b013e3181cf882a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Biventricular pacing (BiVP) can increase cardiac output (CO) during acute failure of the left ventricle (LV) after cardiac surgery. This CO benefit is maximized by adjustment of atrioventricular (AVD) and interventricular (VVD) pacing delays. Real-time CO calculation could facilitate this optimization. Accordingly, we compared real-time automated analysis (AA) of CO with manual analysis (MA) in an animal model of pressure overload of the right ventricle (RV). In six anesthetized pigs, pacing leads were placed on the right atrium, RV, and LV. Complete heart block was induced with ethanol injection, and RV systolic pressure was doubled with a pulmonary artery snare. Atrioventricular pacing delay was varied over seven common values and VVD over nine, in random sequence. Two LV pacing sites (LVPS) were also tested. Aortic flow velocity, measured by ultrasonic flow probe, was integrated by AA and MA to calculate CO. Interexaminer Reliability Coefficient (IRC) was determined by Analysis of Variance (ANOVA) for two 10-second runs in each animal. Cardiac output-AVD and CO-VVD relations were similar for AA and MA. Interexaminer Reliability Coefficients were 0.997 and 0.994 for MA vs. AA. Automated analysis was available in real-time. Manual analysis was delayed at 2 hours or more. Automated analysis merits development for real-time optimization of intraoperative BiVP.
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Quinn TA, Cabreriza SE, Richmond ME, Weinberg AD, Holmes JW, Spotnitz HM. Simultaneous variation of ventricular pacing site and timing with biventricular pacing in acute ventricular failure improves function by interventricular assist. Am J Physiol Heart Circ Physiol 2009; 297:H2220-6. [PMID: 19855057 DOI: 10.1152/ajpheart.00802.2009] [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] [Indexed: 11/22/2022]
Abstract
The goal of this work was to investigate the hemodynamic effects of simultaneous left ventricular (LV) pacing site (LVPS) and interventricular pacing delay (VVD) variation with biventricular pacing (BiVP) during acute LV failure. Simultaneously varying LVPS and VVD with BiVP has been shown to improve hemodynamics during acute right ventricular (RV) failure. However, effects during acute LV failure have not been reported. In six open-chest pigs, acute LV volume overload was induced by regurgitant flow via an aortic-LV conduit. Epicardial BiVP was implemented with right atrial and ventricular leads and a custom LV pacing array. Fifty-four LVPS-VVD combinations were tested in random order. Cardiac output was evaluated by aortic flow probe, ventricular systolic function by maximum rate of ventricular pressure change, and mechanical interventricular synchrony by normalized RV-LV pressure diagram area. Simultaneous LVPS-VVD variation improved all measures of cardiac function. The observed effect was different for each functional index, with evidence of LVPS-VVD interaction. Compared with effects of LVPS-VVD variation in a model of acute RV failure, hemodynamic changes were markedly different. However, in both models, maximum rate of ventricular pressure change of the failing ventricle was improved with synchronous interventricular contraction, suggesting that, in acute ventricular failure, BiVP can recruit the unstressed ventricle to support systolic function of the failing one. Thus simultaneously varying LVPS and VVD with BiVP during acute ventricular failure can improve cardiac function by "interventricular assist", with hemodynamic effects dependent on the type of failure. This supports the potential utility of temporary BiVP for the treatment of acute ventricular failure commonly seen after cardiac surgery.
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Affiliation(s)
- T Alexander Quinn
- Department of Biomedical Engineering, Columbia University, New York, NY, USA.
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