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Świerżyńska E, Oręziak A, Główczyńska R, Rossillo A, Grabowski M, Szumowski Ł, Caprioglio F, Sterliński M. Rate-Responsive Cardiac Pacing: Technological Solutions and Their Applications. SENSORS (BASEL, SWITZERLAND) 2023; 23:s23031427. [PMID: 36772467 PMCID: PMC9920425 DOI: 10.3390/s23031427] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/18/2023] [Accepted: 01/20/2023] [Indexed: 05/12/2023]
Abstract
Modern cardiac pacemakers are equipped with a function that allows the heart rate to adapt to the current needs of the patient in situations of increased demand related to exercise and stress ("rate-response" function). This function may be based on a variety of mechanisms, such as a built-in accelerometer responding to increased chest movement or algorithms sensing metabolic demand for oxygen, analysis of intrathoracic impedance, and analysis of the heart rhythm (Q-T interval). The latest technologies in the field of rate-response functionality relate to the use of an accelerometer in leadless endocavitary pacemakers; in these devices, the accelerometer enables mapping of the mechanical wave of the heart's work cycle, enabling the pacemaker to correctly sense native impulses and stimulate the ventricles in synchrony with the cycles of atria and heart valves. Another modern system for synchronizing pacing rate with the patient's real-time needs requires a closed-loop system that continuously monitors changes in the dynamics of heart contractions. This article discusses the technical details of various solutions for detecting and responding to situations related to increased oxygen demand (e.g., exercise or stress) in implantable pacemakers, and reviews the results of clinical trials regarding the use of these algorithms.
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Affiliation(s)
- Ewa Świerżyńska
- Department of Arrhythmia, The Cardinal Stefan Wyszynski National Institute of Cardiology, 04-628 Warsaw, Poland
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland
- Correspondence:
| | - Artur Oręziak
- Department of Arrhythmia, The Cardinal Stefan Wyszynski National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Renata Główczyńska
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Antonio Rossillo
- Department of Cardiology, San Bortolo Hospital, 36100 Vicenza, Italy
| | - Marcin Grabowski
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Łukasz Szumowski
- Department of Arrhythmia, The Cardinal Stefan Wyszynski National Institute of Cardiology, 04-628 Warsaw, Poland
| | | | - Maciej Sterliński
- Department of Arrhythmia, The Cardinal Stefan Wyszynski National Institute of Cardiology, 04-628 Warsaw, Poland
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Aizawa Y, Nakai T, Ikeya Y, Kogawa R, Saito Y, Toyama K, Yumikura T, Otsuka N, Nagashima K, Okumura Y. AV timing in pacemaker patients with first-degree AV block: which is preferable, intrinsic AV conduction or pacing? Heart Vessels 2022; 37:1411-1417. [PMID: 35133499 PMCID: PMC9239935 DOI: 10.1007/s00380-022-02037-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/28/2022] [Indexed: 11/28/2022]
Abstract
Some patients with pacemakers present with first-degree atrioventricular (AV) block. To avoid right ventricular (RV) pacing, preserving intrinsic AV conduction as much as possible is recommended. However, there is no clear cutoff AV interval to determine whether intrinsic AV conduction should be preserved or RV pacing should be delivered. This study aimed to compare a pacing mode-preserving, intrinsic AV conduction with the DDD mode delivering RV pacing in terms of echocardiographic parameters in patients with first-degree AV block and to investigate whether RV pacing induces heart failure (HF). Stroke volume (SV) was measured to determine the optimal AV delay with the intrinsic AV conduction rhythm and the DDD pacing delivering RV pacing. Echocardiographic evaluation was performed for 6-month follow-up period. Seventeen patients were studied. At baseline, mean intrinsic PQ interval was 250 ± 40 ms. SV was greater with RV pacing with optimal AV delay of 160 ms than with intrinsic AV conduction rhythm in all patients. Therefore, pacemakers were set to the DDD to deliver RV pacing. During follow-up, seven patients developed HF. Mean baseline E/E′ ratio in patients who developed HF (HF group) during RV pacing was higher than in patients without HF (non = HF group; 17.9 ± 8 versus 11.5 ± 2, P = 0.018) Even within HF group patients without a high baseline E/E′ ratio, it increased with RV pacing (22.2 ± 6 versus 11.6 ± 2; P < 0.001). In patients with pacemaker and first-degree AV block, RV pacing with the optimal AV delay of 160 ms increased SV. However, the risk of HF may be increased with RV pacing if the E/Eʹ ratio is > 15 during intrinsic AV conduction or RV pacing. RV pacing should be avoided in patients with high E/Eʹ ratio under intrinsic AV conduction or RV pacing.
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Affiliation(s)
- Yoshihiro Aizawa
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Toshiko Nakai
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Yukitoshi Ikeya
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Rikitake Kogawa
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yuki Saito
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Kazuto Toyama
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Tetsuro Yumikura
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Naoto Otsuka
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Koichi Nagashima
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yasuo Okumura
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
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Fukuhara K, Okura H, Koyama T, Kume T, Neishi Y, Hayashida A, Yoshida K. Feasibility of a novel atrioventricular delay optimization method using transmitral and pulmonary venous flow in patients with sequential ventricular pacing or cardiac resynchronization therapy. J Echocardiogr 2015; 13:52-8. [PMID: 26069448 PMCID: PMC4454827 DOI: 10.1007/s12574-014-0237-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 11/07/2014] [Accepted: 11/25/2014] [Indexed: 11/28/2022]
Abstract
Background Although several echo-Doppler methods were proposed to optimize atrioventricular (AV) delay in patients with sequential ventricular pacing, “echo-guided” AV optimization has not been widely adopted clinically. A combination of trasmitral flow (TMF) and pulmonary venous flow (PVF) measurements may be beneficial to further optimize AV delay to achieve better cardiac function. The aim of this study was to assess the feasibility and usefulness of AV delay optimization by combined use of TMF and PVF. Methods A total of 32 patients after sequential ventricular pacemaker implantation were enrolled and studied. The optimal AV delay was defined as the timing to minimize the duration between PVF reversal (a) wave and the duration of the “A” wave of TMF. Stroke volume was measured at the “optimized” AV delay (AVDOPT) and was compared with that obtained at shorter (AVDOPT − 50 ms) and longer (AVDOPT + 50 ms) AV delays. Results AV optimization was feasible in 27 of 32 patients (87 %). Stroke volume at AVDOPT was significantly higher than that at shorter or longer AV delay (63 ± 18 ml vs. 57 ± 15 ml vs. 56 ± 16 ml, P = 0.001). Conclusions AV delay optimization using TMF and PV flow was feasible. Usefulness of this method requires further investigation with a larger study population.
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Affiliation(s)
- Kenzo Fukuhara
- Division of Cardiology, Kawasaki Medical School, Kurashiki, Japan
| | - Hiroyuki Okura
- Division of Cardiology, Kawasaki Medical School, Kurashiki, Japan
| | - Terumasa Koyama
- Division of Cardiology, Kawasaki Medical School, Kurashiki, Japan
| | - Teruyoshi Kume
- Division of Cardiology, Kawasaki Medical School, Kurashiki, Japan
| | - Yoji Neishi
- Division of Cardiology, Kawasaki Medical School, Kurashiki, Japan
| | | | - Kiyoshi Yoshida
- Division of Cardiology, Kawasaki Medical School, Kurashiki, Japan
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Miki Y, Ishikawa T, Matsushita K, Yamakawa Y, Matsumoto K, Sumita S, Uchino K, Kimura K, Umemura S. Novel method of predicting the optimal atrioventricular delay in patients with complete AV block, normal left ventricular function and an implanted DDD pacemaker. Circ J 2009; 73:654-7. [PMID: 19246815 DOI: 10.1253/circj.cj-08-0351] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The optimal atrioventricular (AV) delay setting is important for achieving optimal AV synchrony in patients with an implanted DDD pacemaker. Using pulsed Doppler echocardiography is the most common method of predicting the optimal AV delay, but it is a complicated and time-consuming method. Therefore, an automatic optimizing function of the AV delay at different atrial rates is desirable for achieving a favorable hemodynamic state. This study aimed to predict the optimal AV delay using phonocardiography. METHODS AND RESULTS The amplitude of the first heart sound (S1) recorded on the phonocardiogram was measured with different AV delays in 6 patents with complete AV block, normal left ventricular function and an implanted DDD pacemaker. The correlation between the amplitude of S1 and the length of the AV delay was a cubic curve (y=974.15x(3)-23.084x(2)-8.0074x+0.7495, R2=0.9511). The length of the AV delay at the inflection point of the curve showed a significant positive correlation with the optimal AV delay determined by pulsed Doppler echocardiography (R=0.9254, P<0.01). CONCLUSIONS This study demonstrated a novel simple method of predicting the optimal AV delay using phono-cardiography.
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Affiliation(s)
- Yuko Miki
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University School of Medicine, Yokohama, Japan
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Akbarzadeh F, Toufan M. Atrioventricular delays, cardiac output and diastolic function in patients with implanted dual chamber pacing and sensing pacemakers. Pak J Biol Sci 2008; 11:2407-2412. [PMID: 19137850 DOI: 10.3923/pjbs.2008.2407.2412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The Cardiac Output (CO), Filling Time (FT) and Myocardial Performance Index (MPI) derived optimal atrioventricular delay (AVD), were compared and systolic and diastolic performance at every optimal AVD were analyzed. Thirty-two patients with implanted DDD pacemaker were investigated from implantation time to 6 months following PM implantation, in Cardiovascular Research Center of Tabriz University of Medical Sciences. The evaluation was performed during AV sequential pacing with different programmed AVDS ranged from 100 to 200 msec by steps of 20-30 msec. At every AVD, the following parameters were measured: FT, mitral VTI, ET, aortic VTI, ICT and IRT. CO and FT derived optimal AVDs were significantly different (146 +/- 37 and 126 +/- 35 msec, respectively), but their difference with MPI derived optimal AVDs was not significant (130 +/- 28 msec). ICT/ET was similar at CO, FT and MPI derived optimal AVD (0.24 +/- 0.10, 0.22 +/- 0.05 and 0.20 +/- 0.07, respectively). IRT/ET ratio was similar at CO, FT and MPI derived optimal AVDs (0.46 +/- 0.14, 0.45 +/- 0.10 and 0.42 +/- 0.10, respectively). Different methods indicate different optimal AVDs. However analysis of systolic and diastolic performance shows that different AVDs result in similar systolic or diastolic performance. At MPI optimized AVD, a high CO combined with the most advantageous conditions of both isovolumic contraction and relaxation phases is achieved.
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Affiliation(s)
- F Akbarzadeh
- Cardiovascular Research Center of Shahid Madani Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
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Tomczak CR, Wojcik W, Busse EFG, Haennel RG. Phase I and Phase II Oxygen Uptake Kinetics During Atrioventricular Dyssynchrony in Chronotropically Competent Pacemaker Patients. Chest 2005; 128:1782-9. [PMID: 16162787 DOI: 10.1378/chest.128.3.1782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE To elucidate the effects of atrioventricular (AV) dyssynchrony on phase I and phase II oxygen uptake (V(O2)) kinetics in chronotropically competent pacemaker patients during exercise of an intensity comparable to activities of daily living. DESIGN Blinded patients completed sub-ventilatory threshold (VT) work rate (WR) cycle ergometry exercise in random order during asynchronous AV pacing (AV OFF) and synchronous AV pacing. SETTING Tertiary care hospital in a major city. SUBJECTS Six chronotropically competent male pacemaker patients (mean [+/- SD] age, 68 +/- 10 years) with high-degree AV block and varying cardiac histories. RESULTS The phase I and phase II V(O2) amplitude response and gain (deltaV(O2)/WR ratio) were lower (p < 0.05) and the time course of phase II was slower (p < 0.05) during AV OFF; however, the O2 deficit was similar (p > 0.05) across pacing modes. The stroke volume index (SVI) was consistently lower (p < 0.05) during AV OFF pacing and was significantly correlated with the time course of phase II V(O2). A significant compensatory amplitude response in heart rate (HR) was observed in addition to a higher (p < 0.05) deltaHR/V(O2) ratio during AV OFF. Ventilatory responses were consistent with ventilatory-perfusion mismatching and perceived exertion was higher during asynchronous pacing. CONCLUSION This study demonstrated that the contribution of SVI affects V(O2) kinetics and underscores the importance of the atrial contribution to ventricular filling and, consequently, to metabolic and hemodynamic responses. This study supports the theory of an O2 transport limitation and further implicates SV as a potential limiting factor during sub-VT exercise intensities that are comparable to those encountered in activities of daily living.
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Affiliation(s)
- Corey R Tomczak
- Faculty of Kinesiology and Health Studies, University of Regina, SK, Canada
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Ishikawa T, Sugano T, Sumita S, Kosuge M, Kobayashi I, Kobayashi T, Yamakawa Y, Matsusita K, Matsumoto K, Ohkusu Y, Uchino K, Kimura K, Usui T, Umemura S. Changes in evoked QT intervals according to variations in atrioventricular delay and cardiac function in patients with implanted QT-driven DDDR pacemakers. Circ J 2003; 67:515-8. [PMID: 12808269 DOI: 10.1253/circj.67.515] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In patients with implanted DDD pacemaker, cardiac output is maximal when atrioventricular (AV) delay is set to give the maximum QT interval (QTI). QTI is used as a sensor of a rate-responsive pacemaker and the evoked QTI (eQTI) is measured as the time duration from the ventricular pace-pulse and the T sense point, which is the steepest point of the intracardiac T wave. The relationship between the changes in eQTI according to AV delay variations and cardiac function was studied in 13 patients (74.2+/-9.3 [SD] years old) with an implanted QT-driven DDDR-pacemaker. A special software module was downloaded into the pacemaker memory and a personal computer equipped with the special software was connected to the programmer for eQTI date-logging. AV delay was set at 100, 120, 150, 180 and 210 ms. Delta eQTI was defined as maximal eQTI - minimal eQTI. The ejection fraction (EF) was measured by echocardiography. When the AV delay was prolonged, eQTI gradually increased and reached a peak, and then decreased. Delta eQTI in patients with reduced cardiac function (EF <40%) was significantly greater than that in normal cardiac function (EF >55%, 7.6+/-4.9 vs 2.7+/-9.8 ms, p<0.05). There was significant negative correlation between EF and delta eQTI (r=-0.63, p<0.05). The peak of changes in eQTI according to AV delay variations was steeper in patients with reduced cardiac function than in those with normal cardiac function. In conclusion, changes in eQTI according to AV delay variation are greater in patients with reduced cardiac function than in those with normal cardiac function, and the AV delay that gives the maximal eQTI can be easily determined in patients with reduced cardiac function.
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Affiliation(s)
- Toshiyuki Ishikawa
- Second Department of Internal Medicine, Yokohama City University School of Medicine, Japan
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