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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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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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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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Wang A, Cabreriza SE, Havalad V, Aponte-Patel L, Gonzalez G, Velez de Villa B, Cheng B, Spotnitz HM. Effects of biventricular pacing on left heart twist and strain in a porcine model of right heart failure. J Surg Res 2013; 185:645-52. [PMID: 23890399 DOI: 10.1016/j.jss.2013.06.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 06/10/2013] [Accepted: 06/19/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Biventricular pacing (BiVP) improves cardiac output (CO) in selected cardiac surgery patients, but response remains variable, necessitating a better understanding of the mechanism. Accordingly, we used speckle tracking echocardiography (STE) to analyze BiVP during acute right ventricular pressure overload (RVPO). MATERIALS AND METHODS In nine pigs, the inferior vena cava (IVC) was snared to decrease CO and establish a control model. Heart block was induced, the pulmonary artery snared, and BiVP initiated. Echocardiograms of the left ventricular midpapillary level were taken at varying atrioventricular delay (AVD) and interventricular delay (VVD) for STE analysis of regional circumferential strain (CS) and radial strain (RS). Echocardiograms were taken of the left ventricular base, midpapillary, and apex during baseline, IVC occlusion, and each BiVP setting for STE analysis of twist, apical and basal rotations, CS, RS, and synchrony. Indices were correlated against CO with mixed linear models. RESULTS During IVC occlusion, CO correlated with twist, apical rotation, RS, RS synchrony, and CS (P < 0.05). During RVPO with BiVP, CO only correlated with RS synchrony and CS (P < 0.05). During AVD and VVD variations, CO was associated with free wall RS (P < 0.008). CO correlated with septal wall CS during AVD variation and free wall CS during VVD variation (P < 0.008). CONCLUSIONS In an open chest model, twist, RS, RS synchrony, and CS analyzed by STE may be noninvasive surrogates for changes in CO. During RVPO, changes in RS synchrony and CS with varying regional strain contributions may be the primary mechanism in which BiVP improves CO. Lack of correlation of remaining indices may reflect postsystolic function.
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Affiliation(s)
- Alice Wang
- Department of Surgery, Columbia Presbyterian Medical Center, New York, New York; Department of Surgery, Duke University Medical Center, Durham, North Carolina
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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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Atrioventricular delay programming in cardiac resynchronization therapy devices: fixed or adaptive? A randomized monocenter trial. J Electrocardiol 2012; 45:783-6. [PMID: 22727475 DOI: 10.1016/j.jelectrocard.2012.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Cardiac resynchronization therapy devices are routinely programmed on fixed atrioventricular delays (AVD) under resting conditions based on echocardiographic techniques. Whether this AVD also ensures optimal exercise hemodynamics, is unclear. METHODS In order to compare fixed-AVD with rate-adaptive AVD, 100 patients with cardiac resynchronization therapy systems and sinus rhythm were randomized to fixed-AVD or adaptive-AVD. The patients then underwent bicycle ergometry with noninvasive hemodynamic monitoring. At rest and at peak exercise, stroke volume, cardiac output, and cardiac index were determined using "electrical velocimetry." RESULTS There were no significant differences in clinical characteristics and baseline hemodynamic parameters between fixed or adaptive AVD. In patients randomized to adaptive AVD, a trend towards higher stroke volume, cardiac output, and cardiac index at peak exercise was encountered. CONCLUSIONS Based on the trend towards better exercise hemodynamics demonstrated by this pilot study, a randomized follow-up study with clinical end points appears to be justified to clarify this issue.
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Pérez Vela J, Martín Benítez J, Carrasco González M, De la Cal López M, Hinojosa Pérez R, Sagredo Meneses V, del Nogal Saez F. Guías de práctica clínica para el manejo del síndrome de bajo gasto cardíaco en el postoperatorio de cirugía cardíaca. Med Intensiva 2012; 36:e1-44. [DOI: 10.1016/j.medin.2012.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 01/07/2012] [Indexed: 01/04/2023]
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Straka F, Pirk J, Pindak M, Marek T, Schornik D, Cihak R, Skibova J. A Pilot Study of Systolic Dyssynchrony Index by Real Time Three-Dimensional Echocardiography and Doppler Tissue Imaging Parameters Predicting the Hemodynamic Response to Biventricular Pacing in the Early Postoperative Period after Cardiac Surgery. Echocardiography 2012; 29:827-39. [DOI: 10.1111/j.1540-8175.2012.01694.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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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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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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STRAKA FRANTISEK, PIRK JAN, PINDAK MARIAN, SKALSKY IVO, VANCURA VLASTIMIL, CIHAK ROBERT, MAREK TOMAS, LUPINEK PETR, MASIN JAROSLAV, SCHORNIK DAVID, ZEMAN MICHAL, SKROBAKOVA JANKA, DORAZILOVA ZORA, SKIBOVA JELENA. The Hemodynamic Effect of Right Ventricle (RV), RT3DE Targeted Left Ventricle (LV) and Biventricular (BIV) Pacing in the Early Postoperative Period After Cardiac Surgery. Pacing Clin Electrophysiol 2011; 34:1231-40. [DOI: 10.1111/j.1540-8159.2011.03161.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Spotnitz ME, Wang DY, Quinn TA, Richmond ME, Rusanov A, Johnston T, Cheng B, Cabreriza SE, Spotnitz HM. Hemodynamic stability during biventricular pacing after cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2011; 25:238-42. [PMID: 20638864 PMCID: PMC3033485 DOI: 10.1053/j.jvca.2010.04.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To assess the stability of cardiac output, mean arterial pressure, and systemic vascular resistance during biventricular pacing (BiVP) optimization. DESIGN Substudy analysis of data collected as part of a randomized controlled study examining the effects of optimized temporary BiVP after cardiopulmonary bypass (CPB). SETTING A single-center study at a university-affiliated tertiary care hospital. PARTICIPANTS Cardiac surgery patients at risk of left ventricular failure after CPB. INTERVENTIONS BiVP was optimized immediately after CPB. Atrioventricular delay (7 unique settings) was optimized first, followed by the left ventricular pacing site (3 unique settings) and then the interventricular delay (9 unique settings). Each setting was tested twice for 10 seconds each time. Vasoactive medication and fluid infusion rates were held constant. MEASUREMENTS AND MAIN RESULTS Aortic flow velocity and radial artery pressure were digitized, recorded, and averaged over single respiratory cycles. Least squares and linear regression/Wilcoxon analyses were applied to the first 7 patients studied. Subsequently, curvilinear analysis was applied to 15 patients. Changes in mean arterial pressure and systemic vascular resistance were statistically insignificant or too small to be meaningful by least squares analysis. During interventricular synchrony optimization, cardiac output and mean arterial pressure decreased (mean changes -5.7% and -2.5%, respectively; with standard errors 2.3% and 1.5%, respectively), whereas SVR increased (mean change 3.1% with standard error 3.4%). Only the change in cardiac output was statistically significant (p = 0.043). Curvilinear fits to data for 15 patients demonstrated progressive hemodynamic stability over the total testing period. CONCLUSION BiVP optimization may be done safely in patients after CPB. With continuous monitoring of mean arterial pressure and cardiac output, the procedure results in no harmful hemodynamic perturbation.
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Affiliation(s)
- Mathew E Spotnitz
- Department of Surgery, Columbia University Medical Center, New York, NY 10032-3784, USA.
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Wang DY, Gerrah R, Rusanov A, Yalamanchi V, Cabreriza SE, Spotnitz HM. Left ventricular pacing lead insertion via the coronary sinus cardioplegia cannula: a novel method for temporary biventricular pacing during reoperative cardiac surgery. J Thorac Cardiovasc Surg 2010; 142:73-6. [PMID: 20965517 DOI: 10.1016/j.jtcvs.2010.08.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Revised: 06/25/2010] [Accepted: 08/01/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Temporary biventricular pacing to treat low output states after cardiac surgery is an active area of investigation. Reoperative cases are not studied due to adhesions, which preclude left ventricular mobilization to place epicardial pacing wires. In such patients, inserting a temporary left ventricular lead via the coronary sinus cardioplegia cannula may allow for biventricular pacing. We developed a novel technique for intraoperative left ventricular lead placement. METHODS Eight domestic pigs underwent median sternotomy and pericardiotomy. Temporary pacing wires were sewn to the right atrium and right ventricle. Complete heart block was induced by ethanol ablation of the atrioventricular node. A 13-French retrograde cardioplegia catheter was introduced via the right atrial free wall into the coronary sinus. A 6-French left ventricular pacing lead was inserted into the cardioplegia catheter and advanced into the coronary sinus during biventricular pacing until left ventricular capture was detected by electrocardiogram and arterial pressure monitoring. Left ventricular capture success rate and electrical performance were recorded during five placement attempts. RESULTS Left ventricular capture was achieved on 80% of insertion attempts. Left ventricular capture without diaphragmatic pacing was achieved in 7 pigs. Lead tip locations were mostly in lateral and posterior basal coronary vein branches. There were no arrhythmias, bleeding, or perforation associated with lead insertion. CONCLUSIONS Intraoperative biventricular pacing with a left ventricular pacing lead inserted via the coronary sinus cardioplegia cannula is feasible, using standard instrumentation and without requiring cardiac manipulation. This approach merits further study in patients undergoing reoperative cardiac surgery.
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Affiliation(s)
- Daniel Y Wang
- Department of Medicine, Columbia University, New York, NY 10032, USA
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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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Wang DY, Richmond ME, Quinn TA, Mirani AJ, Rusanov A, Yalamanchi V, Weinberg AD, Cabreriza SE, Spotnitz HM. Optimized temporary biventricular pacing acutely improves intraoperative cardiac output after weaning from cardiopulmonary bypass: a substudy of a randomized clinical trial. J Thorac Cardiovasc Surg 2010; 141:1002-8, 1008.e1. [PMID: 20800242 DOI: 10.1016/j.jtcvs.2010.07.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Revised: 06/24/2010] [Accepted: 07/06/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Permanent biventricular pacing benefits patients with heart failure and interventricular conduction delay, but the importance of pacing with and without optimization in patients at risk of low cardiac output after cardiac surgery is unknown. We hypothesized that pacing parameters independently affect cardiac output. Accordingly, we analyzed aortic flow measured with an electromagnetic flowmeter in patients at risk of low cardiac output during an ongoing randomized clinical trial of biventricular pacing (n = 11) versus standard of care (n = 9). METHODS A substudy was conducted in all 20 patients in both groups with stable pacing after coronary artery bypass grafting, valve surgery, or both. Ejection fraction averaged 33% ± 15%, and QRS duration was 116 ± 19 ms. Effects were measured within 1 hour of the conclusion of cardiopulmonary bypass. Atrioventricular delay (7 settings) and interventricular delay (9 settings) were optimized in random sequence. RESULTS Optimization of atrioventricular delay (171 ± 8 ms) at an interventricular delay of 0 ms increased flow by 14% versus the worst setting (111 ± 11 ms, P < .001) and 7% versus nominal atrioventricular delay (120 ms, P < .001). Interventricular delay optimization increased flow 10% versus the worst setting (P < .001) and 5% versus nominal interventricular delay (0 ms, P < .001). Optimized pacing increased cardiac output 13% versus atrial pacing at matched heart rate (5.5 ± 0.5 vs 4.9 ± 0.6 L/min, P = .003) and 10% versus sinus rhythm (5.0 ± 0.6 L/min, P = .019). CONCLUSIONS Temporary biventricular pacing increases intraoperative cardiac output in patients with left ventricular dysfunction undergoing cardiac surgery. Atrioventricular and interventricular delay optimization maximizes this benefit.
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Affiliation(s)
- Daniel Y Wang
- Department of Medicine, Columbia University, New York, NY, USA
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Dixit NK, Vazquez LD, Cross NJ, Kuhl EA, Serber ER, Kovacs A, Dede DE, Conti JB, Sears SF. Cardiac resynchronization therapy: a pilot study examining cognitive change in patients before and after treatment. Clin Cardiol 2010; 33:84-8. [PMID: 20186985 DOI: 10.1002/clc.20710] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiovascular patients with reduced cardiovascular output and capacity such as those with congestive heart failure (CHF) have demonstrated cognitive-related dysfunction. The use of cardiac resynchronization therapy (CRT) is considered standard care for CHF patients who do not improve despite optimal medical therapy. Cardiac resynchronization therapy may improve neurocognitive and psychosocial functioning in patients by increasing cardiac output and cerebral perfusion. METHODS A total of 20 patients were examined before and 3 months after CRT device implantation, via administration of standard neurocognitive and psychosocial testing measures. RESULTS Significant improvements in neurocognitive measures of attention (Digit Span: t[20] = - 2.695 [55.94+/-9.27-62.31+/-10.05], P = 0.015) and information processing (Digit Symbol: t[20] = - 4.577, P < 0.001; Controlled Oral Word Association Test: t[20] = - 3.338, P = 0.004) were demonstrated. Improvements in cardiac-specific quality of life were also significant (Minnesota Living with Heart Failure Questionnaire: t[16] = 3.544, P = 0.005 [55.17+/-18.23-36.75+/-18.00]; The Left Ventricular Dysfunction Questionnaire: t[16] = 3.544, P = 0.003 [63.43+/-23.35-43.29+/-21.62]). CONCLUSION These results represent clinically significant, qualitative, and quantitative cognitive functional benefits for patients from a neurocognitive and psychosocial perspective. Results suggest that biventricular pacing improves cardiovascular outcome and psychosocial functioning in patients with CHF. The future investigation of a larger sample would be beneficial in establishing the depth and breadth of this improvement.
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Affiliation(s)
- Neha K Dixit
- NF/SG Veterans Health System, Department of Psychology, Gainesville, Florida, USA
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Barosi A, Lunati M, Speca G, Mazzola A, Paglino G, De Bonis M, Iacopino S, Cassese M, Dicandia CD, Esposito G, Vimercati M, Della Scala A, Vitali E. Cardiac resynchronization therapy in patients undergoing open-chest cardiac surgery. J Interv Card Electrophysiol 2010; 30:251-9. [DOI: 10.1007/s10840-009-9451-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 10/11/2009] [Indexed: 11/29/2022]
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Hamad MAS, van Gelder BM, Bracke FA, van Zundert AAJ, van Straten AHM. Acute Hemodynamic Effects of Cardiac Resynchronization Therapy in Patients with Poor Left Ventricular Function During Cardiac Surgery. J Card Surg 2009; 24:585-90. [DOI: 10.1111/j.1540-8191.2009.00878.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hanke T, Misfeld M, Heringlake M, Schreuder JJ, Wiegand UK, Eberhardt F. The effect of biventricular pacing on cardiac function after weaning from cardiopulmonary bypass in patients with reduced left ventricular function: A pressure–volume loop analysis. J Thorac Cardiovasc Surg 2009; 138:148-56. [DOI: 10.1016/j.jtcvs.2009.02.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Revised: 12/31/2008] [Accepted: 02/01/2009] [Indexed: 11/29/2022]
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Eberhardt F, Heringlake M, Massalme MS, Dyllus A, Misfeld M, Sievers HH, Wiegand UKH, Hanke T. The effect of biventricular pacing after coronary artery bypass grafting: a prospective randomized trial of different pacing modes in patients with reduced left ventricular function. J Thorac Cardiovasc Surg 2009; 137:1461-7. [PMID: 19464465 DOI: 10.1016/j.jtcvs.2008.11.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2008] [Revised: 10/21/2008] [Accepted: 11/19/2008] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Biventricular pacing acutely improves left ventricular function in patients with heart failure and left ventricular dyssynchrony. Pressure-volume loop analysis has shown acute perioperative hemodynamic benefits of biventricular pacing immediately after weaning from cardiopulmonary bypass in patients undergoing coronary artery bypass grafting, but whether these effects can be maintained for the early postoperative period is unclear. We hypothesized that biventricular pacing is superior to atrioventricular universal pacing at right ventricular outflowtract and atrial inhibited pacing in patients undergoing coronary artery bypass grafting. METHODS Ninety-four patients (mean age, 67 +/- 9 years; mean ejection fraction, 35% +/- 4%) were prospectively randomized to undergo biventricular, atrioventricular universal, or atrial inhibited pacing at 90 beats/min for 96 postoperative hours. Clinical end points and postoperative hemodynamics, aminoterminal pro-brain natriuretic peptide, inotropic support, atrial fibrillation, ventricular arrhythmias, and renal function were evaluated. RESULTS Diastolic pulmonary arterial pressure, mean arterial pressure, mixed venous saturation, cardiac index, and cardiac power index did not differ significantly among groups for all time points. Neither raw aminoterminal pro-brain natriuretic peptide nor differential from preoperative values differed significantly among groups at any time point. Median intensive care unit stay (19.5 hours) did not differ significantly by pacing mode. Incidences of postoperative atrial fibrillation were 40% for atrial inhibited, 29% for atrioventricular universal, and 37% for biventricular (differences not significant). Renal function was unaffected by pacing mode. CONCLUSION Despite short-term hemodynamic benefits for patients with reduced left ventricular function, biventricular pacing did not lead to improved postoperative hemodynamics or clinical outcome.
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Dzemali O, Monsefi N, Moritz A, Kleine P. Permanent biventricular ICD-implantation in a heart failure second re-do-CABG patient: a case report. CASES JOURNAL 2009; 2:59. [PMID: 19146686 PMCID: PMC2634764 DOI: 10.1186/1757-1626-2-59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2008] [Accepted: 01/15/2009] [Indexed: 11/10/2022]
Abstract
Biventricular pacing has been suggested in end-stage heart failure. We present a 59-year-old patient undergoing second re-do CABG (coronary artery bypass graft) and carotid artery endarterectomy. Ejection fraction was 15%, QRS-width 175 ms. Following the carotid and CABG procedure, an implanted single-chamber ICD (implantable cardioverter defibrillator) was upgraded to permanent biventricular DDD pacing by implantation of one epicardial left ventricular and one epicardial atrial electrode. At follow-up two months postoperatively ejection fraction had significantly improved to 45%, the patient underwent stress test with adequate load and reported a good quality of life.
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Affiliation(s)
- Omer Dzemali
- Department of Thoracic & Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany.
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Healy DG, Hargrove M, Doddakulla K, Hinchion J, O'Donnell A, Aherne T. Impact of pacing modality and biventricular pacing on cardiac output and coronary conduit flow in the post-cardiotomy patient. Interact Cardiovasc Thorac Surg 2008; 7:805-8. [DOI: 10.1510/icvts.2008.180497] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Barandon L, Richebé P, Munos E, Calderon J, Lafitte M, Lafitte S, Couffinhal T, Roques X. Off-pump coronary artery bypass surgery in very high-risk patients: adjustment and preliminary results. Interact Cardiovasc Thorac Surg 2008; 7:789-93. [PMID: 18641012 DOI: 10.1510/icvts.2008.183665] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Left ventricle dysfunction and comorbidities are responsible for a large number of complications after CABG. OPCAB could be an interesting alternative for very high-risk patients. Patients were included if EuroSCORE >9, or with at least two of the following criteria, severe LV dysfunction, recent myocardial infarction (MI), terminal renal failure, lung dysfunction, PVD, BMI>30. Patients were operated using the Octopus (Medtronic) system. One hundred and twenty patients, mean age 68+/-10 years, 72% male, were operated. Mean EuroSCORE was 10.2+/-5.3, LV function 36.79+/-11.3%, recent MI 57%, renal failure 52%, COPD 44%, PVD 52%, obesity 34%. Mean graft per patient was 2.1+/-0.8. Three patients underwent secondary PTCA treatment for incomplete revascularization. Combined surgery was required for 20%. Early mortality was 3%. Intensive care unit stay was 2.7 days. Early complications were: low output syndrome 3%, MI 0.8%, stroke 0.8%, kidney support 7%. Graft patency was systematically analyzed with MCTA or angiocardiography. OPCAB strategy seems to be safe and secure in this population of very high-risk patients reducing multi-organ failure. However, long-term results are needed to confirm this strategy.
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Affiliation(s)
- Laurent Barandon
- Department of Cardiac Surgery and Anesthesiology, Hôpital Cardiologique du Haut-Levêque, 33600 Pessac, France.
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Pichlmaier M, Bagaev E, Lichtenberg A, Teebken O, Klein G, Niehaus M, Haverich A. Four-chamber pacing in patients with poor ejection fraction but normal QRS durations undergoing open heart surgery. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:184-91. [PMID: 18233971 DOI: 10.1111/j.1540-8159.2007.00967.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Poor ejection fraction (EF) comprises a critical risk factor in cardiac bypass surgery (CABG). It has been unclear, whether biventricular or four-chamber pacing confers benefit upon patients with intact atrioventricular and interventricular conduction especially following surgery. METHODS Twenty-one consecutive patients with an EF <or= 35% underwent hemodynamic evaluation (continuous pressures and thermodilution) 3, 6, and 18 hours post-CABG and biatrial (AA), biatrial-right ventricular (AAV), and biatrial-biventricular (AAVV) pacing were compared. RESULTS Patients (65 +/- 9 years) presented with an average EF of 29.5% (15-35%). 514 measurements of cardiac index (CI) were taken. Nineteen patients (91%) showed highly significant increases in CI with AAVV as compared to AA pacing (P < 0,001) at all times post surgery. The increase in CI with pacing mode varied from 6% to 25% and decreased with time following surgery. No consistent difference in CI was seen between four-chamber (AAVV) and biventricular pacing (AVV). The QRS-widths prior to surgery never exceeded 120 ms; postoperatively QRS-complexes widened in all patients on average by 15.9 ms +/-6 and returned to starting values by 48 hours. CONCLUSIONS Biventricular pacing improves CI in patients with poor EF following cardiac surgery in the absence of preoperative atrioventricular- or interventricular conduction block. This benefit decreases with time after surgery as the QRS width returns to preoperative values. Four-chamber pacing did not confer additional benefit as compared to biventricular pacing in this series. Biventricular pacing should be considered as an adjunct in patients with critically low EF undergoing cardiac surgery.
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Affiliation(s)
- Maximilian Pichlmaier
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
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Bakhtiary F, Dogan S, Dzemali O, Ackermann H, Kleine P, Schächinger V, Moritz A, Aybek T. Impact of Different Pacing Modes on Left Ventricular Contractility Following Cardiopulmonary Bypass. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30:1083-90. [PMID: 17725750 DOI: 10.1111/j.1540-8159.2007.00817.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acute left ventricular (LV) dysfunction after cardiopulmonary bypass (CBP) is a serious complication in cardiac surgery. The aim of this study was to investigate the effect of different epicardial pacing modes on LV contractility and changes of myocardial oxygen extraction (MVO(2)) following CPB in an animal model. The utility of conductance catheter measurement versus left ventricular outflow tract mean systolic acceleration (LVOT(Acc)) for quantification of LV function was evaluated. METHODS Fourteen piglets underwent median sternotomy and CPB for 90 minutes, myocardial ischemia for 60 minutes, and reperfusion for 30 minutes. Different pacing modes were obtained before and after CPB to investigate changes in LV function. LV Function was quantified by end-systolic-pressure-volume relationships (ESPVR) as measured by the conductance catheter method and by LVOT(Acc) obtained from transepicardial echocardiographic studies. RESULTS LV contractility improved significantly by biventricular and atrial pacing compared with natural sinus rhythm (SR). MVO(2) remained stable or even decreased with biventricular pacing after surgery compared with SR. Right ventricular pacing resulted in poor LV-function with a rise of MVO(2). LVOT(Acc) showed a strong correlation to invasively measured ESPVR. CONCLUSION Postoperative biventricular pacing was associated with an improved LV contractility without rise of MVO(2) compared with SR and atrial pacing. At termination of CPB, this appears to facilitate the management of LV failure and potentially may reduce the need for inotropic support, additionally protecting myocardial metabolism. The echocardiographic assessment of LVOT(Acc) was a simple and reliable as well as effective method to quantify LV contractility and showed a good correlation with the more invasive conductance catheter.
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Affiliation(s)
- Farhad Bakhtiary
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University Hospital, Frankfurt/Main, Germany.
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