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Sedláček K, Polášek R, Jansová H, Grieco D, Kučera P, Kautzner J, Francis DP, Wichterle D. Inadvertent QRS prolongation by an optimization device-based algorithm in patients with cardiac resynchronization therapy. PLoS One 2022; 17:e0275276. [PMID: 36155997 PMCID: PMC9512171 DOI: 10.1371/journal.pone.0275276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 09/13/2022] [Indexed: 11/22/2022] Open
Abstract
Background Device-based algorithms offer the potential for automated optimization of cardiac resynchronization therapy (CRT), but the process for accepting them into clinical use is currently still ad-hoc, rather than based on pre-clinical and clinical testing of specific features of validity. We investigated how the QuickOpt-guided VV delay (VVD) programming performs against the clinical and engineering heuristic of QRS complex shortening by CRT. Methods A prospective, 2-center study enrolled 37 consecutive patients with CRT. QRS complex duration (QRSd) was assessed during intrinsic atrioventricular conduction, synchronous biventricular pacing, and biventricular pacing with QuickOpt-proposed VVD. The measurements were done manually by electronic calipers in signal-averaged and magnified 12-lead QRS complexes. Results Native QRSd was 174 ± 22 ms. Biventricular pacing with empiric AVD and synchronous VVD resulted in QRSd 156 ± 20 ms, a significant narrowing from the baseline QRSd by 17 ± 27 ms, P = 0.0003. In 36 of 37 patients, the QuickOpt algorithm recommended left ventricular preexcitation with VVD of 42 ± 18 ms (median 40 ms; interquartile range 30–55 ms, P <0.00001). QRSd in biventricular pacing with QuickOpt-based VVD was significantly longer compared with synchronous biventricular pacing (168 ± 25 ms vs. 156 ± 20 ms; difference 12 ± 11ms; P <0.00001). This prolongation correlated with the absolute VVD value (R = 0.66, P <0.00001). Conclusions QuickOpt algorithm systematically favours a left-preexcitation VVD which translates into a significant prolongation of the QRSd compared to synchronous biventricular pacing. There is no reason to believe that a manipulation that systematically widens QRSd should be considered to optimize physiology. Device-based CRT optimization algorithms should undergo systematic mechanistic pre-clinical evaluation in various scenarios before they are tested in large clinical studies.
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Affiliation(s)
- Kamil Sedláček
- 1 Department of Internal Medicine–Cardiology and Angiology, University Hospital and Charles University Faculty of Medicine, Hradec Králové, Czech Republic
- * E-mail:
| | - Rostislav Polášek
- Cardiology Department, Liberec Regional Hospital, Liberec, Czech Republic
| | - Helena Jansová
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Domenico Grieco
- Department of Cardiovascular Sciences, Policlinico Casilino of Rome, Rome, Italy
| | - Pavel Kučera
- Cardiology Department, Liberec Regional Hospital, Liberec, Czech Republic
| | - Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Darrel P. Francis
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Dan Wichterle
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- 2 Department of Internal Cardiovascular Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic
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Sinner GJ, Gupta VA, Seratnahaei A, Charnigo RJ, Darrat YH, Elayi SC, Leung SW, Sorrell VL. Atrioventricular dyssynchrony from empiric device settings is common in cardiac resynchronization therapy and adversely impacts left ventricular morphology and function. Echocardiography 2017; 34:496-503. [DOI: 10.1111/echo.13486] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Gregory J. Sinner
- Department of Internal Medicine; University of Kentucky Medical Center; University of Kentucky; Lexington KY USA
| | - Vedant A. Gupta
- Division of Cardiovascular Medicine; Gill Heart Institute; University of Kentucky Medical Center; University of Kentucky; Lexington KY USA
| | - Arash Seratnahaei
- Division of Cardiovascular Medicine; Gill Heart Institute; University of Kentucky Medical Center; University of Kentucky; Lexington KY USA
| | | | - Yousef H. Darrat
- Division of Cardiovascular Medicine; Gill Heart Institute; University of Kentucky Medical Center; University of Kentucky; Lexington KY USA
| | - Samy C. Elayi
- Division of Cardiovascular Medicine; Gill Heart Institute; University of Kentucky Medical Center; University of Kentucky; Lexington KY USA
| | - Steve W. Leung
- Division of Cardiovascular Medicine; Gill Heart Institute; University of Kentucky Medical Center; University of Kentucky; Lexington KY USA
| | - Vincent L. Sorrell
- Division of Cardiovascular Medicine; Gill Heart Institute; University of Kentucky Medical Center; University of Kentucky; Lexington KY USA
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Cobb DB, Gold MR. The Role of Atrioventricular and Interventricular Optimization for Cardiac Resynchronization Therapy. Heart Fail Clin 2017; 13:209-223. [DOI: 10.1016/j.hfc.2016.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Nikolaidou T, Ghosh JM, Clark AL. Outcomes Related to First-Degree Atrioventricular Block and Therapeutic Implications in Patients With Heart Failure. JACC Clin Electrophysiol 2016; 2:181-192. [PMID: 29766868 DOI: 10.1016/j.jacep.2016.02.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 02/18/2016] [Accepted: 02/25/2016] [Indexed: 02/08/2023]
Abstract
The prevalence of first-degree atrioventricular block in the general population is approximately 4%, and it is associated with an increased risk of atrial fibrillation. Cardiac pacing for any indication in patients with first-degree heart block is associated with worse outcomes compared with patients with normal atrioventricular conduction. Among patients with heart failure, first-degree atrioventricular block is present in anywhere between 15% and 51%. Data from cardiac resynchronization therapy studies have shown that first-degree atrioventricular block is associated with an increased risk of mortality and heart failure hospitalization. Recent studies suggest that optimization of atrioventricular delay in patients with cardiac resynchronization therapy is an important target for therapy; however, the optimal method for atrioventricular resynchronization remains unknown. Understanding the role of first-degree atrioventricular block in the treatment of patients with heart failure will improve medical and device therapy.
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Affiliation(s)
- Theodora Nikolaidou
- Department of Academic Cardiology, Hull York Medical School, University of Hull, Hull, United Kingdom.
| | - Justin M Ghosh
- Department of Academic Cardiology, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Andrew L Clark
- Department of Academic Cardiology, Hull York Medical School, University of Hull, Hull, United Kingdom
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Cobb DB, Gold MR. The Role of Atrioventricular and Interventricular Optimization for Cardiac Resynchronization Therapy. Card Electrophysiol Clin 2015; 7:765-779. [PMID: 26596818 DOI: 10.1016/j.ccep.2015.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Many patients with left ventricular systolic dysfunction may benefit from cardiac resynchronization therapy; however, approximately 30% of patients do not experience significant clinical improvement with this treatment. AV and VV delay optimization techniques have included echocardiography, device-based algorithms, and several other novel noninvasive techniques. Using these techniques to optimize device settings has been shown to improve hemodynamic function acutely; however, the long-term clinical benefit is limited. In most cases, an empiric AV delay with simultaneous biventricular or left ventricular pacing is adequate. The value of optimization of these intervals in "nonresponders" still requires further investigation.
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Affiliation(s)
- Daniel B Cobb
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Michael R Gold
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
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Pastromas S, Manolis AS. Cardiac resynchronization therapy: Dire need for targeted left ventricular lead placement and optimal device programming. World J Cardiol 2014; 6:1270-1277. [PMID: 25548617 PMCID: PMC4278162 DOI: 10.4330/wjc.v6.i12.1270] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 07/27/2014] [Accepted: 11/03/2014] [Indexed: 02/06/2023] Open
Abstract
Cardiac resynchronization therapy (CRT) effected via biventricular pacing has been established as prime therapy for heart failure patients of New York Heart Association functional class II, III and ambulatory IV, reduced left ventricular (LV) function, and a widened QRS complex. CRT has been shown to improve symptoms, LV function, hospitalization rates, and survival. In order to maximize the benefit from CRT and reduce the number of non-responders, consideration should be given to target the optimal site for LV lead implantation away from myocardial scar and close to the latest LV site activation; and also to appropriately program the device paying particular attention to optimal atrioventricular and interventricular intervals. We herein review current data related to both optimal LV lead placement and device programming and their effects on CRT clinical outcomes.
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Nayar V, Khan FZ, Pugh PJ. Optimizing atrioventricular and interventricular intervals following cardiac resynchronization therapy. Expert Rev Cardiovasc Ther 2014; 9:185-97. [DOI: 10.1586/erc.10.187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Ulč I, Vančura V. Optimization of pacing intervals in cardiac resynchronization therapy. COR ET VASA 2013. [DOI: 10.1016/j.crvasa.2013.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Kleijn SA, Aly MF, Knol DL, Terwee CB, Jansma EP, Abd El-Hady YA, Kandil HI, Sorour KA, van Rossum AC, Kamp O. A meta-analysis of left ventricular dyssynchrony assessment and prediction of response to cardiac resynchronization therapy by three-dimensional echocardiography. Eur Heart J Cardiovasc Imaging 2012; 13:763-775. [DOI: 10.1093/ehjci/jes041] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
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Cheng CM, Huang JL, Wu TJ, Su CS, Pai HY, Liao MF, Ting CT, Chen SA. Comparison of quick optimization of interventricular delay between simple methods: intracardiac electrogram and surface electrocardiogram after cardiac resynchronization therapy. Europace 2012; 14:1317-23. [DOI: 10.1093/europace/eus061] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Antonini L, Auriti A, Pasceri V, Meo A, Pristipino C, Varveri A, Greco S, Santini M. Optimization of the atrioventricular delay in sequential and biventricular pacing: physiological bases, critical review, and new purposes. Europace 2012; 14:929-38. [DOI: 10.1093/europace/eur425] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
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CUOCO FRANKA, GOLD MICHAELR. Optimization of Cardiac Resynchronization Therapy: Importance of Programmed Parameters. J Cardiovasc Electrophysiol 2011; 23:110-8. [DOI: 10.1111/j.1540-8167.2011.02235.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Jensen C, Liadski A, Bell M, Naber C, Bruder O, Sabin G, Küpper B, Wieneke H. Echocardiography versus intracardiac electrocardiography-based optimization for cardiac resynchronization therapy. Herz 2011; 36:592-9. [DOI: 10.1007/s00059-011-3507-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Golovchiner G, Dorian P, Mangat I, Korley V, Ahmad K, Sharef K, Posan E, Crystal E, O'Donnell S, Pinter A. Electrogram-based optimal atrioventricular and interventricular delays of cardiac resynchronization change individually during exercise. Can J Cardiol 2011; 27:351-7. [PMID: 21489747 DOI: 10.1016/j.cjca.2010.12.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Accepted: 12/16/2010] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Limited data suggest that optimal atrioventricular (AV) and interventricular (VV) delays are different at rest than during exercise in patients with heart failure. We assessed the feasibility and reproducibility of an electrogram-based method of optimization called QuickOpt at rest and during exercise. METHODS Patients with a St Jude Medical cardiac resynchronization therapy implantable cardioverter-defibrillator were subjected to a graded treadmill test, and QuickOpt was repeatedly measured prior to, during, and after the exercise. RESULTS Twenty-four patients (16 males, aged 67.4 ± 7.7 years) participated. At rest, delays (in ms) were 110.4 ± 20.1 for sensed AV delay and -70 (LV pacing first) to +20 (RV pacing first) for VV delay. The changes in QuickOpt-derived delays at rest were not significant despite change in body position. During exercise, QuickOpt-derived AV delays did not change in 11 patients, were shorter during peak exercise in 8 patients, and were longer in 3 patients (average value during peak exercise was 126.5 ± 15.8 ms, P = 0.04 compared to baseline). The QuickOpt-derived VV delay gradually shifted toward earlier right ventricular pacing during exercise in 19 patients, while no changes were seen in 3 patients, and a shift occurred toward earlier left ventricular pacing in 2 patients (average value during peak exercise was -30.7 ± 22.2; P = 0.001 compared to baseline). There was no correlation between changes in the QuickOpt-derived AV and VV delays and heart rate. CONCLUSIONS The application of electrogram-based algorithm is feasible both at rest and during exercise. The results are reproducible. QuickOpt-derived AV and VV delays individually change during exercise.
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Affiliation(s)
- Gregory Golovchiner
- St. Michael's Hospital, Division of Cardiology, University of Toronto, Toronto, Ontario, Canada.
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Impact of moderate exercise workload on predicted optimal AV and VV delays determined by an intracardiac electrogram-based method for optimizing cardiac resynchronization therapy. Clin Res Cardiol 2010; 99:735-41. [PMID: 20517697 DOI: 10.1007/s00392-010-0178-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Accepted: 05/18/2010] [Indexed: 10/19/2022]
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Abraham WT, Gras D, Yu CM, Guzzo L, Gupta MS. Rationale and design of a randomized clinical trial to assess the safety and efficacy of frequent optimization of cardiac resynchronization therapy: the Frequent Optimization Study Using the QuickOpt Method (FREEDOM) trial. Am Heart J 2010; 159:944-948.e1. [PMID: 20569704 DOI: 10.1016/j.ahj.2010.02.034] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2009] [Accepted: 02/24/2010] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim of the study was to describe the rationale, design, and end points of a randomized, double-blind, controlled trial evaluating frequent systematic optimization of atrioventricular (AV) and interventricular (VV) delays in patients receiving cardiac resynchronization therapy (CRT). METHODS One thousand five hundred eighty heart failure patients, with standard clinical indications for CRT, were enrolled at 178 sites in 16 countries. Within 2 weeks after implantation of a CRT system capable of using a new device-based algorithm for AV and VV optimization, patients were randomly assigned to frequent optimization arm versus empiric device programming or any other non-device-based method of CRT optimization (standard of care arm). In patients in the frequent optimization arm, the AV and VV delays were calculated, reevaluated, and, if necessary, reprogrammed every 3 months. In patients in the standard of care arm, device programming was left to the implanting physician's discretion and remained unchanged throughout the trial unless mandated by a change in clinical status. The primary end point of the trial is the heart failure clinical composite, which classifies patients as worsened, unchanged, or improved based on prespecified definitions. Secondary end points include hospitalizations for cardiovascular reasons and all-cause mortality. End points are adjudicated by an independent committee blinded to study assignment. CONCLUSIONS The FREEDOM trial, expected to conclude late in 2009, will determine whether frequent optimization of CRT, using a new device-based algorithm, is associated with better clinical outcomes than current standard of care. In addition to improving patient care, this approach might alleviate the workload and economic burden imposed by current approaches to optimization of CRT devices.
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Khan FZ, Virdee MS, Pugh PJ, Read PA, Fynn SP, Dutka DP. Non-invasive cardiac output measurements based on bioreactance for optimization of atrio- and interventricular delays. Europace 2009; 11:1666-74. [PMID: 19910316 DOI: 10.1093/europace/eup358] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Harkel AT, Van Osch-Gevers M, Helbing W. Real-Time Transthoracic Three Dimensional Echocardiography: Normal Reference Data for Left Ventricular Dyssynchrony in Adolescents. J Am Soc Echocardiogr 2009; 22:933-8. [DOI: 10.1016/j.echo.2009.04.024] [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: 05/26/2008] [Indexed: 10/20/2022]
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Ballo P, Motto A, Mondillo S, Galderisi M. Three-dimensional echocardiography for optimization of cardiac resynchronization therapy. Eur Heart J 2009; 30:505; author reply 505-6. [PMID: 19168528 DOI: 10.1093/eurheartj/ehp001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Current World Literature. Curr Opin Cardiol 2009; 24:95-101. [DOI: 10.1097/hco.0b013e32831fb366] [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: 11/26/2022]
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Martínez Ferrer J, Fidalgo Andrés ML, Barba Pichardo R, Sancho-Tello de Carranza MJ. Novedades en estimulación cardiaca. Rev Esp Cardiol (Engl Ed) 2009; 62 Suppl 1:117-28. [DOI: 10.1016/s0300-8932(09)70046-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Valzania C, Eriksson MJ, Boriani G, Gadler F. Cardiac resynchronization therapy during rest and exercise: comparison of two optimization methods. Europace 2008; 10:1161-9. [PMID: 18753213 PMCID: PMC2552406 DOI: 10.1093/europace/eun216] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Aims Optimal exercise programming of cardiac resynchronization therapy (CRT) devices is unknown. We aimed to: (i) investigate variations in optimal atrioventricular (AV) and interventricular (VV) delays from rest to exercise, assessed by both echocardiography and an automated intracardiac electrogram (IEGM) method; (ii) evaluate the acute haemodynamic impact of CRT optimization performed during exercise. Methods and results Twenty-four heart failure patients, previously implanted with a CRT defibrillator, underwent AV and VV delay optimization, by echocardiography and IEGM methods, both at rest and during supine bicycle exercise. Rest-to-exercise variations in optimal VV delay were observed in 58% of patients. Conversely, optimal AV delay did not change during exercise compared with rest. Substantial agreement of AV and VV delays was observed between both the optimization methods. Exercise optimization of VV delay by either method improved intraventricular dyssynchrony and increased aortic velocity time integral compared with the resting setting (P < 0.001). Conclusion In patients implanted with a CRT device, optimal VV delay varied considerably from rest to exercise, while AV delay did not change. Re-assessment of the optimal pacing configuration during supine exercise, by echocardiography as well as IEGM methods, yielded an additional haemodynamic benefit to that provided by resting optimization.
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Affiliation(s)
- Cinzia Valzania
- Department of Medicine, Division of Cardiology, Karolinska Institutet, Stockholm, Sweden.
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Stanton T, Hawkins NM, Hogg KJ, Goodfield NE, Petrie MC, McMurray JJ. How should we optimize cardiac resynchronization therapy? Eur Heart J 2008; 29:2458-72. [DOI: 10.1093/eurheartj/ehn380] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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