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Kasagawa A, Nakajima I, Izumo M, Nakayama Y, Yamada M, Takano M, Matsuda H, Furukawa T, Miyazaki H, Harada T, Akashi YJ. Novel Device-Based Algorithm Provides Optimal Hemodynamics During Exercise in Patients With Cardiac Resynchronization Therapy. Circ J 2019; 83:2002-2009. [PMID: 31462585 DOI: 10.1253/circj.cj-19-0512] [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] [Indexed: 11/09/2022]
Abstract
BACKGROUND An adaptive cardiac resynchronization therapy (aCRT) algorithm has been described for synchronized left ventricular (LV) pacing and continuous optimization of cardiac resynchronization therapy (CRT). However, there are few algorithmic data on the effect of changes during exercise.Methods and Results:We enrolled 27 patients with availability of the aCRT algorithm. Eligible patients were manually programmed to optimal atrioventricular (AV) and interventricular (VV) delays by using echocardiograms at rest or during 2 stages of supine bicycle exercise. We compared the maximum cardiac output between manual echo-optimization and aCRT-on during each phase. After initiating exercise, the optimal AV delay progressively shortened (P<0.05) with incremental exercise levels. The manual-optimized settings and aCRT resulted in similar cardiac performance, as demonstrated by a high concordance correlation coefficient between the LV outflow tract velocity time integral (LVOT-VTI) during each exercise stage (Ex.1: r=0.94 P<0.0008, Ex.2: r=0.88 P<0.001, respectively). Synchronized LV-only pacing in patients with normal AV conduction could provide a higher LVOT-VTI as compared with manual-optimized conventional biventricular pacing at peak exercise (P<0.05). CONCLUSIONS The aCRT algorithm was physiologically sound during exercise by patients.
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Affiliation(s)
- Akira Kasagawa
- Division of Cardiology, St. Marianna University School of Medicine
| | - Ikutaro Nakajima
- Division of Cardiology, St. Marianna University School of Medicine
| | - Masaki Izumo
- Division of Cardiology, St. Marianna University School of Medicine
| | - Yui Nakayama
- Division of Cardiology, St Marianna University School of Medicine, Yokohama City Seibu Hospital
| | - Marika Yamada
- Division of Cardiology, St. Marianna University School of Medicine
| | - Makoto Takano
- Division of Cardiology, St. Marianna University School of Medicine
| | - Hisao Matsuda
- Division of Cardiology, St Marianna University School of Medicine, Yokohama City Seibu Hospital
| | - Toshiyuki Furukawa
- Division of Cardiology, St. Marianna University School of Medicine, Toyoko Hospital
| | | | - Tomoo Harada
- Division of Cardiology, St. Marianna University School of Medicine
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Kyriacou A, Rajkumar CA, Pabari PA, Sohaib SA, Willson K, Peters NS, Lim PB, Kanagaratnam P, Hughes AD, Mayet J, Whinnett ZI, Francis DP. Distinct impacts of heart rate and right atrial-pacing on left atrial mechanical activation and optimal AV delay in CRT. Pacing Clin Electrophysiol 2018; 41:959-966. [PMID: 29856077 PMCID: PMC6099378 DOI: 10.1111/pace.13401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 04/28/2018] [Accepted: 05/21/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Controversy exists regarding how atrial activation mode and heart rate affect optimal atrioventricular (AV) delay in cardiac resynchronization therapy. We studied these questions using high-reproducibility hemodynamic and echocardiographic measurements. METHODS Twenty patients were hemodynamically optimized using noninvasive beat-to-beat blood pressure at rest (62 ± 11 beats/min), during exercise (80 ± 6 beats/min), and at three atrially paced rates: 5, 25, and 45 beats/min above rest, denoted as Apaced,r+5 , Apaced,r+25 , and Apaced,r+45 , respectively. Left atrial myocardial motion and transmitral flow were timed echocardiographically. RESULTS During atrial sensing, raising heart rate shortened optimal AV delay by 25 ± 6 ms (P < 0.001). During atrial pacing, raising heart rate from Apaced,r+5 to Apaced,r+25 shortened it by 16 ± 6 ms; Apaced,r+45 shortened it 17 ± 6 ms further (P < 0.001). In comparison to atrial-sensed activation, atrial pacing lengthened optimal AV delay by 76 ± 6 ms (P < 0.0001) at rest, and at ∼20 beats/min faster, by 85 ± 7 ms (P < 0.0001), 9 ± 4 ms more (P = 0.017). Mechanically, atrial pacing delayed left atrial contraction by 63 ± 5 ms at rest and by 73 ± 5 ms (i.e., by 10 ± 5 ms more, P < 0.05) at ∼20 beats/min faster. Raising atrial rate by exercise advanced left atrial contraction by 7 ± 2 ms (P = 0.001). Raising it by atrial pacing did not (P = 0.2). CONCLUSIONS Hemodynamic optimal AV delay shortens with elevation of heart rate. It lengthens on switching from atrial-sensed to atrial-paced at the same rate, and echocardiography shows this sensed-paced difference in optima results from a sensed-paced difference in atrial electromechanical delay. The reason for the widening of the sensed-paced difference in AV optimum may be physiological stimuli (e.g., adrenergic drive) advancing left atrial contraction during exercise but not with fast atrial pacing.
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Affiliation(s)
- Andreas Kyriacou
- The Northern General HospitalSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Christopher A. Rajkumar
- International Centre for Circulatory Health, National Heart and Lung InstituteImperial College LondonLondonW12 0HSUK
| | - Punam A. Pabari
- International Centre for Circulatory Health, National Heart and Lung InstituteImperial College LondonLondonW12 0HSUK
| | - S.M. Afzal Sohaib
- International Centre for Circulatory Health, National Heart and Lung InstituteImperial College LondonLondonW12 0HSUK
| | - Keith Willson
- International Centre for Circulatory Health, National Heart and Lung InstituteImperial College LondonLondonW12 0HSUK
| | - Nicholas S. Peters
- International Centre for Circulatory Health, National Heart and Lung InstituteImperial College LondonLondonW12 0HSUK
| | - Phang B. Lim
- International Centre for Circulatory Health, National Heart and Lung InstituteImperial College LondonLondonW12 0HSUK
| | - Prapa Kanagaratnam
- International Centre for Circulatory Health, National Heart and Lung InstituteImperial College LondonLondonW12 0HSUK
| | - Alun D. Hughes
- International Centre for Circulatory Health, National Heart and Lung InstituteImperial College LondonLondonW12 0HSUK
| | - Jamil Mayet
- International Centre for Circulatory Health, National Heart and Lung InstituteImperial College LondonLondonW12 0HSUK
| | - Zachary I. Whinnett
- International Centre for Circulatory Health, National Heart and Lung InstituteImperial College LondonLondonW12 0HSUK
| | - Darrel P. Francis
- International Centre for Circulatory Health, National Heart and Lung InstituteImperial College LondonLondonW12 0HSUK
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Rowe MK, Kaye GC. Advances in atrioventricular and interventricular optimization of cardiac resynchronization therapy - what's the gold standard? Expert Rev Cardiovasc Ther 2018; 16:183-196. [PMID: 29338475 DOI: 10.1080/14779072.2018.1427582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Cardiac resynchronization therapy (CRT) is one of the most important advances in heart failure management in the last twenty years. Approximately one-third of patients appear not to respond to therapy. Although there are a number of possible mechanisms for non-response, an important factor is suboptimal atrioventricular (AV) and interventricular (VV) timing intervals. There remains controversy over whether routinely optimizing intervals is necessary and there is no agreed gold standard methodology. Optimization has classically been performed using echocardiography which has limits related to resource use, time-cost and variable reproducibility. Newer optimization methods using device-based sensors and algorithms show promise in reducing heart-failure hospitalization compared with echocardiography. Areas covered: This review outlines the rationale for optimization, the principles of AV and VV optimization, the standard echocardiographic approach and newer device-based algorithms and the evidence base for their use. Expert commentary: The incremental gains of optimization are likely to be real, but small, compared to the overall improvement gained from cardiac resynchronization itself. At this time routine optimization may not be mandatory but should be performed where there is no response to CRT. Device-based optimization algorithms appear to be practical and in some cases, deliver superior clinical outcomes compared to echocardiography.
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Affiliation(s)
- Matthew K Rowe
- a Department of Cardiology , Princess Alexandra Hospital , Brisbane , Australia.,b Faculty of Medicine , The University of Queensland , Brisbane , Australia
| | - Gerald C Kaye
- a Department of Cardiology , Princess Alexandra Hospital , Brisbane , Australia.,b Faculty of Medicine , The University of Queensland , Brisbane , Australia
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Houmsse M, Abraham WT. Continuously adjusting CRT therapy: clinical impact of adaptive cardiac resynchronization therapy. Expert Rev Cardiovasc Ther 2014; 12:541-8. [DOI: 10.1586/14779072.2014.901150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Singh JP, Abraham WT, Chung ES, Rogers T, Sambelashvili A, Coles JA, Martin DO. Clinical response with adaptive CRT algorithm compared with CRT with echocardiography-optimized atrioventricular delay: a retrospective analysis of multicentre trials. Europace 2013; 15:1622-8. [PMID: 24014804 DOI: 10.1093/europace/eut107] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Adaptive cardiac resynchronization therapy (aCRT) is a novel algorithm for CRT pacing that provides automatic ambulatory selection between synchronized left ventricular (LV) or bi-ventricular (BiV) pacing and optimization of atrioventricular (AV) and inter-ventricular (VV) delays based on periodic measurement of intrinsic conduction. We aimed to compare the clinical response between aCRT and standard CRT in historical trials. METHODS AND RESULTS The treatment arm of the aCRT trial was compared with a pooled historical control (HC) derived from the CRT arms of four clinical trials (MIRACLE, MIRACLE ICD, PROSPECT, and InSync III Marquis) with respect to the proportion of patients who had an improved clinical composite score (CCS) at the 6-month follow-up. Patients in the HC underwent echocardiography-guided AV optimization after the implant. A propensity score model was used to adjust for 22 potential baseline confounders of the effect of CRT. Patients were stratified into quintiles according to the propensity score and the adjusted absolute treatment effect was obtained by averaging estimates across these quintiles. The propensity score model included 751 patients (aCRT: 266, historical trials: 485). The adjusted absolute difference in percent improved in CCS between the aCRT and HC arms was 11.9% [95% confidence interval (CI): 2.7-19.2%] favouring aCRT. The patients in the aCRT group were significantly more likely to have an improved CCS than the patients in the HC (odds ratio = 1.65, 95% CI: 1.1-2.5). CONCLUSION The aCRT algorithm may be associated with additional improvement in clinical response compared with historical CRT with echocardiographic AV optimization.
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Affiliation(s)
- Jagmeet P Singh
- Massachusetts General Hospital Heart Center, Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA
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Lee MS, Naqvi TZ. Echocardiography-guided pacemaker programming can improve cardiac hemodynamics in patients undergoing transcatheter aortic valve replacement. Echocardiography 2013; 30:853-7. [PMID: 23627861 DOI: 10.1111/echo.12223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVR) is an effective treatment option for patients with severe aortic stenosis who are at high surgical risk because of multiple comorbidities. Many of these patients have been treated with pacemakers for concomitant conduction disease. The combination of severe aortic stenosis, cardiomyopathy, and conduction abnormalities results in a state of low cardiac output. Here, we report 2 complex TAVR cases where Doppler echocardiography was used to guide adjustment of device settings, leading to improved cardiac hemodynamic profiles.
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Affiliation(s)
- Ming-Sum Lee
- Division of Cardiology, Department of Medicine, Cardiac Non Invasive Laboratories, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA
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Shanmugam N, Prada-Delgado O, Campos AG, Grimster A, Valencia O, Baltabaeva A, Jones S, Anderson L. Rate-adaptive AV delay and exercise performance following cardiac resynchronization therapy. Heart Rhythm 2012; 9:1815-21. [PMID: 22772135 DOI: 10.1016/j.hrthm.2012.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Nesan Shanmugam
- Department of Cardiology, St George's Healthcare NHS Trust, London, United Kingdom.
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Krum H, Lemke B, Birnie D, Lee KLF, Aonuma K, Starling RC, Gasparini M, Gorcsan J, Rogers T, Sambelashvili A, Kalmes A, Martin D. A novel algorithm for individualized cardiac resynchronization therapy: rationale and design of the adaptive cardiac resynchronization therapy trial. Am Heart J 2012; 163:747-752.e1. [PMID: 22607850 DOI: 10.1016/j.ahj.2012.02.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 02/02/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND The magnitude of benefit of cardiac resynchronization therapy (CRT) varies significantly among its recipients; approximately 30% of CRT patients do not report clinical improvement. Optimization of CRT pacing parameters can further improve cardiac function, both acutely and chronically. Echocardiographic optimization is used in clinical practice, but it is time and resource consuming. In addition, optimal settings at rest may change later with activity or cardiac remodeling. The adaptive CRT (aCRT) algorithm was designed to provide automatic ambulatory adjustment of CRT pacing configuration (left ventricular or biventricular pacing) and device delays based on periodic measurement of electrical conduction intervals. METHODS The aCRT algorithm is currently undergoing evaluation in a prospective, randomized, double-blinded, worldwide clinical trial. The trial enrolled 522 patients, who satisfied standard clinical indications for a CRT device. Within 2 weeks after the implant, the patients were randomized to aCRT versus echo-optimized biventricular pacing (Echo) settings in 2:1 ratio and followed up at 1-, 3-, 6-, and 12-month postrandomization. The noninferiority primary trial objectives at 6-month postrandomization are to demonstrate that (a) the percentage of aCRT patients who improved in their clinical composite score is at least as high as the percentage of Echo patients; (b) cardiac performance as assessed by echocardiography is similar when using aCRT settings versus echo-optimized settings; and (c) aCRT does not result in inappropriate device settings. First and last patient enrollments occurred in November 2009 and December 2010, respectively. CONCLUSIONS The safety and efficacy of the aCRT algorithm will be evaluated in this ongoing clinical trial.
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Affiliation(s)
- Henry Krum
- Department of Epidemiology & Preventive Medicine, Monash Centre of Cardiovascular Research & Education in Therapeutics, 89 Commercial Road, Melbourne, VIC 3004 Australia.
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Rafie R, Qamruddin S, Ozhand A, Taha N, Naqvi TZ. Shortening of atrioventricular delay at increased atrial paced heart rates improves diastolic filling and functional class in patients with biventricular pacing. Cardiovasc Ultrasound 2012; 10:2. [PMID: 22269022 PMCID: PMC3292936 DOI: 10.1186/1476-7120-10-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Accepted: 01/24/2012] [Indexed: 11/22/2022] Open
Abstract
Background Use of rate adaptive atrioventricular (AV) delay remains controversial in patients with biventricular (Biv) pacing. We hypothesized that a shortened AV delay would provide optimal diastolic filling by allowing separation of early and late diastolic filling at increased heart rate (HR) in these patients. Methods 34 patients (75 ± 11 yrs, 24 M, LVEF 34 ± 12%) with Biv and atrial pacing had optimal AV delay determined at baseline HR by Doppler echocardiography. Atrial pacing rate was then increased in 10 bpm increments to a maximum of 90 bpm. At each atrial pacing HR, optimal AV delay was determined by changing AV delay until best E and A wave separation was seen on mitral inflow pulsed wave (PW) Doppler (defined as increased atrial duration from baseline or prior pacemaker setting with minimal atrial truncation). Left ventricular (LV) systolic ejection time and velocity time integral (VTI) at fixed and optimal AV delay was also tested in 13 patients. Rate adaptive AV delay was then programmed according to the optimal AV delay at the highest HR tested and patients were followed for 1 month to assess change in NYHA class and Quality of Life Score as assessed by Minnesota Living with Heart Failure Questionnaire. Results 81 AV delays were evaluated at different atrial pacing rates. Optimal AV delay decreased as atrial paced HR increased (201 ms at 60 bpm, 187 ms at 70 bpm, 146 ms at 80 bpm and 123 ms at 90 bpm (ANOVA F-statistic = 15, p = 0.0010). Diastolic filling time (P < 0.001 vs. fixed AV delay), mitral inflow VTI (p < 0.05 vs fixed AV delay) and systolic ejection time (p < 0.02 vs. fixed AV delay) improved by 14%, 5% and 4% respectively at optimal versus fixed AV delay at the same HR. NYHA improved from 2.6 ± 0.7 at baseline to 1.7 ± 0.8 (p < 0.01) 1 month post optimization. Physical component of Quality of Life Score improved from 32 ± 17 at baseline to 25 ± 12 (p < 0.05) at follow up. Conclusions Increased heart rate by atrial pacing in patients with Biv pacing causes compromise in diastolic filling time which can be improved by AV delay shortening. Aggressive AV delay shortening was required at heart rates in physiologic range to achieve optimal diastolic filling and was associated with an increase in LV ejection time during optimization. Functional class improved at 1 month post optimization using aggressive AV delay shortening algorithm derived from echo-guidance at the time of Biv pacemaker optimization.
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Affiliation(s)
- Reza Rafie
- Echocardiographic Laboratories, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA
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LEVIN VADIM, RAZAVI MEHDI, COLL ROBERT, COLES Jr JAMESA, SAMBELASHVILI ALEKSANDRE. Interatrial Conduction Correlates with Optimal Atrioventricular Timing in Cardiac Resynchronization Therapy Devices. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 34:443-9. [DOI: 10.1111/j.1540-8159.2010.02988.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Echocardiography-Guided Biventricular Pacemaker Optimization. JACC Cardiovasc Imaging 2010; 3:1168-80. [DOI: 10.1016/j.jcmg.2010.06.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Revised: 05/24/2010] [Accepted: 06/08/2010] [Indexed: 11/18/2022]
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BOGAARD MARGOTD, KIRKELS JHANS, HAUER RICHARDN, LOH PETER, DOEVENDANS PIETERA, MEINE MATHIAS. Should We Optimize Cardiac Resynchronization Therapy During Exercise? J Cardiovasc Electrophysiol 2010; 21:1307-16. [DOI: 10.1111/j.1540-8167.2010.01815.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ståhlberg M, Kessels R, Linde C, Braunschweig F. Acute haemodynamic effects of increase in paced heart rate in heart failure patients recorded with an implantable haemodynamic monitor. ACTA ACUST UNITED AC 2010; 13:237-43. [DOI: 10.1093/europace/euq354] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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