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Niu H, Yu Y, Sturdivant JL, An Q, Gold MR. The effect of posture, exercise, and atrial pacing on atrioventricular conduction in systolic heart failure. J Cardiovasc Electrophysiol 2019; 30:2892-2899. [PMID: 31691436 DOI: 10.1111/jce.14264] [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] [Received: 05/29/2019] [Revised: 08/29/2019] [Accepted: 11/01/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Optimization of atrioventricular (AV) intervals for cardiac resynchronization therapy (CRT) programming is typically performed in supine patients at rest, which may not reflect AV timing in other conditions. OBJECTIVE To evaluate the effects of posture, exercise, and atrial pacing on intrinsic AV intervals in patients with CRT devices. METHODS Rate-dependent A-V delay by exercise was a multicenter, prospective trial of patients in sinus rhythm following CRT implantation. Intracardiac electrograms were recorded to analyze atrial to right ventricular (ARV), atrial to left ventricular (ALV), and RV to LV (VV) time intervals. Heart rate was increased with incremental atrial pacing in different postures, followed by an exercise treadmill test. RESULTS This study included 36 patients. At rest, AV intervals changed minimally with posture. With atrial pacing, AV interval immediately increased compared with sinus rhythm, with ARV slopes being 8.1 ± 7.7, 8.8 ± 13.4, and 6.8 ± 6.5 milliseconds per beat per minute (ms/bpm) and ALV slopes being 8.2 ± 7.7, 9.1 ± 12.8, and 7.0 ± 6.5 ms/bpm for supine, standing and sitting positions, respectively. As the paced heart rate increased, ARV and ALV intervals increased more gradually with similar trends. Interventricular conduction times changed less than 0.2 ms/bpm with atrial pacing. During exercise, the direction of change of intrinsic ARV intervals, as heart rate increased, was variable between patients with relatively small overall group changes (0.1 ± 1.4 and 0.2 ± 1.2 ms/bpm for ARV and ALV, respectively). CONCLUSION Posture and exercise have a smaller effect on AV timing compared with atrial pacing. However, individualized optimization and dynamic rate related changes may be needed to maintain optimal fusion with left ventricular (LV) stimulation.
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Affiliation(s)
- Hongxia Niu
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Yinghong Yu
- Division of Cardiology, Medical University of South Carolina, St. Paul, Minnesota
| | - John L Sturdivant
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Qi An
- Division of Cardiology, Medical University of South Carolina, St. Paul, Minnesota
| | - Michael R Gold
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
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Ellenbogen KA, Gold MR, Meyer TE, Fernndez Lozano I, Mittal S, Waggoner AD, Lemke B, Singh JP, Spinale FG, Van Eyk JE, Whitehill J, Weiner S, Bedi M, Rapkin J, Stein KM. Primary Results From the SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in Cardiac Resynchronization Therapy (SMART-AV) Trial. Circulation 2010; 122:2660-8. [PMID: 21098426 DOI: 10.1161/circulationaha.110.992552] [Citation(s) in RCA: 292] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
One variable that may influence cardiac resynchronization therapy response is the programmed atrioventricular (AV) delay. The SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in Cardiac Resynchronization Therapy (SMART-AV) Trial prospectively randomized patients to a fixed empirical AV delay (120 milliseconds), echocardiographically optimized AV delay, or AV delay optimized with SmartDelay, an electrogram-based algorithm.
Methods and Results
A total of 1014 patients (68% men; mean age, 66±11 years; mean left ventricular ejection fraction, 25±7%) who met enrollment criteria received a cardiac resynchronization therapy defibrillator, and 980 patients were randomized in a 1:1:1 ratio. All patients were programmed (DDD-60 or DDDR-60) and evaluated after implantation and 3 and 6 months later. The primary end point was left ventricular end-systolic volume. Secondary end points included New York Heart Association class, quality-of-life score, 6-minute walk distance, left ventricular end-diastolic volume, and left ventricular ejection fraction. The medians (quartiles 1 and 3) for change in left ventricular end-systolic volume at 6 months for the SmartDelay, echocardiography, and fixed arms were −21 mL (−45 and 6 mL), −19 mL (−45 and 6 mL), and −15 mL (−41 and 6 mL), respectively. No difference in improvement in left ventricular end-systolic volume at 6 months was observed between the SmartDelay and echocardiography arms (
P
=0.52) or the SmartDelay and fixed arms (
P
=0.66). Secondary end points, including structural (left ventricular end-diastolic volume and left ventricular ejection fraction) and functional (6-minute walk, quality of life, and New York Heart Association classification) measures, were not significantly different between arms.
Conclusions
Neither SmartDelay nor echocardiography was superior to a fixed AV delay of 120 milliseconds. The routine use of AV optimization techniques assessed in this trial is not warranted. However, these data do not exclude possible utility in selected patients who do not respond to cardiac resynchronization therapy.
Clinical Trial Registration
URL:
http://www.clinicaltrials.gov
Unique identifier: NCT00677014.
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Affiliation(s)
- Kenneth A. Ellenbogen
- From the Virginia Commonwealth University Medical Center, Richmond (K.A.E.); Medical University of South Carolina, Charleston (M.R.G., F.G.S.); Boston Scientific, St. Paul, MN (T.E.M., J.R., K.M.S.); Hospital Puerta de Hierro, Madrid, Spain (I.F.L.); St. Luke's–Roosevelt Hospital Center, New York, NY (S.M.); Washington University School of Medicine, St. Louis, MO (A.D.W.); Maerkische Kliniken GmbH, Luedenscheid, Germany (B.L.); Massachusetts General Hospital, Harvard Medical School, Boston (J.P.S.)
| | - Michael R. Gold
- From the Virginia Commonwealth University Medical Center, Richmond (K.A.E.); Medical University of South Carolina, Charleston (M.R.G., F.G.S.); Boston Scientific, St. Paul, MN (T.E.M., J.R., K.M.S.); Hospital Puerta de Hierro, Madrid, Spain (I.F.L.); St. Luke's–Roosevelt Hospital Center, New York, NY (S.M.); Washington University School of Medicine, St. Louis, MO (A.D.W.); Maerkische Kliniken GmbH, Luedenscheid, Germany (B.L.); Massachusetts General Hospital, Harvard Medical School, Boston (J.P.S.)
| | - Timothy E. Meyer
- From the Virginia Commonwealth University Medical Center, Richmond (K.A.E.); Medical University of South Carolina, Charleston (M.R.G., F.G.S.); Boston Scientific, St. Paul, MN (T.E.M., J.R., K.M.S.); Hospital Puerta de Hierro, Madrid, Spain (I.F.L.); St. Luke's–Roosevelt Hospital Center, New York, NY (S.M.); Washington University School of Medicine, St. Louis, MO (A.D.W.); Maerkische Kliniken GmbH, Luedenscheid, Germany (B.L.); Massachusetts General Hospital, Harvard Medical School, Boston (J.P.S.)
| | - Ignacio Fernndez Lozano
- From the Virginia Commonwealth University Medical Center, Richmond (K.A.E.); Medical University of South Carolina, Charleston (M.R.G., F.G.S.); Boston Scientific, St. Paul, MN (T.E.M., J.R., K.M.S.); Hospital Puerta de Hierro, Madrid, Spain (I.F.L.); St. Luke's–Roosevelt Hospital Center, New York, NY (S.M.); Washington University School of Medicine, St. Louis, MO (A.D.W.); Maerkische Kliniken GmbH, Luedenscheid, Germany (B.L.); Massachusetts General Hospital, Harvard Medical School, Boston (J.P.S.)
| | - Suneet Mittal
- From the Virginia Commonwealth University Medical Center, Richmond (K.A.E.); Medical University of South Carolina, Charleston (M.R.G., F.G.S.); Boston Scientific, St. Paul, MN (T.E.M., J.R., K.M.S.); Hospital Puerta de Hierro, Madrid, Spain (I.F.L.); St. Luke's–Roosevelt Hospital Center, New York, NY (S.M.); Washington University School of Medicine, St. Louis, MO (A.D.W.); Maerkische Kliniken GmbH, Luedenscheid, Germany (B.L.); Massachusetts General Hospital, Harvard Medical School, Boston (J.P.S.)
| | - Alan D. Waggoner
- From the Virginia Commonwealth University Medical Center, Richmond (K.A.E.); Medical University of South Carolina, Charleston (M.R.G., F.G.S.); Boston Scientific, St. Paul, MN (T.E.M., J.R., K.M.S.); Hospital Puerta de Hierro, Madrid, Spain (I.F.L.); St. Luke's–Roosevelt Hospital Center, New York, NY (S.M.); Washington University School of Medicine, St. Louis, MO (A.D.W.); Maerkische Kliniken GmbH, Luedenscheid, Germany (B.L.); Massachusetts General Hospital, Harvard Medical School, Boston (J.P.S.)
| | - Bernd Lemke
- From the Virginia Commonwealth University Medical Center, Richmond (K.A.E.); Medical University of South Carolina, Charleston (M.R.G., F.G.S.); Boston Scientific, St. Paul, MN (T.E.M., J.R., K.M.S.); Hospital Puerta de Hierro, Madrid, Spain (I.F.L.); St. Luke's–Roosevelt Hospital Center, New York, NY (S.M.); Washington University School of Medicine, St. Louis, MO (A.D.W.); Maerkische Kliniken GmbH, Luedenscheid, Germany (B.L.); Massachusetts General Hospital, Harvard Medical School, Boston (J.P.S.)
| | - Jagmeet P. Singh
- From the Virginia Commonwealth University Medical Center, Richmond (K.A.E.); Medical University of South Carolina, Charleston (M.R.G., F.G.S.); Boston Scientific, St. Paul, MN (T.E.M., J.R., K.M.S.); Hospital Puerta de Hierro, Madrid, Spain (I.F.L.); St. Luke's–Roosevelt Hospital Center, New York, NY (S.M.); Washington University School of Medicine, St. Louis, MO (A.D.W.); Maerkische Kliniken GmbH, Luedenscheid, Germany (B.L.); Massachusetts General Hospital, Harvard Medical School, Boston (J.P.S.)
| | - Francis G. Spinale
- From the Virginia Commonwealth University Medical Center, Richmond (K.A.E.); Medical University of South Carolina, Charleston (M.R.G., F.G.S.); Boston Scientific, St. Paul, MN (T.E.M., J.R., K.M.S.); Hospital Puerta de Hierro, Madrid, Spain (I.F.L.); St. Luke's–Roosevelt Hospital Center, New York, NY (S.M.); Washington University School of Medicine, St. Louis, MO (A.D.W.); Maerkische Kliniken GmbH, Luedenscheid, Germany (B.L.); Massachusetts General Hospital, Harvard Medical School, Boston (J.P.S.)
| | - Jennifer E. Van Eyk
- From the Virginia Commonwealth University Medical Center, Richmond (K.A.E.); Medical University of South Carolina, Charleston (M.R.G., F.G.S.); Boston Scientific, St. Paul, MN (T.E.M., J.R., K.M.S.); Hospital Puerta de Hierro, Madrid, Spain (I.F.L.); St. Luke's–Roosevelt Hospital Center, New York, NY (S.M.); Washington University School of Medicine, St. Louis, MO (A.D.W.); Maerkische Kliniken GmbH, Luedenscheid, Germany (B.L.); Massachusetts General Hospital, Harvard Medical School, Boston (J.P.S.)
| | - Jeffrey Whitehill
- From the Virginia Commonwealth University Medical Center, Richmond (K.A.E.); Medical University of South Carolina, Charleston (M.R.G., F.G.S.); Boston Scientific, St. Paul, MN (T.E.M., J.R., K.M.S.); Hospital Puerta de Hierro, Madrid, Spain (I.F.L.); St. Luke's–Roosevelt Hospital Center, New York, NY (S.M.); Washington University School of Medicine, St. Louis, MO (A.D.W.); Maerkische Kliniken GmbH, Luedenscheid, Germany (B.L.); Massachusetts General Hospital, Harvard Medical School, Boston (J.P.S.)
| | - Stanislav Weiner
- From the Virginia Commonwealth University Medical Center, Richmond (K.A.E.); Medical University of South Carolina, Charleston (M.R.G., F.G.S.); Boston Scientific, St. Paul, MN (T.E.M., J.R., K.M.S.); Hospital Puerta de Hierro, Madrid, Spain (I.F.L.); St. Luke's–Roosevelt Hospital Center, New York, NY (S.M.); Washington University School of Medicine, St. Louis, MO (A.D.W.); Maerkische Kliniken GmbH, Luedenscheid, Germany (B.L.); Massachusetts General Hospital, Harvard Medical School, Boston (J.P.S.)
| | - Maninder Bedi
- From the Virginia Commonwealth University Medical Center, Richmond (K.A.E.); Medical University of South Carolina, Charleston (M.R.G., F.G.S.); Boston Scientific, St. Paul, MN (T.E.M., J.R., K.M.S.); Hospital Puerta de Hierro, Madrid, Spain (I.F.L.); St. Luke's–Roosevelt Hospital Center, New York, NY (S.M.); Washington University School of Medicine, St. Louis, MO (A.D.W.); Maerkische Kliniken GmbH, Luedenscheid, Germany (B.L.); Massachusetts General Hospital, Harvard Medical School, Boston (J.P.S.)
| | - Joshua Rapkin
- From the Virginia Commonwealth University Medical Center, Richmond (K.A.E.); Medical University of South Carolina, Charleston (M.R.G., F.G.S.); Boston Scientific, St. Paul, MN (T.E.M., J.R., K.M.S.); Hospital Puerta de Hierro, Madrid, Spain (I.F.L.); St. Luke's–Roosevelt Hospital Center, New York, NY (S.M.); Washington University School of Medicine, St. Louis, MO (A.D.W.); Maerkische Kliniken GmbH, Luedenscheid, Germany (B.L.); Massachusetts General Hospital, Harvard Medical School, Boston (J.P.S.)
| | - Kenneth M. Stein
- From the Virginia Commonwealth University Medical Center, Richmond (K.A.E.); Medical University of South Carolina, Charleston (M.R.G., F.G.S.); Boston Scientific, St. Paul, MN (T.E.M., J.R., K.M.S.); Hospital Puerta de Hierro, Madrid, Spain (I.F.L.); St. Luke's–Roosevelt Hospital Center, New York, NY (S.M.); Washington University School of Medicine, St. Louis, MO (A.D.W.); Maerkische Kliniken GmbH, Luedenscheid, Germany (B.L.); Massachusetts General Hospital, Harvard Medical School, Boston (J.P.S.)
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