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Bonsignore MR, La Rovere MT. Sympathetic activation in patients with heart failure and central sleep apnoea: is it friend or foe? Eur Respir J 2023; 61:61/2/2202170. [PMID: 36758996 DOI: 10.1183/13993003.02170-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 11/12/2022] [Indexed: 02/11/2023]
Affiliation(s)
- Maria R Bonsignore
- PROMISE Department, University of Palermo, Palermo, Italy
- IRIB-CNR, Palermo, Italy
- Respiratory Division, V Cervello Hospital, Ospedali Riuniti Villa Sofia Cervello, Palermo, Italy
| | - Maria Teresa La Rovere
- Department of Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS, Istituto Scientifico di Montescano, Montescano, Italy
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A Methodological Perspective on the Function and Assessment of Peripheral Chemoreceptors in Heart Failure: A Review of Data from Clinical Trials. Biomolecules 2022; 12:biom12121758. [PMID: 36551186 PMCID: PMC9775522 DOI: 10.3390/biom12121758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Augmented peripheral chemoreceptor sensitivity (PChS) is a common feature of many sympathetically mediated diseases, among others, and it is an important mechanism of the pathophysiology of heart failure (HF). It is related not only to the greater severity of symptoms, especially to dyspnea and lower exercise tolerance but also to a greater prevalence of complications and poor prognosis. The causes, mechanisms, and impact of the enhanced activity of peripheral chemoreceptors (PChR) in the HF population are subject to intense research. Several methodologies have been established and utilized to assess the PChR function. Each of them presents certain advantages and limitations. Furthermore, numerous factors could influence and modulate the response from PChR in studied subjects. Nevertheless, even with the impressive number of studies conducted in this field, there are still some gaps in knowledge that require further research. We performed a review of all clinical trials in HF human patients, in which the function of PChR was evaluated. This review provides an extensive synthesis of studies evaluating PChR function in the HF human population, including methods used, factors potentially influencing the results, and predictors of increased PChS.
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Stavrakis S, Kulkarni K, Singh JP, Katritsis DG, Armoundas AA. Autonomic Modulation of Cardiac Arrhythmias: Methods to Assess Treatment and Outcomes. JACC Clin Electrophysiol 2021; 6:467-483. [PMID: 32439031 DOI: 10.1016/j.jacep.2020.02.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/06/2020] [Accepted: 02/14/2020] [Indexed: 02/08/2023]
Abstract
The autonomic nervous system plays a central role in the pathogenesis of multiple cardiac arrhythmias, including atrial fibrillation and ventricular tachycardia. As such, autonomic modulation represents an attractive therapeutic approach in these conditions. Notably, autonomic modulation exploits the plasticity of the neural tissue to induce neural remodeling and thus obtain therapeutic benefit. Different forms of autonomic modulation include vagus nerve stimulation, tragus stimulation, renal denervation, baroreceptor activation therapy, and cardiac sympathetic denervation. This review seeks to highlight these autonomic modulation therapeutic modalities, which have shown promise in early preclinical and clinical trials and represent exciting alternatives to standard arrhythmia treatment. We also present an overview of the various methods used to assess autonomic tone, including heart rate variability, skin sympathetic nerve activity, and alternans, which can be used as surrogate markers and predictors of the treatment effect. Although the use of autonomic modulation to treat cardiac arrhythmias is supported by strong preclinical data and preliminary studies in humans, in light of the disappointing results of a number of recent randomized clinical trials of autonomic modulation therapies in heart failure, the need for optimization of the stimulation parameters and rigorous patient selection based on appropriate biomarkers cannot be overemphasized.
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Affiliation(s)
- Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.
| | - Kanchan Kulkarni
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jagmeet P Singh
- Cardiology Division, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Antonis A Armoundas
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.
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Gauthey A, Morra S, van de Borne P, Deriaz D, Maes N, le Polain de Waroux JB. Sympathetic Effect of Auricular Transcutaneous Vagus Nerve Stimulation on Healthy Subjects: A Crossover Controlled Clinical Trial Comparing Vagally Mediated and Active Control Stimulation Using Microneurography. Front Physiol 2020; 11:599896. [PMID: 33343394 PMCID: PMC7744823 DOI: 10.3389/fphys.2020.599896] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/16/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction: Auricular low-level transcutaneous vagus nerve stimulation (aLL-tVNS) has emerged as a promising technology for cardiac arrhythmia management but is still experimental. In this physiological study, we hypothesized that aLL-tVNS modulated the autonomic nervous balance through a reduction of sympathetic tone and an increase in heart rate variability (HRV). We investigated the muscle sympathetic nerve activity (MSNA) recorded by microneurography during vagally mediated aLL-tVNS and active control on healthy volunteers. Methods: In this crossover, double-blind controlled study, healthy men (N = 28; 27 ± 4 years old) were assigned to aLL-tVNS applied to cymba and lobe (active control) of the right ear. Each participant was randomly allocated to the three sequences (5 Hz, 20 Hz, and active control-5 Hz) during one session. MSNA signal was recorded at rest, during voluntarily apnea and aLL-tVNS. Sympathetic activity was expressed as: 1) number of bursts per minute (burst frequency, BF) and 2) MSNA activity calculated as BF x mean burst amplitude and expressed as changes from baseline (%). RR intervals, HRV parameters and sympathetic activity were analyzed during 5 min-baseline, 10 min-stimulation, and 10 min-recovery periods. Mixed regression models were performed to evaluate cymba-(5—20 Hz) effects on the parameters with stimulation. Results: During apnea and compared to baseline, BF and MSNA activity increased (p = 0.002, p = 0.001, respectively). No stimulation effect on RR intervals and HRV parameters were showed excepted a slightly increase of the LF/HF ratio with stimulation in the cymba-5Hz sequence (coef. ± SE: 0.76 ± 0.32%; p = 0.02). During stimulation, reductions from baseline in BF (Coef. ± SE: −4.8 ± 1.1, p < 0.001) was observed but was not statistically different from that one in the active control. Reduction of MSNA activity was not significantly different between sequences. Conclusion: Acute right cymba aLL-tVNS did not induce any overall effects neither on heart rate, HRV nor MSNA variables on healthy subjects when compared to active control. Interestingly, these findings questioned the role of active controls in medical device clinical trials that implied subjective endpoints.
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Affiliation(s)
- Anaïs Gauthey
- Department of Cardiology, Saint-Luc Hospital, Université catholique de Louvain, Brussels, Belgium
| | - Sofia Morra
- Department of Cardiology, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Philippe van de Borne
- Department of Cardiology, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Denis Deriaz
- Department of Biomedical and Preclinical Sciences, Université de Liège, Liège, Belgium
| | - Nathalie Maes
- Department of Biostatistic and Medico-Economic Information, CHU Hospital of Liège, Liège, Belgium
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Xiao PL, Cai C, Zhang P, DeSimone CV, Ernst DK, Yin YH, Chen PS, Cha YM. Cardiac resynchronization therapy modulates peripheral sympathetic activity. Heart Rhythm 2020; 17:1139-1146. [DOI: 10.1016/j.hrthm.2020.02.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 02/18/2020] [Indexed: 01/06/2023]
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Tschöpe C, Kherad B, Klein O, Lipp A, Blaschke F, Gutterman D, Burkhoff D, Hamdani N, Spillmann F, Van Linthout S. Cardiac contractility modulation: mechanisms of action in heart failure with reduced ejection fraction and beyond. Eur J Heart Fail 2019; 21:14-22. [PMID: 30485591 PMCID: PMC6607484 DOI: 10.1002/ejhf.1349] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 08/04/2018] [Accepted: 08/20/2018] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) is responsible for substantial morbidity and mortality and is increasing in prevalence. Although there has been remarkable progress in the treatment of HF with reduced ejection fraction (HFrEF), morbidity and mortality are still substantial. Cardiac contractility modulation (CCM) signals, consisting of biphasic high-voltage bipolar signals delivered to the right ventricular septum during the absolute refractory period, have been shown to improve symptoms, exercise tolerance and quality of life and reduce the rate of HF hospitalizations in patients with ejection fractions (EF) between 25% and 45%. CCM therapy is currently approved in the European Union, China, India, Australia and Brazil for use in symptomatic HFrEF patients with normal or slightly prolonged QRS duration. CCM is particularly beneficial in patients with baseline EF between 35% and 45%, which includes half the range of HF patients with mid-range EFs (HFmrEF). At the cellular level, CCM has been shown in HFrEF patients to improve calcium handling, to reverse the foetal myocyte gene programme associated with HF, and to facilitate reverse remodelling. This review highlights the preclinical and clinical literature related to CCM in HFrEF and HFmrEF and outlines the potential of CCM for HF with preserved EF, concluding that CCM may fill an important unmet need in the therapeutic approach to HF across the range of EFs.
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Affiliation(s)
- Carsten Tschöpe
- Department of CardiologyUniversitätsmedizin Berlin, Campus Virchow Klinikum (CVK)BerlinGermany
- Berlin Center for Regenerative Therapies (BCRT), Campus Virchow Klinikum (CVK)Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site BerlinBerlinGermany
| | - Behrouz Kherad
- Department of CardiologyUniversitätsmedizin Berlin, Campus Virchow Klinikum (CVK)BerlinGermany
| | - Oliver Klein
- Department of CardiologyUniversitätsmedizin Berlin, Campus Virchow Klinikum (CVK)BerlinGermany
- Berlin Center for Regenerative Therapies (BCRT), Campus Virchow Klinikum (CVK)Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site BerlinBerlinGermany
| | - Axel Lipp
- Department of NeurologyUniversitätsmedizin Berlin, CVKBerlinGermany
| | - Florian Blaschke
- Department of CardiologyUniversitätsmedizin Berlin, Campus Virchow Klinikum (CVK)BerlinGermany
| | | | | | - Nazha Hamdani
- Department of Cardiovascular PhysiologyRuhr University BochumBochumGermany
| | - Frank Spillmann
- Department of CardiologyUniversitätsmedizin Berlin, Campus Virchow Klinikum (CVK)BerlinGermany
| | - Sophie Van Linthout
- Department of CardiologyUniversitätsmedizin Berlin, Campus Virchow Klinikum (CVK)BerlinGermany
- Berlin Center for Regenerative Therapies (BCRT), Campus Virchow Klinikum (CVK)Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site BerlinBerlinGermany
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Shelton RS, Ogawa M, Lin H, Shen C, Wong J, Lin SF, Chen PS, Everett TH. Effects of Stellate Ganglion Cryoablation on Subcutaneous Nerve Activity and Atrial Tachyarrhythmias in a Canine Model of Pacing-Induced Heart Failure. JACC Clin Electrophysiol 2018; 4:686-695. [PMID: 29798799 DOI: 10.1016/j.jacep.2018.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 01/23/2018] [Accepted: 02/08/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study aimed to test the hypothesis that subcutaneous nerve activity (SCNA) can adequately estimate the cardiac sympathetic tone and the effects of cryoablation of the stellate ganglion in dogs with pacing-induced heart failure (HF). BACKGROUND Recording of SCNA is a new method to estimate sympathetic tone in dogs. HF is known to increase sympathetic tone and atrial arrhythmias. METHODS Twelve dogs with pacing-induced HF were studied using implanted radiotransmitters to record the stellate ganglia nerve activity (SGNA), vagal nerve activity, and SCNA. Of these, 6 dogs (ablation group) underwent bilateral stellate ganglia cryoablation before the rapid ventricular pacing; the remaining 6 dogs (control group) had rapid ventricular pacing only. In both groups, SCNA was compared with SGNA and the occurrence of arrhythmias. RESULTS SCNA invariably increased before the 360 identified atrial tachyarrhythmia episodes in the 6 control dogs before and after HF induction. SCNA and SGNA correlated in all dogs with an average correlation coefficient of 0.64 (95% confidence interval: 0.58 to 0.70). Cryoablation of bilateral stellate ganglia significantly reduced SCNA from 0.34 ± 0.033 μV to 0.25 ± 0.028 μV (p = 0.03) and eliminated all atrial tachyarrhythmias. CONCLUSIONS SCNA can be used to estimate cardiac sympathetic tone in dogs with pacing-induced HF. Cryoablation of the stellate ganglia reduced SCNA and arrhythmia vulnerability.
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Affiliation(s)
- Richard S Shelton
- Krannert Institute of Cardiology and the Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Masahiro Ogawa
- Krannert Institute of Cardiology and the Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Hongbo Lin
- Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Changyu Shen
- Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Johnson Wong
- Krannert Institute of Cardiology and the Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Shien-Fong Lin
- Institute of Biomedical Engineering, National Chiao Tung University, Hsin-Chu, Taiwan
| | - Peng-Sheng Chen
- Krannert Institute of Cardiology and the Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Thomas H Everett
- Krannert Institute of Cardiology and the Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
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Abstract
INTRODUCTION A dysregulated sympathetic nervous system is a major factor in the development and progression of cardiovascular disease; thus, understanding the mechanism and function of the sympathetic nervous system and appropriately regulating sympathetic activity to treat various cardiovascular diseases are crucial. Areas covered: This review focused on previous studies in managing hypertension, atrial fibrillation, coronary artery disease, heart failure, and perioperative management with sympathetic blockade. We reviewed both pharmacological and non-pharmacological management. Expert commentary: Chronic sympathetic nervous system activation is related to several cardiovascular diseases mediated by various pathways. Advancement in measuring sympathetic activity makes visualizing noninvasively and evaluating the activation level even in single fibers possible. Evidence suggests that sympathetic blockade still has a role in managing hypertension and controlling the heart rate in atrial fibrillation. For ischemic heart disease, beta-adrenergic receptor antagonists have been considered a milestone drug to control symptoms and prevent long-term adverse effects, although its clinical implication has become less potent in the era of successful revascularization. Owing to pathologic involvement of sympathetic nervous system activation in heart failure progression, sympathetic blockade has proved its value in improving the clinical course of patients with heart failure.
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Affiliation(s)
- Chan Soon Park
- a Department of Internal Medicine , Seoul National University College of Medicine, Seoul National University Hospital , Seoul , Korea
| | - Hae-Young Lee
- a Department of Internal Medicine , Seoul National University College of Medicine, Seoul National University Hospital , Seoul , Korea
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Abstract
Dyssynchronous contraction of the ventricle significantly worsens morbidity and mortality in patients with heart failure (HF). Approximately one-third of patients with HF have cardiac dyssynchrony and are candidates for cardiac resynchronization therapy (CRT). The initial understanding of dyssynchrony and CRT was in terms of global mechanics and hemodynamics, but lack of clinical benefit in a sizable subgroup of recipients who appear otherwise appropriate has challenged this paradigm. This article reviews current understanding of these cellular and subcellular mechanisms, arguing that these aspects are key to improving CRT use, as well as translating its benefits to a wider HF population.
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Affiliation(s)
- Jonathan A Kirk
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Ross Research Building, Room 858, 720 Rutland Avenue, Baltimore, MD 21205, USA.
| | - David A Kass
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Ross Research Building, Room 858, 720 Rutland Avenue, Baltimore, MD 21205, USA
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Nobre TS, Antunes-Correa LM, Groehs RV, Alves MJNN, Sarmento AO, Bacurau AV, Urias U, Alves GB, Rondon MUPB, Brum PC, Martinelli M, Middlekauff HR, Negrao CE. Exercise training improves neurovascular control and calcium cycling gene expression in patients with heart failure with cardiac resynchronization therapy. Am J Physiol Heart Circ Physiol 2016; 311:H1180-H1188. [PMID: 27591218 PMCID: PMC6347073 DOI: 10.1152/ajpheart.00275.2016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 08/31/2016] [Indexed: 01/06/2023]
Abstract
Heart failure (HF) is characterized by decreased exercise capacity, attributable to neurocirculatory and skeletal muscle factors. Cardiac resynchronization therapy (CRT) and exercise training have each been shown to decrease muscle sympathetic nerve activity (MSNA) and increase exercise capacity in patients with HF. We hypothesized that exercise training in the setting of CRT would further reduce MSNA and vasoconstriction and would increase Ca2+-handling gene expression in skeletal muscle in patients with chronic systolic HF. Thirty patients with HF, ejection fraction <35% and CRT for 1 mo, were randomized into two groups: exercise-trained (ET, n = 14) and untrained (NoET, n = 16) groups. The following parameters were compared at baseline and after 4 mo in each group: V̇o2 peak, MSNA (microneurography), forearm blood flow, and Ca2+-handling gene expression in vastus lateralis muscle. After 4 mo, exercise duration and V̇o2 peak were significantly increased in the ET group (P = 0.04 and P = 0.01, respectively), but not in the NoET group. MSNA was significantly reduced in the ET (P = 0.001), but not in NoET, group. Similarly, forearm vascular conductance significantly increased in the ET (P = 0.0004), but not in the NoET, group. The expression of the Na+/Ca2+ exchanger (P = 0.01) was increased, and ryanodine receptor expression was preserved in ET compared with NoET. In conclusion, the exercise training in the setting of CRT improves exercise tolerance and neurovascular control and alters Ca2+-handling gene expression in the skeletal muscle of patients with systolic HF. These findings highlight the importance of including exercise training in the treatment of patients with HF even following CRT.
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Affiliation(s)
- Thais S Nobre
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | | | - Raphaela V Groehs
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | | | - Adriana O Sarmento
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Aline V Bacurau
- School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
| | - Ursula Urias
- School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
| | - Guilherme B Alves
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | | | - Patrícia C Brum
- School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
| | - Martino Martinelli
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Holly R Middlekauff
- Department of Medicine (Cardiology) and Physiology, Geffen School of Medicine at UCLA, University of California, Los Angeles, California
| | - Carlos E Negrao
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil;
- School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
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Fernandes Serôdio J, Martins Oliveira M, Matoso Laranjo S, Tavares C, Silva Cunha P, Abreu A, Branco L, Alves S, Rocha I, Cruz Ferreira R. The arterial baroreflex effectiveness index in risk stratification of chronic heart failure patients who are candidates for cardiac resynchronization therapy. Rev Port Cardiol 2016; 35:343-50. [PMID: 27255174 DOI: 10.1016/j.repc.2015.11.021] [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: 09/01/2015] [Accepted: 11/22/2015] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Baroreflex function is an independent marker of prognosis in heart failure (HF). However, little is known about its relation to response to cardiac resynchronization therapy (CRT). The aim of this study is to assess arterial baroreflex function in HF patients who are candidates for CRT. METHODS The study population consisted of 25 patients with indication for CRT, aged 65±10 years, NYHA functional class ≥III in 52%, QRS width 159±15 ms, left ventricular ejection fraction (LVEF) 29±5%, left ventricular end-systolic volume (LVESV) 150±48 ml, B-type natriuretic peptide (BNP) 357±270 pg/ml, and peak oxygen consumption (peak VO2) 18.4±5.0 ml/kg/min. An orthostatic tilt test was performed to assess the baroreflex effectiveness index (BEI) by the sequence method. This group was compared with 15 age-matched healthy individuals. RESULTS HF patients showed a significantly depressed BEI during tilt (31±12% vs. 49±18%, p=0.001). A lower BEI was associated with higher BNP (p=0.038), lower peak VO2 (p=0.048), and higher LVESV (p=0.031). By applying a cut-off value of 25% for BEI, two clusters of patients were identified: lower risk cluster (BEI >25%) QRS 153 ms, LVESV 129 ml, BNP 146 pg/ml, peak VO2 19.0 ml/kg/min; and higher risk cluster (IEB ≤25%) QRS 167 ms, LVESV 189 ml, BNP 590 pg/ml, peak VO2 16.2 ml/kg/min. CONCLUSIONS Candidates for CRT show depressed arterial baroreflex function. Lower BEI was observed in high-risk HF patients. Baroreflex function correlated closely with other clinical HF parameters. Therefore, BEI may improve risk stratification in HF patients undergoing CRT.
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Affiliation(s)
| | - Mário Martins Oliveira
- Institute of Physiology, Faculty of Medicine, University of Lisbon, Lisbon, Portugal; Department of Cardiology, Santa Marta Hospital, Lisbon, Portugal
| | - Sérgio Matoso Laranjo
- Institute of Physiology, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Cristiano Tavares
- Institute of Physiology, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | | | - Ana Abreu
- Department of Cardiology, Santa Marta Hospital, Lisbon, Portugal
| | - Luísa Branco
- Department of Cardiology, Santa Marta Hospital, Lisbon, Portugal
| | - Sandra Alves
- Department of Cardiology, Santa Marta Hospital, Lisbon, Portugal
| | - Isabel Rocha
- Institute of Physiology, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
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Fernandes Serôdio J, Martins Oliveira M, Matoso Laranjo S, Tavares C, Silva Cunha P, Abreu A, Branco L, Alves S, Rocha I, Cruz Ferreira R. The arterial baroreflex effectiveness index in risk stratification of chronic heart failure patients who are candidates for cardiac resynchronization therapy. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.repce.2015.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
Dyssynchronous contraction of the ventricle significantly worsens morbidity and mortality in patients with heart failure (HF). Approximately one-third of patients with HF have cardiac dyssynchrony and are candidates for cardiac resynchronization therapy (CRT). The initial understanding of dyssynchrony and CRT was in terms of global mechanics and hemodynamics, but lack of clinical benefit in a sizable subgroup of recipients who appear otherwise appropriate has challenged this paradigm. This article reviews current understanding of these cellular and subcellular mechanisms, arguing that these aspects are key to improving CRT use, as well as translating its benefits to a wider HF population.
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Affiliation(s)
- Jonathan A Kirk
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Ross Research Building, Room 858, 720 Rutland Avenue, Baltimore, MD 21205, USA.
| | - David A Kass
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Ross Research Building, Room 858, 720 Rutland Avenue, Baltimore, MD 21205, USA
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14
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Ghotbi AA, Sander M, Køber L, Philbert BT, Gustafsson F, Hagemann C, Kjær A, Jacobsen PK. Optimal Cardiac Resynchronization Therapy Pacing Rate in Non-Ischemic Heart Failure Patients: A Randomized Crossover Pilot Trial. PLoS One 2015; 10:e0138124. [PMID: 26382243 PMCID: PMC4575161 DOI: 10.1371/journal.pone.0138124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 08/21/2015] [Indexed: 12/27/2022] Open
Abstract
Background The optimal pacing rate during cardiac resynchronization therapy (CRT) is unknown. Therefore, we investigated the impact of changing basal pacing frequencies on autonomic nerve function, cardiopulmonary exercise capacity and self-perceived quality of life (QoL). Methods Twelve CRT patients with non-ischemic heart failure (NYHA class II–III) were enrolled in a randomized, double-blind, crossover trial, in which the basal pacing rate was set at DDD-60 and DDD-80 for 3 months (DDD-R for 2 patients). At baseline, 3 months and 6 months, we assessed sympathetic nerve activity by microneurography (MSNA), peak oxygen consumption (pVO2), N-terminal pro-brain natriuretic peptide (p-NT-proBNP), echocardiography and QoL. Results DDD-80 pacing for 3 months increased the mean heart rate from 77.3 to 86.1 (p = 0.001) and reduced sympathetic activity compared to DDD-60 (51±14 bursts/100 cardiac cycles vs. 64±14 bursts/100 cardiac cycles, p<0.05). The mean pVO2 increased non-significantly from 15.6±6 mL/min/kg during DDD-60 to 16.7±6 mL/min/kg during DDD-80, and p-NT-proBNP remained unchanged. The QoL score indicated that DDD-60 was better tolerated. Conclusion In CRT patients with non-ischemic heart failure, 3 months of DDD-80 pacing decreased sympathetic outflow (burst incidence only) compared to DDD-60 pacing. However, Qol scores were better during the lower pacing rate. Further and larger scale investigations are indicated. Trial Registration ClinicalTrials.gov NCT02258061
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Affiliation(s)
- Adam Ali Ghotbi
- The Heart Center, Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
- * E-mail:
| | - Mikael Sander
- The Heart Center, Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Køber
- The Heart Center, Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Berit Th. Philbert
- The Heart Center, Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Finn Gustafsson
- The Heart Center, Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Christoffer Hagemann
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Andreas Kjær
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter K. Jacobsen
- The Heart Center, Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
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PIERAGNOLI PAOLO, PEREGO GIOVANNIBATTISTA, RICCIARDI GIUSEPPE, SACCHI STEFANIA, PADELETTI MARGHERITA, MICHELUCCI ANTONIO, VALSECCHI SERGIO, PADELETTI LUIGI. Cardiac Resynchronization Therapy Acutely Improves Ventricular-Arterial Coupling by Reducing the Arterial Load: Assessment by Pressure-Volume Loops. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:431-7. [DOI: 10.1111/pace.12585] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 11/21/2014] [Accepted: 12/21/2014] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | | | | | | | | | - LUIGI PADELETTI
- University of Florence; Florence Italy
- Gavazzeni Hospital; Bergamo Italy
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Abstract
The pathophysiology of heart failure (HF) is characterized by hemodynamic abnormalities that result in neurohormonal activation and autonomic imbalance with increase in sympathetic activity and withdrawal of vagal activity. Alterations in receptor activation from this autonomic imbalance may have profound effects on cardiac function and structure. Inhibition of the sympathetic drive to the heart through β-receptor blockade has become a standard component of therapy for HF with a dilated left ventricle because of its effectiveness in inhibiting the ventricular structural remodeling process and in prolonging life. Several devices for selective modulation of sympathetic and vagal activity have recently been developed in an attempt to alter the natural history of HF. The optimal counteraction of the excessive sympathetic activity is still unclear. A profound decrease in adrenergic support with excessive blockade of the sympathetic nervous system may result in adverse outcomes in clinical HF. In this review, we analyze the data supporting a contributory role of the autonomic functional alterations on the course of HF, the techniques used to assess autonomic nervous system activity, the evidence for clinical effectiveness of pharmacological and device interventions, and the potential future role of autonomic nervous system modifiers in the management of this syndrome.
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Affiliation(s)
- Viorel G Florea
- From the Minneapolis VA Health Care System, Section of Cardiology (V.G.F.) and Rasmussen Center for Cardiovascular Disease Prevention, Department of Medicine (J.N.C.), University of Minnesota Medical School
| | - Jay N Cohn
- From the Minneapolis VA Health Care System, Section of Cardiology (V.G.F.) and Rasmussen Center for Cardiovascular Disease Prevention, Department of Medicine (J.N.C.), University of Minnesota Medical School.
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Valzania C, Gadler F, Boriani G, Eriksson MJ. Effects of cardiac resynchronization therapy on myocardial contractile reserve during exercise. Eur J Heart Fail 2014; 13:406-11. [DOI: 10.1093/eurjhf/hfq220] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Cinzia Valzania
- Institute of Cardiology, University of Bologna; via Massarenti 9 40138 Bologna Italy
| | - Fredrik Gadler
- Department of Cardiology; Karolinska University Hospital; Stockholm Sweden
- Department of Medicine; Karolinska Institutet; Stockholm Sweden
| | - Giuseppe Boriani
- Institute of Cardiology, University of Bologna; via Massarenti 9 40138 Bologna Italy
| | - Maria J. Eriksson
- Department of Clinical Physiology; Karolinska University Hospital; Stockholm Sweden
- Department of Molecular Medicine and Surgery; Karolinska Institutet; Stockholm Sweden
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Patel HC, Rosen SD, Lindsay A, Hayward C, Lyon AR, di Mario C. Targeting the autonomic nervous system: Measuring autonomic function and novel devices for heart failure management. Int J Cardiol 2013; 170:107-17. [DOI: 10.1016/j.ijcard.2013.10.058] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 09/03/2013] [Accepted: 10/19/2013] [Indexed: 01/08/2023]
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19
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Abstract
Patients with heart failure and decreased function frequently develop discoordinate contraction because of electric activation delay. Often termed dyssynchrony, this further decreases systolic function and chamber efficiency and worsens morbidity and mortality. In the mid- 1990s, a pacemaker-based treatment termed cardiac resynchronization therapy (CRT) was developed to restore mechanical synchrony by electrically activating both right and left sides of the heart. It is a major therapeutic advance for the new millennium. Acute chamber effects of CRT include increased cardiac output and mechanical efficiency and reduced mitral regurgitation, whereas reduction in chamber volumes ensues more chronically. Patient candidates for CRT have a prolonged QRS duration and discoordinate wall motion, although other factors may also be important because ≈30% of such selected subjects do not respond to the treatment. In contrast to existing pharmacological inotropes, CRT both acutely and chronically increases cardiac systolic function and work, yet it also reduces long-term mortality. Recent studies reveal unique molecular and cellular changes from CRT that may also contribute to this success. Heart failure with dyssynchrony displays decreased myocyte and myofilament function, calcium handling, β-adrenergic responsiveness, mitochondrial ATP synthase activity, cell survival signaling, and other changes. CRT reverses many of these abnormalities often by triggering entirely new pathways. In this review, we discuss chamber, circulatory, and basic myocardial effects of dyssynchrony and CRT in the failing heart, and we highlight new research aiming to better target and implement CRT, as well as leverage its molecular effects.
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Affiliation(s)
- Jonathan A Kirk
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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20
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Zócalo Y, Bia D, Armentano RL, González-Moreno J, Varela G, Calleriza F, Reyes-Caorsi W. Resynchronization improves heart-arterial coupling reducing arterial load determinants. ACTA ACUST UNITED AC 2012; 15:554-65. [DOI: 10.1093/europace/eus285] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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21
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Cho H, Barth AS, Tomaselli GF. Basic science of cardiac resynchronization therapy: molecular and electrophysiological mechanisms. Circ Arrhythm Electrophysiol 2012; 5:594-603. [PMID: 22715238 DOI: 10.1161/circep.111.962746] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Hana Cho
- Department of Physiology, Sungkyunkwan University School of Medicine, Suwon, Korea.
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22
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Shalaby A, Atwood CW, Selzer F, Suffoletto M, Gorcsan Iii J, Strollo P. Cardiac Resynchronization Therapy and Obstructive Sleep-Related Breathing Disorder in Patients with Congestive Heart Failure. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 34:593-603. [PMID: 21609340 DOI: 10.1111/j.1540-8159.2010.03015.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Alaa Shalaby
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.
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23
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Cha YM, Chareonthaitawee P, Dong YX, Kemp BJ, Oh JK, Miyazaki C, Hayes DL, Rea RF, Asirvatham SJ, Webster TL, Dalzell CM, Hodge DO, Herges RM, Yong YZ, Zhang Y, Chen PS. Cardiac Sympathetic Reserve and Response to Cardiac Resynchronization Therapy. Circ Heart Fail 2011; 4:339-44. [DOI: 10.1161/circheartfailure.110.959858] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Yong-Mei Cha
- From the Division of Cardiovascular Diseases (Y.-M.C., P.C., J.K.O., C.M., D.L.H., R.F.R., S.J.A., T.L.W., C.M.D.), the Department of Radiology, (B.J.K.), and the Division of Biomedical Statistics and Informatics (D.O.H., R.M.H.), Mayo Clinic, Rochester, MN; the Department of Cardiology (Y.-X.D., Y.-z.Y.), the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; and the Krannert Institute of Cardiology (Y.Z., P.-S.C.), Indiana University School of Medicine, Indianapolis, IN
| | - Panithaya Chareonthaitawee
- From the Division of Cardiovascular Diseases (Y.-M.C., P.C., J.K.O., C.M., D.L.H., R.F.R., S.J.A., T.L.W., C.M.D.), the Department of Radiology, (B.J.K.), and the Division of Biomedical Statistics and Informatics (D.O.H., R.M.H.), Mayo Clinic, Rochester, MN; the Department of Cardiology (Y.-X.D., Y.-z.Y.), the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; and the Krannert Institute of Cardiology (Y.Z., P.-S.C.), Indiana University School of Medicine, Indianapolis, IN
| | - Ying-Xue Dong
- From the Division of Cardiovascular Diseases (Y.-M.C., P.C., J.K.O., C.M., D.L.H., R.F.R., S.J.A., T.L.W., C.M.D.), the Department of Radiology, (B.J.K.), and the Division of Biomedical Statistics and Informatics (D.O.H., R.M.H.), Mayo Clinic, Rochester, MN; the Department of Cardiology (Y.-X.D., Y.-z.Y.), the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; and the Krannert Institute of Cardiology (Y.Z., P.-S.C.), Indiana University School of Medicine, Indianapolis, IN
| | - Bradley J. Kemp
- From the Division of Cardiovascular Diseases (Y.-M.C., P.C., J.K.O., C.M., D.L.H., R.F.R., S.J.A., T.L.W., C.M.D.), the Department of Radiology, (B.J.K.), and the Division of Biomedical Statistics and Informatics (D.O.H., R.M.H.), Mayo Clinic, Rochester, MN; the Department of Cardiology (Y.-X.D., Y.-z.Y.), the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; and the Krannert Institute of Cardiology (Y.Z., P.-S.C.), Indiana University School of Medicine, Indianapolis, IN
| | - Jae K. Oh
- From the Division of Cardiovascular Diseases (Y.-M.C., P.C., J.K.O., C.M., D.L.H., R.F.R., S.J.A., T.L.W., C.M.D.), the Department of Radiology, (B.J.K.), and the Division of Biomedical Statistics and Informatics (D.O.H., R.M.H.), Mayo Clinic, Rochester, MN; the Department of Cardiology (Y.-X.D., Y.-z.Y.), the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; and the Krannert Institute of Cardiology (Y.Z., P.-S.C.), Indiana University School of Medicine, Indianapolis, IN
| | - Chinami Miyazaki
- From the Division of Cardiovascular Diseases (Y.-M.C., P.C., J.K.O., C.M., D.L.H., R.F.R., S.J.A., T.L.W., C.M.D.), the Department of Radiology, (B.J.K.), and the Division of Biomedical Statistics and Informatics (D.O.H., R.M.H.), Mayo Clinic, Rochester, MN; the Department of Cardiology (Y.-X.D., Y.-z.Y.), the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; and the Krannert Institute of Cardiology (Y.Z., P.-S.C.), Indiana University School of Medicine, Indianapolis, IN
| | - David L. Hayes
- From the Division of Cardiovascular Diseases (Y.-M.C., P.C., J.K.O., C.M., D.L.H., R.F.R., S.J.A., T.L.W., C.M.D.), the Department of Radiology, (B.J.K.), and the Division of Biomedical Statistics and Informatics (D.O.H., R.M.H.), Mayo Clinic, Rochester, MN; the Department of Cardiology (Y.-X.D., Y.-z.Y.), the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; and the Krannert Institute of Cardiology (Y.Z., P.-S.C.), Indiana University School of Medicine, Indianapolis, IN
| | - Robert F. Rea
- From the Division of Cardiovascular Diseases (Y.-M.C., P.C., J.K.O., C.M., D.L.H., R.F.R., S.J.A., T.L.W., C.M.D.), the Department of Radiology, (B.J.K.), and the Division of Biomedical Statistics and Informatics (D.O.H., R.M.H.), Mayo Clinic, Rochester, MN; the Department of Cardiology (Y.-X.D., Y.-z.Y.), the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; and the Krannert Institute of Cardiology (Y.Z., P.-S.C.), Indiana University School of Medicine, Indianapolis, IN
| | - Samuel J. Asirvatham
- From the Division of Cardiovascular Diseases (Y.-M.C., P.C., J.K.O., C.M., D.L.H., R.F.R., S.J.A., T.L.W., C.M.D.), the Department of Radiology, (B.J.K.), and the Division of Biomedical Statistics and Informatics (D.O.H., R.M.H.), Mayo Clinic, Rochester, MN; the Department of Cardiology (Y.-X.D., Y.-z.Y.), the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; and the Krannert Institute of Cardiology (Y.Z., P.-S.C.), Indiana University School of Medicine, Indianapolis, IN
| | - Tracy L. Webster
- From the Division of Cardiovascular Diseases (Y.-M.C., P.C., J.K.O., C.M., D.L.H., R.F.R., S.J.A., T.L.W., C.M.D.), the Department of Radiology, (B.J.K.), and the Division of Biomedical Statistics and Informatics (D.O.H., R.M.H.), Mayo Clinic, Rochester, MN; the Department of Cardiology (Y.-X.D., Y.-z.Y.), the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; and the Krannert Institute of Cardiology (Y.Z., P.-S.C.), Indiana University School of Medicine, Indianapolis, IN
| | - Connie M. Dalzell
- From the Division of Cardiovascular Diseases (Y.-M.C., P.C., J.K.O., C.M., D.L.H., R.F.R., S.J.A., T.L.W., C.M.D.), the Department of Radiology, (B.J.K.), and the Division of Biomedical Statistics and Informatics (D.O.H., R.M.H.), Mayo Clinic, Rochester, MN; the Department of Cardiology (Y.-X.D., Y.-z.Y.), the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; and the Krannert Institute of Cardiology (Y.Z., P.-S.C.), Indiana University School of Medicine, Indianapolis, IN
| | - David O. Hodge
- From the Division of Cardiovascular Diseases (Y.-M.C., P.C., J.K.O., C.M., D.L.H., R.F.R., S.J.A., T.L.W., C.M.D.), the Department of Radiology, (B.J.K.), and the Division of Biomedical Statistics and Informatics (D.O.H., R.M.H.), Mayo Clinic, Rochester, MN; the Department of Cardiology (Y.-X.D., Y.-z.Y.), the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; and the Krannert Institute of Cardiology (Y.Z., P.-S.C.), Indiana University School of Medicine, Indianapolis, IN
| | - Regina M. Herges
- From the Division of Cardiovascular Diseases (Y.-M.C., P.C., J.K.O., C.M., D.L.H., R.F.R., S.J.A., T.L.W., C.M.D.), the Department of Radiology, (B.J.K.), and the Division of Biomedical Statistics and Informatics (D.O.H., R.M.H.), Mayo Clinic, Rochester, MN; the Department of Cardiology (Y.-X.D., Y.-z.Y.), the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; and the Krannert Institute of Cardiology (Y.Z., P.-S.C.), Indiana University School of Medicine, Indianapolis, IN
| | - Yan-zhong Yong
- From the Division of Cardiovascular Diseases (Y.-M.C., P.C., J.K.O., C.M., D.L.H., R.F.R., S.J.A., T.L.W., C.M.D.), the Department of Radiology, (B.J.K.), and the Division of Biomedical Statistics and Informatics (D.O.H., R.M.H.), Mayo Clinic, Rochester, MN; the Department of Cardiology (Y.-X.D., Y.-z.Y.), the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; and the Krannert Institute of Cardiology (Y.Z., P.-S.C.), Indiana University School of Medicine, Indianapolis, IN
| | - Yanhua Zhang
- From the Division of Cardiovascular Diseases (Y.-M.C., P.C., J.K.O., C.M., D.L.H., R.F.R., S.J.A., T.L.W., C.M.D.), the Department of Radiology, (B.J.K.), and the Division of Biomedical Statistics and Informatics (D.O.H., R.M.H.), Mayo Clinic, Rochester, MN; the Department of Cardiology (Y.-X.D., Y.-z.Y.), the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; and the Krannert Institute of Cardiology (Y.Z., P.-S.C.), Indiana University School of Medicine, Indianapolis, IN
| | - Peng-Sheng Chen
- From the Division of Cardiovascular Diseases (Y.-M.C., P.C., J.K.O., C.M., D.L.H., R.F.R., S.J.A., T.L.W., C.M.D.), the Department of Radiology, (B.J.K.), and the Division of Biomedical Statistics and Informatics (D.O.H., R.M.H.), Mayo Clinic, Rochester, MN; the Department of Cardiology (Y.-X.D., Y.-z.Y.), the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; and the Krannert Institute of Cardiology (Y.Z., P.-S.C.), Indiana University School of Medicine, Indianapolis, IN
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LEYVA FRANCISCO, FOLEY PAULWX, CHALIL SHAJIL, IRWIN NICK, SMITH RUSSELLEA. Female Gender is Associated with a Better Outcome after Cardiac Resynchronization Therapy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 34:82-8. [DOI: 10.1111/j.1540-8159.2010.02909.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Chakir K, Kass DA. Rethinking Resynch: Exploring Mechanisms of Cardiac Resynchroniztion Beyond Wall Motion Control. ACTA ACUST UNITED AC 2010; 7:e103-e107. [PMID: 21278834 DOI: 10.1016/j.ddmec.2010.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Cardiac resynchronization (CRT) is a widely used clinical treatment for heart failure patients with depressed function and discoordinate contraction due to conduction delay. It is unique among heart failure treatments as it both acutely and chronically enhances systolic function yet also prolongs survival. While improved chamber mechano-energetics has been considered a primary mechanism for CRT benefit, new animal model data are revealing novel and in many instances unique cellular and molecular modifications from the treatment. Examples of these changes are the reversal of marked regional heterogeneity of the transcriptome and stress kinase signaling, improved ion channel function involved with electrical repolarization, enhanced sarcomere function and calcium handling and upregulation of beta-adrenergic responses, and improved mitochondrial energetic efficiency associated with targeted changes in the mitochondrial proteome. Exploration of these mechanisms may reveal key insights into how CRT can indeed get the failing heart to contract more and perform more work, yet not worsen long-term failure. These changes may provide a more biological marker for both the appropriate patients for CRT as well as point the way for new therapeutic avenues for heart failure in general.
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Affiliation(s)
- Khalid Chakir
- Division of Cardiology Department of Medicine The Johns Hopkins University Medical Institutions Baltimore, Maryland
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Franchitto N, Despas F, Labrunée M, Roncalli J, Boveda S, Galinier M, Senard JM, Pathak A. Tonic chemoreflex activation contributes to increased sympathetic nerve activity in heart failure-related anemia. Hypertension 2010; 55:1012-7. [PMID: 20194300 DOI: 10.1161/hypertensionaha.109.146779] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sympathetic activation contributes to both the initiation and progression of heart failure. The role of anemia in determining sympathetic overactivity in chronic heart failure (CHF) patients is unknown. We tested the hypothesis that, in CHF patients, anemia could lead to increased sympathetic activity through tonic activation of excitatory chemoreceptor afferents. We conducted a double-blind, randomized, vehicle-controlled study to examine the effect of chemoreflex deactivation on muscle sympathetic nerve activity in CHF patients with and without anemia. We compared the effect of breathing 100% oxygen for 15 minutes in 18 stable CHF patients with anemia and 18 control CHF patients matched for age, sex, blood pressure, and body mass index. Baseline muscle sympathetic nerve activity was significantly elevated in CHF patients with anemia compared with patients with CHF alone (56.0+/-3.2 versus 45.5+/-3.1 bursts per minute; P<0.0237). Administration of 100% oxygen led to a significant decrease in muscle sympathetic nerve activity in CHF patients with anemia (from 56.0+/-3.4 to 50.9+/-3.2 bursts per minute; P<0.0019). In contrast, neither room air nor 100% oxygen changed muscle sympathetic nerve activity or hemodynamics in patients with CHF alone. We report for the first time direct evidence of increased sympathetic nerve traffic in patients with CHF-related anemia. Sympathetic hyperactivity in patients with CHF and anemia is partially chemoreflex mediated and could explain how anemia contributes to the progression of CHF and increases morbidity and mortality in these patients.
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Affiliation(s)
- Nicolas Franchitto
- Institut National de la Santé et de la Recherche Médicale U858, Toulouse, France.
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Gademan MGJ, van Bommel RJ, Borleffs CJW, Man S, Haest JCW, Schalij MJ, van der Wall EE, Bax JJ, Swenne CA. Biventricular pacing-induced acute response in baroreflex sensitivity has predictive value for midterm response to cardiac resynchronization therapy. Am J Physiol Heart Circ Physiol 2009; 297:H233-7. [DOI: 10.1152/ajpheart.00113.2009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In a previous study we demonstrated that the institution of biventricular pacing in chronic heart failure (CHF) acutely facilitates the arterial baroreflex. The arterial baroreflex has important prognostic value in CHF. We hypothesized that the acute response in baroreflex sensitivity (BRS) after the institution of cardiac resynchronization therapy (CRT) has predictive value for midterm response. One day after implantation of a CRT device in 33 CHF patients (27 male/6 female; age, 66.5 ± 9.5 yr; left ventricular ejection fraction, 28 ± 7%) we measured noninvasive BRS and heart rate variability (HRV) in two conditions: CRT device switched on and switched off (on/off order randomized). Echocardiography was performed before implantation (baseline) and 6 mo after implantation (follow-up). CRT responders were defined as patients in whom left ventricular end-systolic volume at follow-up had decreased by ≥15%. Responders (69.7%) and nonresponders (30.3%) had similar baseline characteristics. In responders, CRT increased BRS by 30% ( P = 0.03); this differed significantly ( P = 0.02) from the average BRS change (−2%) in the nonresponders. CRT also increased HRV by 30% in responders ( P = 0.02), but there was no significant difference found compared with the increase in HRV (8%) in the nonresponders. Receiver-operating characteristic curve analysis revealed that the percent BRS increase had predictive value for the discrimination of responders and nonresponders (area under the curve, 0.69; 95% confidence interval, 0.51–0.87; maximal accuracy, 0.70). Our study demonstrates that a CRT-induced acute BRS increase has predictive value for the echocardiographic response to CRT. This finding suggests that the autonomic nervous system is actively involved in CRT-related reverse remodeling.
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WANG RUXING, GUO TAO, LI XIAORONG. BNP/NT-ProBNP and Cardiac Pacing: A Review. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:794-9. [DOI: 10.1111/j.1540-8159.2009.02369.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Chakir K, Daya SK, Aiba T, Tunin RS, Dimaano VL, Abraham TP, Jaques-Robinson KM, Jacques K, Lai EW, Pacak K, Zhu WZ, Xiao RP, Tomaselli GF, Kass DA. Mechanisms of enhanced beta-adrenergic reserve from cardiac resynchronization therapy. Circulation 2009; 119:1231-40. [PMID: 19237665 DOI: 10.1161/circulationaha.108.774752] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is the first clinical heart failure treatment that improves chamber systolic function in both the short-term and long-term yet also reduces mortality. The mechanical impact of CRT is immediate and well documented, yet its long-term influences on myocyte function and adrenergic modulation that may contribute to its sustained benefits are largely unknown. METHODS AND RESULTS We used a canine model of dyssynchronous heart failure (DHF; left bundle ablation, atrial tachypacing for 6 weeks) and CRT (DHF for 3 weeks, biventricular tachypacing for subsequent 3 weeks), contrasting both to nonfailing controls. CRT restored contractile synchrony and improved systolic function compared with DHF. Myocyte sarcomere shortening and calcium transients were markedly depressed at rest and after isoproterenol stimulation in DHF (both anterior and lateral walls), and CRT substantially improved both. In addition, beta(1) and beta(2) stimulation was enhanced, coupled to increased beta(1) receptor abundance but no change in binding affinity. CRT also augmented adenylate cyclase activity over DHF. Inhibitory G-protein (Galpha(i)) suppression of beta-adrenergic stimulation was greater in DHF and reversed by CRT. Galpha(i) expression itself was unaltered; however, expression of negative regulators of Galpha(i) signaling (particularly RGS3) rose uniquely with CRT over DHF and controls. CRT blunted elevated myocardial catecholamines in DHF, restoring levels toward control. CONCLUSIONS CRT improves rest and beta-adrenergic-stimulated myocyte function and calcium handling, upregulating beta(1) receptors and adenylate cyclase activity and suppressing G(i)-coupled signaling associated with novel RGS upregulation. The result is greater rest and sympathetic reserve despite reduced myocardial neurostimulation as components underlying its net benefit.
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Affiliation(s)
- Khalid Chakir
- Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Abstract
Sympathetic nervous system activation in heart failure, as indexed by elevated norepinephrine levels, higher muscle sympathetic nerve activity and reduced heart rate variability, is associated with pathologic ventricular remodeling, increased arrhythmias, sudden death, and increased mortality. Recent evidence suggests that 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin) therapy may provide survival benefit in heart failure of both ischemic and nonischemic etiology, and one potential mechanism of benefit of statins in heart failure is modulation of the autonomic nervous system. Animal models of heart failure demonstrate reduced sympathetic activation and improved sympathovagal balance with statin therapy. Initial human studies have reported mixed results. Ongoing translational studies and outcomes trials will help delineate the potentially beneficial effects of statins on the autonomic nervous system in heart failure.
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31
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Gademan MGJ, van Bommel RJ, Ypenburg C, Haest JCW, Schalij MJ, van der Wall EE, Bax JJ, Swenne CA. Biventricular pacing in chronic heart failure acutely facilitates the arterial baroreflex. Am J Physiol Heart Circ Physiol 2008; 295:H755-60. [DOI: 10.1152/ajpheart.00170.2008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Metabolic and mechanical stress in the failing heart activates the cardiac sympathetic afferent reflex (CSAR). It has been demonstrated that cardiac resynchronization therapy (CRT) acutely reduces MSNA in clinical responders. Mechanistically, this beneficial effect might be explained by acute deactivation of the CSAR. In addition to sympathoexcitation, CSAR inhibits the arterial baroreflex at the level of the nucleus tractus solitarii. Hence, in responders, CRT is likely to remove/reduce this inhibition. Therefore, we hypothesized that CRT acutely facilitates the arterial baroreflex. One day after implantation of a CRT device in 32 patients with chronic heart failure (LVEF; 27 ± 6%), we measured noninvasive baroreflex sensitivity (BRS) and heart rate variability (HRV) in two conditions: CRT device switched on and switched off (on/off order randomized). BRS changes were correlated with the difference in unpaced/paced LVEF, a measure of acute mechanical response to CRT. CRT increased BRS by 35% from 2.96 to 3.79 ms/mmHg ( P < 0.02) and increased HRV (standard deviation of the intervals between normal beats) from 18.5 to 24.0 ms ( P < 0.01). The CRT-induced relative change in BRS correlated with the change in LVEF ( r = 0.44; P < 0.01). In conclusion, CRT acutely increases BRS and HRV. This favorable response of the autonomic nervous system might be caused by CRT-induced CSAR deactivation. Follow-up studies should verify the mechanism of the acute response and the possible predictive value of an acute positive BRS response.
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Endomyocardial Upregulation of β1 Adrenoreceptor Gene Expression and Myocardial Contractile Reserve Following Cardiac Resynchronization Therapy. J Card Fail 2008; 14:172-8. [DOI: 10.1016/j.cardfail.2007.10.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Revised: 10/09/2007] [Accepted: 10/18/2007] [Indexed: 11/22/2022]
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Mullens W, Bartunek J, Wilson Tang W, Delrue L, Herbots L, Willems R, De Bruyne B, Goethals M, Verstreken S, Vanderheyden M. Early and late effects of cardiac resynchronization therapy on force–frequency relation and contractility regulating gene expression in heart failure patients. Heart Rhythm 2008; 5:52-9. [DOI: 10.1016/j.hrthm.2007.09.009] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Accepted: 09/07/2007] [Indexed: 11/29/2022]
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Current World Literature. Curr Opin Cardiol 2008; 23:72-8. [DOI: 10.1097/hco.0b013e3282f40209] [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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Vanderheyden M, Mullens W, Delrue L, Goethals M, de Bruyne B, Wijns W, Geelen P, Verstreken S, Wellens F, Bartunek J. Myocardial Gene Expression in Heart Failure Patients Treated With Cardiac Resynchronization Therapy. J Am Coll Cardiol 2008; 51:129-36. [PMID: 18191736 DOI: 10.1016/j.jacc.2007.07.087] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2007] [Revised: 07/02/2007] [Accepted: 07/03/2007] [Indexed: 11/26/2022]
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SCHIFFER ANGÉLIQUEA, DENOLLET JOHAN, PEDERSEN SUSANNES, BROERS HERMAN, WIDDERSHOVEN JOSW. Health Status in Patients Treated with Cardiac Resynchronization Therapy: Modulating Effects of Personality. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 31:28-37. [DOI: 10.1111/j.1540-8159.2007.00922.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Gould PA, Kong G, Kalff V, Duffy SJ, Taylor AJ, Kelly MJ, Kaye DM. Improvement in cardiac adrenergic function post biventricular pacing for heart failure. Europace 2007; 9:751-6. [PMID: 17517804 DOI: 10.1093/europace/eum081] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
AIMS We investigated whether biventricular (BiV) pacing favourably affects cardiac sympathetic activity in heart failure (HF). METHODS AND RESULTS In 10 HF patients treated with BiV pacing, we assessed cardiac sympathetic activity by metaiodobenzylguanidine ((123)I-MIBG) imaging. Patients were randomized in a double-blinded crossover fashion, for two weeks of either inactivation of BiV pacing or BiV pacing, with crossover to the alternate group for a further two weeks. After randomization blocks, cardiac (123)I-MIBG imaging and a 6 min walk test were performed. BiV pacing was associated with significant improvements in cardiac (123)I-MIBG uptake reflected by increases in early (BiV 1.71 +/- 0.09 vs. non-BiV 1.63 +/- 0.06, P = 0.03) and late (at 4 h) heart to mediastinal ratio of uptake (BiV 1.54 +/- 0.08 vs. non-BiV 1.45 +/- 0.06, P = 0.03). Additionally, pulmonary (123)I-MIBG uptake, measured as lung to mediastinal ratio, significantly improved (P = 0.009). Six-minute walk and systolic blood pressure tended to improve with BiV vs. non-BiV pacing (P = 0.09). CONCLUSION In patients with stable HF, BiV pacing is associated with long-term improvements in cardiac sympathetic nerve activity, as reflected by improvements in cardiac (123)I-MIBG uptake. This is a potential mechanism for morbidity and mortality benefits observed in larger studies.
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Affiliation(s)
- Paul A Gould
- Wynn Department of Metabolic Cardiology, Baker Heart Research Institute, Central, Melbourne VIC, Australia
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Cantini F, Varanini M, Macerata A, Piacenti M, Morales MA, Balocchi R. Cardiac resynchronization therapy and phase resetting of the sinoatrial node: a conjecture. CHAOS (WOODBURY, N.Y.) 2007; 17:015106. [PMID: 17411263 DOI: 10.1063/1.2431079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Congestive heart failure is a severe chronic disease often associated with disorders that alter the mechanisms of excitation-contraction coupling that may result in an asynchronous left ventricular motion which may further impair the ability of the failing heart to eject blood. In recent years a therapeutic approach to resynchronize the ventricles (cardiac resynchronization therapy, CRT) has been performed through the use of a pacemaker device able to provide atrial-based biventricular stimulation. Atrial lead senses the spontaneous occurrence of cells depolarization and sends the information to the generator which, in turn, after a settled delay [atrioventricular (AV) delay], sends electrical impulses to both ventricles to stimulate their synchronous contraction. Recent studies performed on heart rate behavior of chronically implanted patients at different epochs after implantation have shown that CRT can lead to sustained overall improvement of heart function with a reduction in morbidity and mortality. At this moment, however, there are no studies about CRT effects on spontaneous heart activity of chronically implanted patients. We performed an experimental study in which the electrocardiographic signal of five subjects under chronic CRT was recorded during the activity of the pacemaker programmed at different AV delays and under spontaneous cardiac activity after pacemaker deactivation. The different behavior of heart rate variability during pacemaker activity and after pacemaker deactivation suggested the hypothesis of a phase resetting mechanism induced by the pacemaker stimulus on the sinoatrial (SA) node, a phenomenon already known in literature for aggregate of cardiac cells, but still unexplored in vivo. The constraints imposed by the nature of our study (in vivo tests) made it impossible to plan an experiment to prove our hypothesis directly. We therefore considered the best attainable result would be to prove the accordance of our data to the conjecture through the use of models and physical considerations. We first used the data of literature on far-field effects of cardiac defibrillators to prove that the pacemaker impulses delivered to the two ventricles were able to induce modifications in membrane voltage at the level of the SA node. To simulate a phase resetting mechanism of the SA node, we used a Van der Pol modified model to allow the possibility of changing the refractory period and the firing frequency of the cells separately. With appropriate parameters of the model we reproduced phase response curves that can account for our experimental data. Furthermore, the simulated curves closely resemble the functional form proposed in literature for perturbed aggregate of cardiac cells. Despite the small sample of subjects investigated and the limited number of ECG recordings at different AV delays, we think we have proved the plausibility of the proposed conjecture.
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Affiliation(s)
- Federico Cantini
- Institute of Clinical Physiology, CNR, via Moruzzi, 1- Pisa, 56124 Italy.
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