1
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Pavri BB. Helping the hypertrophied (but nonobstructed) heart. Heart Rhythm 2023; 20:1314-1315. [PMID: 37247687 DOI: 10.1016/j.hrthm.2023.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 05/25/2023] [Indexed: 05/31/2023]
Affiliation(s)
- Behzad B Pavri
- Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
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2
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Wang C, Shi J, Ge J, Tang H, He Z, Liu Y, Zhao Z, Li C, Gu K, Hou X, Chen M, Zou J, Zhou L, Garcia EV, Li D, Zhou W. Left ventricular systolic and diastolic dyssynchrony to improve cardiac resynchronization therapy response in heart failure patients with dilated cardiomyopathy. J Nucl Cardiol 2021; 28:1023-1036. [PMID: 32405991 PMCID: PMC10961703 DOI: 10.1007/s12350-020-02132-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 03/28/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The systolic and diastolic dyssynchrony is physiologically related, but measure different left ventricular mechanisms. Left ventricular systolic mechanical dyssynchrony (systolic LVMD) has shown significant clinical values in improving cardiac resynchronization therapy (CRT) response in the heart failure patients with dilated cardiomyopathy (DCM). Our recent study demonstrated that LV diastolic dyssynchrony (diastolic LVMD) parameters have important prognostic values for DCM patients. However, there are a limited number of studies about the clinical value of diastolic LVMD for CRT. This study aims to explore the predictive values of both systolic LVMD and diastolic LVMD for CRT in DCM patients. METHODS Eighty-four consecutive CRT patients with both DCM and complete left bundle branch block (CLBBB) who received gated resting SPECT MPI at baseline were included in the present study. The phase analysis technique was applied on resting gated short-axis SPECT MPI images to measure systolic LVMD and diastolic LVMD, characterized by phase standard deviation (PSD) and phase histogram bandwidth (PBW). CRT response was defined as ≥ 5% improvement of LVEF at 6-month follow-up. Variables with P < 0.10 in the univariate analysis were included in the multivariate cox analysis. RESULTS During the follow-up period, 59.5% (50 of 84) patients were CRT responders. The univariate cox regression analysis showed that at baseline QRS duration, non-sustained ventricular tachycardia (NS-VT), systolic PSD, systolic PBW, diastolic PSD, diastolic PBW, scar burden and LV lead in the scarred myocardium were statistically significantly associated with CRT response. The multivariate cox regression analysis showed that QRS duration, NS-VT, systolic PSD, systolic PBW, diastolic PSD, and diastolic PBW were independent predictive factors for CRT response. Furthermore, the rate of CRT response was 94.4% (17 of 18) in patients whose LV lead was in the segments with both the first three late contraction and the first three late relaxation; by contrast, the rate of CRT response was only 6.7% (1 of 15, P < 0.000) in patients whose LV lead was in the segments with neither the first three late contraction nor the first three late relaxation. CONCLUSION Both systolic LVMD and diastolic LVMD from gated SPECT MPI have important predictive values for CRT response in DCM patients. Pacing at LV segments with both late contraction and late relaxation has potential to increase the CRT response.
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Affiliation(s)
- Cheng Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jianzhou Shi
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jiacheng Ge
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Haipeng Tang
- School of Computing, University of Southern Mississippi, Hattiesburg, USA
| | - Zhuo He
- College of Computing, Michigan Technological University, 1400 Townsend Dr, Houghton, MI, 49931, USA
| | - Yanyun Liu
- School of Computer and Communication Engineering, Zhengzhou University of Light Industry, Zhengzhou, Henan, China
| | - Zhongqiang Zhao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Chunxiang Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Kai Gu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Xiaofeng Hou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jiangang Zou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Lei Zhou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
| | - Ernest V Garcia
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Dianfu Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
| | - Weihua Zhou
- College of Computing, Michigan Technological University, 1400 Townsend Dr, Houghton, MI, 49931, USA.
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3
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Hamilton MCK, Neumann S, Szantho G, Rydon L, Lawton CB, Hart E, Manghat NE, Turner MS. The design and use of a simple device for the MRI assessment of changes in cardiovascular function by lower-body negative-pressure-simulated reduction of central blood volume. Clin Radiol 2021; 76:471.e9-471.e16. [PMID: 33637308 DOI: 10.1016/j.crad.2021.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 01/18/2021] [Indexed: 11/19/2022]
Abstract
AIM To use a locally designed and simple lower-body negative-pressure (LBNP) device and 1.5 T magnetic resonance imaging (MRI) to demonstrate the ability to assess changes in cardiovascular function during preload reduction. These effects were evaluated on ventricular volumes and great vessel flow in healthy volunteers, for which there are limited published data. MATERIAL AND METHODS After ethical review, 14 volunteers (mean age 33.9 ± 7 years, mean body mass index [BMI] 23.1 ± 2.5) underwent LBNP prospectively at 0, -5, -10, and -20 mmHg pressure, using a locally designed LBNP box. Expiratory breath-hold biventricular volumes, and free-breathing flow imaging of the ascending aorta and main pulmonary artery were acquired at each level of LBNP. RESULTS At -5 mmHg, there was no change in aortic flow or left ventricular volumes versus baseline. Right ventricular output (p=0.013) and pulmonary net flow (p=0.026) decreased. At -20 mmHg, aortic and pulmonary net flow (p<0.001) decreased, as were left and right ventricular end diastolic volume (p<0.001) and left and right end systolic volumes (p=0.038 and p=0.003 respectively). CONCLUSIONS Use of a MRI-compatible LBNP device is feasible to measure changes in ventricular volume and great arterial flow in the same experiment. This may enhance further research into the effects of preload reduction by MRI in a wide range of important cardiovascular pathologies.
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Affiliation(s)
- M C K Hamilton
- Department of Clinical Radiology, Bristol Royal Infirmary, Bristol BS28HW, UK.
| | - S Neumann
- School of Physiology, Pharmacology and Neurosciences, University of Bristol, Bristol BS8 1TD, UK
| | - G Szantho
- Department of Cardiology, Bristol Heart Institute, Bristol BS28HW, UK
| | - L Rydon
- MEMO Clinical Engineering, Bristol Royal Infirmary, Bristol BS28HW, UK
| | - C B Lawton
- Department of Clinical Radiology, Bristol Royal Infirmary, Bristol BS28HW, UK
| | - E Hart
- School of Physiology, Pharmacology and Neurosciences, University of Bristol, Bristol BS8 1TD, UK
| | - N E Manghat
- Department of Clinical Radiology, Bristol Royal Infirmary, Bristol BS28HW, UK
| | - M S Turner
- Department of Cardiology, Bristol Heart Institute, Bristol BS28HW, UK
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4
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Effects of cardiac pacemakers on left ventricular volumes and function assessed by 3D echocardiography, Doppler method, and global longitudinal strain. Egypt Heart J 2021; 73:16. [PMID: 33616794 PMCID: PMC7900307 DOI: 10.1186/s43044-021-00138-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 02/04/2021] [Indexed: 11/17/2022] Open
Abstract
Background Many previous studies reported the negative effects of right ventricular (RV) pacing on the left ventricular (LV) structure and ejection fraction. Studying pacing hemodynamics is essential to understand these detrimental effects. In this study, we tried to understand RV pacing effects on LV volumes and function using advanced tools like 3D echo and global longitudinal strain (GLS). This was a prospective study of 175 consecutive patients (LVEF>50%) presented permanent pacing. Of 175 patients, only 50 patients met study criteria, divided into two groups (single or dual pacing). LV volumes and function were assessed by full-volume 3D echocardiography and GLS before pacing, at 1-week and 6-month post-pacing. Cardiac output (COP) was calculated by pulsed wave Doppler method and 3D echo. Results Doppler method results were similar to 3D echo in calculating SV and COP. At 1-week post pacing, both groups showed a significant decrease in SV due to a drop in EDV while ESV did not change significantly. Despite the drop in SV, there was a significant increase in cardiac output (COP) due to achieving higher heart rates post-pacing. There was a significant drop in EF and GLS in both groups. At 6 months, SV continued to decrease with a corresponding decrease in COP and LVEF. This drop in SV was due to a significant increase in ESV while EDV did not show a significant change at a 6-month follow-up. Also, the drop EF and GLS became more significant. There were no significant differences between both groups regarding the changes in LV volumes (EDV, ESV, SV), LVEF or GLS throughout the study (pre-pacing, at 1-week and 6-months post pacing). However, dual-chamber pacing group provided higher heart rates and as a result higher COP than the single-chamber group. Conclusions RV pacing led to a significant drop in LV COP, ejection fraction (EF), and GLS over short- and long-term duration. Dual chamber pacing provided higher COP than a single chamber pacing. This was due to tracking the S. A node with pacing at higher heart rates not due to an increase in SV and preserving atrioventricular synchrony. Both Doppler method and 3D echo can be used to calculate SV and COP. Supplementary Information The online version contains supplementary material available at 10.1186/s43044-021-00138-9.
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5
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Borlaug BA, Reddy YNV. The Role of the Pericardium in Heart Failure: Implications for Pathophysiology and Treatment. JACC-HEART FAILURE 2020; 7:574-585. [PMID: 31248569 DOI: 10.1016/j.jchf.2019.03.021] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/15/2019] [Accepted: 03/19/2019] [Indexed: 01/17/2023]
Abstract
The elastic pericardium exerts a compressive contact force on the surface of the myocardium that becomes more substantial when heart volume increases, as in patients with various forms of heart failure (HF). Pericardial restraint plays an important role in determining hemodynamics and ventricular function in both health and disease. This review discusses the physiology of pericardial restraint in HF and explores the question of whether it can be targeted indirectly through medical interventions or directly through a number of existing and future therapies.
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Affiliation(s)
- Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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6
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Zweerink A, Allaart CP, Burri H. Shifting diastolic filling from right to left in non‐obstructive hypertrophic cardiomyopathy: exploring new indications for biventricular pacing. Eur J Heart Fail 2020; 22:1273-1275. [DOI: 10.1002/ejhf.1775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 02/04/2020] [Indexed: 11/08/2022] Open
Affiliation(s)
- Alwin Zweerink
- Department of Cardiology University Hospital of Geneva Geneva Switzerland
- Department of Cardiology, and Amsterdam Cardiovascular Sciences (ACS) Amsterdam University Medical Centers (AUMC), location VU University Medical Center Amsterdam The Netherlands
| | - Cornelis P. Allaart
- Department of Cardiology, and Amsterdam Cardiovascular Sciences (ACS) Amsterdam University Medical Centers (AUMC), location VU University Medical Center Amsterdam The Netherlands
| | - Haran Burri
- Department of Cardiology University Hospital of Geneva Geneva Switzerland
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7
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Solimene F, Nigro G, Canciello M, Tavoletta V, Shopova G, Calvanese R, Rago A, La Rosa C, Nappi F, Viscusi M, Urraro F, Manzo G, Gallo P, Andriani A, Rovaris G, Palmisano P, Innocenti S, D'Onofrio A. Design and rationale of the Impact of MultiPoint pacing in CRT patients with reduced RV-to-LV delay (IMAGE-CRT) study. J Cardiovasc Med (Hagerstown) 2020; 21:250-258. [PMID: 32004245 DOI: 10.2459/jcm.0000000000000928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is an established treatment in patients with heart failure and prolonged QRS duration. A biventricular device is implanted to achieve faster activation and more synchronous contraction of the ventricles. Despite the convincing effect of CRT, 30-40% of patients do not respond. We decided to investigate the role of multipoint pacing (MPP) in a selected group of patients with right ventricle (RV)-to-left ventricle (LV) intervals less than 80 ms that do not respond to traditional CRT. METHODS We will enrol 248 patients in this patient-blinded, observational, clinical study aiming to investigate if MPP could decrease LV end-systolic volume (ESV) in patients with RV-to-LV interval less than 80 ms. MPP will be activated ON at implant in patients with RV-to-LV delay less than 80 ms and OFF in RV-to-LV at least 80 ms. At follow-up the activation of MPP will be related to CRT response. The primary study endpoint will be the responder rate at 6 months, defined as a decrease in LV ejection fraction, LV end-diastolic volume, LV end-systolic volume (LVESV) at least 15% from baseline. Secondary outcomes include 12 months relative percentage reduction in LVESV and a combined clinical outcome measure of response to CRT defined as the patient being alive, no hospitalization due to heart failure, and experiencing an improvement in New York Heart Association functional class (Composite-Score). CONCLUSION Reducing the nonresponder rate continues to be an important goal for CRT.If an increase in reverse remodelling can be achieved by MPP, this study supports the conduct of larger trials investigating the role of MPP on clinical outcomes in selected patients treated, right now, only with traditional CRT. TRIAL REGISTRATION ClinicalTrials.gov, NCT02713308. Registered on 18 March 2016.
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Affiliation(s)
| | - Gerardo Nigro
- University of Campania 'Luigi Vanvitelli', Monaldi Hospital
| | | | | | | | | | - Anna Rago
- University of Campania 'Luigi Vanvitelli', Monaldi Hospital
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8
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Ahmed I, Loudon BL, Abozguia K, Cameron D, Shivu GN, Phan TT, Maher A, Stegemann B, Chow A, Marshall H, Nightingale P, Leyva F, Vassiliou VS, McKenna WJ, Elliott P, Frenneaux MP. Biventricular pacemaker therapy improves exercise capacity in patients with non-obstructive hypertrophic cardiomyopathy via augmented diastolic filling on exercise. Eur J Heart Fail 2020; 22:1263-1272. [PMID: 31975494 PMCID: PMC7540697 DOI: 10.1002/ejhf.1722] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 11/19/2019] [Accepted: 11/26/2019] [Indexed: 11/11/2022] Open
Abstract
AIMS Treatment options for patients with non-obstructive hypertrophic cardiomyopathy (HCM) are limited. We sought to determine whether biventricular (BiV) pacing improves exercise capacity in HCM patients, and whether this is via augmented diastolic filling. METHODS AND RESULTS Thirty-one patients with symptomatic non-obstructive HCM were enrolled. Following device implantation, patients underwent detailed assessment of exercise diastolic filling using radionuclide ventriculography in BiV and sham pacing modes. Patients then entered an 8-month crossover study of BiV and sham pacing in random order, to assess the effect on exercise capacity [peak oxygen consumption (VO2 )]. Patients were grouped on pre-specified analysis according to whether left ventricular end-diastolic volume increased (+LVEDV) or was unchanged/decreased (-LVEDV) with exercise at baseline. Twenty-nine patients (20 male, mean age 55 years) completed the study. There were 14 +LVEDV patients and 15 -LVEDV patients. Baseline peak VO2 was lower in -LVEDV patients vs. +LVEDV patients (16.2 ± 0.9 vs. 19.9 ± 1.1 mL/kg/min, P = 0.04). BiV pacing significantly increased exercise ΔLVEDV (P = 0.004) and Δstroke volume (P = 0.008) in -LVEDV patients, but not in +LVEDV patients. Left ventricular ejection fraction and end-systolic elastance did not increase with BiV pacing in either group. This translated into significantly greater improvements in exercise capacity (peak VO2 + 1.4 mL/kg/min, P = 0.03) and quality of life scores (P = 0.02) in -LVEDV patients during the crossover study. There was no effect on left ventricular mechanical dyssynchrony in either group. CONCLUSION Symptomatic patients with non-obstructive HCM may benefit from BiV pacing via augmentation of diastolic filling on exercise rather than contractile improvement. This may be due to relief of diastolic ventricular interaction. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT00504647.
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Affiliation(s)
- Ibrar Ahmed
- Department of Cardiovascular Medicine, University of Birmingham, Birmingham, UK
| | - Brodie L Loudon
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Khalid Abozguia
- Department of Cardiovascular Medicine, University of Birmingham, Birmingham, UK.,Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, UK
| | - Donnie Cameron
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Ganesh N Shivu
- Department of Cardiovascular Medicine, University of Birmingham, Birmingham, UK
| | - Thanh T Phan
- Department of Cardiovascular Medicine, University of Birmingham, Birmingham, UK.,Cardiology Department, Royal Stoke University Hospital UHNM NHS Trust, Newcastle, UK
| | - Abdul Maher
- Department of Cardiovascular Medicine, University of Birmingham, Birmingham, UK
| | | | - Anthony Chow
- Department of Cardiovascular Medicine, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Howard Marshall
- Queen Elizabeth Hospital Birmingham, Welcome Trust Clinical Research Facility, Birmingham, UK
| | - Peter Nightingale
- Queen Elizabeth Hospital Birmingham, Welcome Trust Clinical Research Facility, Birmingham, UK
| | - Francisco Leyva
- Department of Cardiovascular Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | | | - William J McKenna
- Institute of Cardiovascular Science, University College of London, London, UK
| | - Perry Elliott
- Institute of Cardiovascular Science, University College of London, London, UK
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Improvement of Reverse Remodeling Using Electrocardiogram Fusion-Optimized Intervals in Cardiac Resynchronization Therapy. JACC Clin Electrophysiol 2018; 4:181-189. [DOI: 10.1016/j.jacep.2017.11.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 11/13/2017] [Accepted: 11/16/2017] [Indexed: 01/20/2023]
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10
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Killu AM, Park JY, Sara JD, Hodge DO, Gersh BJ, Nishimura RA, Asirvatham SJ, McLeod CJ. Cardiac resynchronization therapy in patients with end-stage hypertrophic cardiomyopathy. Europace 2016; 20:82-88. [DOI: 10.1093/europace/euw327] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/19/2016] [Indexed: 01/19/2023] Open
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Jackson T, Claridge S, Behar J, Sammut E, Webb J, Carr-White G, Razavi R, Rinaldi CA. Narrow QRS systolic heart failure: is there a target for cardiac resynchronization? Expert Rev Cardiovasc Ther 2015; 13:783-97. [PMID: 26048215 DOI: 10.1586/14779072.2015.1049945] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cardiac resynchronization therapy has revolutionized the management of systolic heart failure in patients with prolonged QRS during the past 20 years. Initially, the use of this treatment in patients with shorter QRS durations showed promising results, which have since been opposed by larger randomized controlled trials. Despite this, some questions remain, such as, whether correction of mechanical dyssynchrony is the therapeutic target by which biventricular pacing may confer benefit in this group, or are there other mechanisms that need consideration? In addition, novel techniques of cardiac resynchronization therapy delivery such as endocardial and multisite pacing may reduce potential detrimental effects of biventricular pacing, thereby improving the benefit/harm balance of this therapy in some patients.
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Affiliation(s)
- Tom Jackson
- Department of Cardiovascular Imaging, 4th Floor Lambeth Wing, St Thomas' Hospital, London, SE1 7EH, UK
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12
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Boe E, Russell K, Remme EW, Gjesdal O, Smiseth OA, Skulstad H. Cardiac responses to left ventricular pacing in hearts with normal electrical conduction: beneficial effect of improved filling is counteracted by dyssynchrony. Am J Physiol Heart Circ Physiol 2014; 307:H370-8. [PMID: 24906920 DOI: 10.1152/ajpheart.00089.2014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cardiac resynchronization therapy (CRT) has been proposed in heart failure patients with narrow QRS, but the mechanism of a potential beneficial effect is unknown. The present study investigated the hypothesis that left ventricular (LV) pacing increases LV end-diastolic volume (LVEDV) by allowing the LV to start filling before the right ventricle (RV) during narrow QRS in an experimental model. LV and biventricular pacing were studied in six anesthetized dogs before and after the induction of LV failure. Function was evaluated by pressures and dimensions, and dyssynchrony was evaluated by electromyograms and deformation. In the nonfailing heart, LV pacing gave the LV a head start in filling relative to the RV (P < 0.05) and increased LVEDV (P < 0.05). The response was similar during LV failure when RV diastolic pressure was elevated. The pacing-induced increase in LVEDV was attributed to a rightward shift of the septum (P < 0.01) due to an increased left-to-right transseptal pressure gradient (P < 0.05). LV pacing, however, also induced dyssynchrony (P < 0.05) and therefore reduced LV stroke work (P < 0.05) during baseline, and similar results were seen in failing hearts. Biventricular pacing did not change LVEDV, but systolic function was impaired. This effect was less marked than with LV pacing. In conclusion, pacing of the LV lateral wall increased LVEDV by displacing the septum rightward, suggesting a mechanism for a favorable effect of CRT in narrow QRS. The pacing, however, induced dyssynchrony and therefore reduced LV systolic function. These observations suggest that detrimental effects should be considered when applying CRT in patients with narrow QRS.
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Affiliation(s)
- Espen Boe
- Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kristoffer Russell
- Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; and
| | - Espen W Remme
- Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway; KG Jebsen Cardiac Research Center, University of Oslo, Oslo, Norway
| | - Ola Gjesdal
- Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Otto A Smiseth
- Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; KG Jebsen Cardiac Research Center, University of Oslo, Oslo, Norway; Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; and Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Helge Skulstad
- Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; and
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13
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Foley PW, Chalil S, Khadjooi K, Irwin N, Smith RE, Leyva F. Left ventricular reverse remodelling, long-term clinical outcome, and mode of death after cardiac resynchronization therapy. Eur J Heart Fail 2014; 13:43-51. [DOI: 10.1093/eurjhf/hfq182] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Paul W.X. Foley
- Centre for Cardiovascular Sciences; University of Birmingham, Queen Elizabeth Hospital; Birmingham UK
| | - Shajil Chalil
- Centre for Cardiovascular Sciences; University of Birmingham, Queen Elizabeth Hospital; Birmingham UK
| | - Kayvan Khadjooi
- Department of Cardiology; Good Hope Hospital; Sutton Coldfield UK
| | - Nick Irwin
- Department of Cardiology; Good Hope Hospital; Sutton Coldfield UK
| | - Russell E.A. Smith
- Centre for Cardiovascular Sciences; University of Birmingham, Queen Elizabeth Hospital; Birmingham UK
| | - Francisco Leyva
- Centre for Cardiovascular Sciences; University of Birmingham, Queen Elizabeth Hospital; Birmingham UK
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14
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Haemodynamics and left ventricular function in heart failure patients: Comparison of awake versus intra-operative conditions. Eur J Heart Fail 2014; 10:467-74. [DOI: 10.1016/j.ejheart.2008.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2007] [Revised: 02/27/2008] [Accepted: 03/27/2008] [Indexed: 11/18/2022] Open
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15
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Rogers DP, Marazia S, Chow AW, Lambiase PD, Lowe MD, Frenneaux M, McKenna WJ, Elliott PM. Effect of biventricular pacing on symptoms and cardiac remodelling in patients with end-stage hypertrophic cardiomyopathy. Eur J Heart Fail 2014; 10:507-13. [DOI: 10.1016/j.ejheart.2008.03.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2007] [Revised: 12/27/2007] [Accepted: 03/12/2008] [Indexed: 11/25/2022] Open
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16
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Piazza L, Chessa M, Giamberti A, Bussadori CM, Butera G, Negura DG, Micheletti A, Callus E, Carminati M. Timing of pulmonary valve replacement after tetralogy of Fallot repair. Expert Rev Cardiovasc Ther 2014; 10:917-23. [DOI: 10.1586/erc.12.67] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Stiver C, Gokhale J, Husain N, Nicholson L, Cordier J, Van Lente L, Holzer RJ, Cua CL. Catheterization diastolic pressures correlate with diastolic dyssynchrony in patients with single right ventricles. Echocardiography 2013; 31:370-4. [PMID: 24298988 DOI: 10.1111/echo.12373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Diastolic dyssynchrony has correlated with pulmonary capillary wedge pressures in patients with normal cardiac anatomy. No data exist in single right ventricle (sRV) patients. Goal of this study was to determine if diastolic dyssynchrony in sRV patients correlates with ventricular end-diastolic pressures (VEDP). METHODS Tissue Doppler imaging (TDI) and strain rate (SR) analysis of sRV patients undergoing catheterization were performed. Time interval from onset of QRS to peak TDI e'-wave was obtained. Differences in intervals were calculated: QRS (RV) - QRS (IVS) and QRS (RV) - QRS (LV). Time interval from onset of QRS to peak strain rate early diastolic wave (SRe) was obtained for the 6 segment model sRV. Standard deviation of the 6 SRe time intervals was calculated. Correlation of VEDP with timing intervals was analyzed. RESULTS Forty sRV patients were evaluated. Age was 2.8 ± 3.5 years. Catheterization VEDP of the sRV was 9.3 ± 3.9 mmHg (median 8 mmHg range 4-24 mmHg). QRS (RV) - QRS (IVS) was 22.3 ± 18.1 msec and QRS (RV) - QRS (LV) was 23.7 ± 19.0 msec. SRe standard deviation of the sRV was 61.6 ± 23.9 msec. There was no significant correlation with VEDP and QRS (RV) - QRS (IVS) (r = 0.1, P = NS) or with QRS (RV) - QRS (LV) (r = 0.2, P = NS). There was a significant correlation of VEDP with the SRe standard deviation value (r = 0.4, P < 0.05). CONCLUSION Diastolic dyssynchrony correlated with VEDP in patients with sRV physiology. Future studies are needed to determine the significance of these findings.
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Affiliation(s)
- Corey Stiver
- Heart Center, Nationwide Children's Hospital, Columbus, Ohio
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Kyriacou A, Pabari PA, Mayet J, Peters NS, Davies DW, Lim PB, Lefroy D, Hughes AD, Kanagaratnam P, Francis DP, Whinnett ZI. Cardiac resynchronization therapy and AV optimization increase myocardial oxygen consumption, but increase cardiac function more than proportionally. Int J Cardiol 2013; 171:144-52. [PMID: 24332598 PMCID: PMC3919205 DOI: 10.1016/j.ijcard.2013.10.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 09/08/2013] [Accepted: 10/07/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND The mechanoenergetic effects of atrioventricular delay optimization during biventricular pacing ("cardiac resynchronization therapy", CRT) are unknown. METHODS Eleven patients with heart failure and left bundle branch block (LBBB) underwent invasive measurements of left ventricular (LV) developed pressure, aortic flow velocity-time-integral (VTI) and myocardial oxygen consumption (MVO2) at 4 pacing states: biventricular pacing (with VV 0 ms) at AVD 40 ms (AV-40), AVD 120 ms (AV-120, a common nominal AV delay), at their pre-identified individualised haemodynamic optimum (AV-Opt); and intrinsic conduction (LBBB). RESULTS AV-120, relative to LBBB, increased LV developed pressure by a mean of 11(SEM 2)%, p=0.001, and aortic VTI by 11(SEM 3)%, p=0.002, but also increased MVO2 by 11(SEM 5)%, p=0.04. AV-Opt further increased LV developed pressure by a mean of 2(SEM 1)%, p=0.035 and aortic VTI by 4(SEM 1)%, p=0.017. MVO2 trended further up by 7(SEM 5)%, p=0.22. Mechanoenergetics at AV-40 were no different from LBBB. The 4 states lay on a straight line for Δexternal work (ΔLV developed pressure × Δaortic VTI) against ΔMVO2, with slope 1.80, significantly >1 (p=0.02). CONCLUSIONS Biventricular pacing and atrioventricular delay optimization increased external cardiac work done but also myocardial oxygen consumption. Nevertheless, the increase in cardiac work was ~80% greater than the increase in oxygen consumption, signifying an improvement in cardiac mechanoenergetics. Finally, the incremental effect of optimization on external work was approximately one-third beyond that of nominal AV pacing, along the same favourable efficiency trajectory, suggesting that AV delay dominates the biventricular pacing effect - which may therefore not be mainly "resynchronization".
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Affiliation(s)
- Andreas Kyriacou
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - Punam A Pabari
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - Jamil Mayet
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - Nicholas S Peters
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - D Wyn Davies
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - P Boon Lim
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - David Lefroy
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - Alun D Hughes
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - Prapa Kanagaratnam
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - Darrel P Francis
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK.
| | - Zachary I Whinnett
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
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Pett K, Hauton D. The effects of asymmetric ventricular filling on left-right ventricular interaction in the normal rat heart. Pflugers Arch 2012; 464:523-34. [PMID: 23001120 DOI: 10.1007/s00424-012-1154-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 08/31/2012] [Accepted: 09/04/2012] [Indexed: 11/28/2022]
Abstract
Heart failure is characterised by ventricular dysfunction and with the potential for changes to ventricular volumes constraining the mechanical performance of the heart. The contribution of this interaction from geometric changes rather than fibrosis or metabolic changes is unclear. Using the constant pressure Langendorff-perfused rat heart, the volume interaction between left ventricle (LV) and right ventricle (RV) was investigated. RV diastolic stiffness (P < 0.001) and developed pressure (P < 0.001) were significantly lower than LV. When the RV was fixed at the end-diastolic volume (EDV) or EDV + 50 %, both LV systolic and diastolic performance were unaffected with increasing LV balloon volume. However, at fixed LV volume, RV systolic performance was significantly decreased when LV volume increased to EDV + 50 % when RV volume was increased incrementally between 50 and 300 μl (P < 0.001). Systolic interaction in RV was noted as declining RV peak systolic load with increasing LV systolic pressure (P < 0.05) and diastolic interaction was noted for RV when LV volume was increased from EDV to EDV + 50 % (P < 0.05). RV diastolic wall stress was increased with increasing LV balloon volume (P < 0.05), but LV wall stress was unaltered at fixed RV balloon volume. Taken together, increasing LV volume above EDV decreased systolic performance and triggered ventricular constraint in the RV but the RV itself had no effect on the performance of the LV. These results are consistent with overload of the LV impairing pulmonary perfusion by direct ventricular interaction with potential alteration to ventilation-perfusion characteristics within the lung.
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Affiliation(s)
- Kimberley Pett
- School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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20
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Tomczak CR, Paterson I, Haykowsky MJ, Lawrance R, Martellotto A, Pantano A, Gulamhusein S, Haennel RG. Cardiac resynchronization therapy modulation of exercise left ventricular function and pulmonary O₂ uptake in heart failure. Am J Physiol Heart Circ Physiol 2012; 302:H2635-45. [PMID: 22523249 DOI: 10.1152/ajpheart.01119.2011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
To better understand the mechanisms contributing to improved exercise capacity with cardiac resynchronization therapy (CRT), we studied the effects of 6 mo of CRT on pulmonary O(2) uptake (Vo(2)) kinetics, exercise left ventricular (LV) function, and peak Vo(2) in 12 subjects (age: 56 ± 15 yr, peak Vo(2): 12.9 ± 3.2 ml·kg(-1)·min(-1), ejection fraction: 18 ± 3%) with heart failure. We hypothesized that CRT would speed Vo(2) kinetics due to an increase in stroke volume secondary to a reduction in LV end-systolic volume (ESV) and that the increase in peak Vo(2) would be related to an increase in cardiac output reserve. We found that Vo(2) kinetics were faster during the transition to moderate-intensity exercise after CRT (pre-CRT: 69 ± 21 s vs. post-CRT: 54 ± 17 s, P < 0.05). During moderate-intensity exercise, LV ESV reserve (exercise - resting) increased 9 ± 7 ml (vs. a 3 ± 9-ml decrease pre-CRT, P < 0.05), and steady-state stroke volume increased (pre-CRT: 42 ± 8 ml vs. post-CRT: 61 ± 12 ml, P < 0.05). LV end-diastolic volume did not change from rest to steady-state exercise post-CRT (P > 0.05). CRT improved heart rate, measured as a lower resting and steady-state exercise heart rate and as faster heart rate kinetics after CRT (pre-CRT: 89 ± 12 s vs. post-CRT: 69 ± 21 s, P < 0.05). For peak exercise, cardiac output reserve increased significantly post-CRT and was 22% higher at peak exercise post-CRT (both P < 0.05). The increase in cardiac output was due to both a significant increase in peak and reserve stroke volume and to a nonsignificant increase in heart rate reserve. Similar patterns in LV volumes as moderate-intensity exercise were observed at peak exercise. Cardiac output reserve was related to peak Vo(2) (r = 0.48, P < 0.05). These findings demonstrate the chronic CRT-mediated cardiac factors that contribute, in part, to the speeding in Vo(2) kinetics and increase in peak Vo(2) in clinically stable heart failure patients.
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Affiliation(s)
- Corey R Tomczak
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada.
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21
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Echocardiographic prediction of outcome after cardiac resynchronization therapy: conventional methods and recent developments. Heart Fail Rev 2011; 16:235-50. [PMID: 21104122 PMCID: PMC3074077 DOI: 10.1007/s10741-010-9200-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Echocardiography plays an important role in patient assessment before cardiac resynchronization therapy (CRT) and can monitor many of its mechanical effects in heart failure patients. Encouraged by the highly variable individual response observed in the major CRT trials, echocardiography-based measurements of mechanical dyssynchrony have been extensively investigated with the aim of improving response prediction and CRT delivery. Despite recent setbacks, these techniques have continued to develop in order to overcome some of their initial flaws and limitations. This review discusses the concepts and rationale of the available echocardiographic techniques, highlighting newer quantification methods and discussing some of the unsolved issues that need to be addressed.
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Leyva F, Foley PWX, Chalil S, Ratib K, Smith REA, Prinzen F, Auricchio A. Cardiac resynchronization therapy guided by late gadolinium-enhancement cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2011; 13:29. [PMID: 21668964 PMCID: PMC3141552 DOI: 10.1186/1532-429x-13-29] [Citation(s) in RCA: 162] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 06/13/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Myocardial scarring at the LV pacing site leads to incomplete resynchronization and a suboptimal symptomatic response to CRT. We sought to determine whether the use of late gadolinium cardiovascular magnetic resonance (LGE-CMR) to guide left ventricular (LV) lead deployment influences the long-term outcome of cardiac resynchronization therapy (CRT). METHODS 559 patients with heart failure (age 70.4 ± 10.7 yrs [mean ± SD]) due to ischemic or non-ischemic cardiomyopathy underwent CRT. Implantations were either guided (+CMR) or not guided (-CMR) by LGE-CMR prior to implantation. Fluoroscopy and LGE-CMR were used to localize the LV lead tip and and myocardial scarring retrospectively. Clinical events were assessed in three groups: +CMR and pacing scar (+CMR+S); CMR and not pacing scar (+CMR-S), and; LV pacing not guided by CMR (-CMR). RESULTS Over a maximum follow-up of 9.1 yrs, +CMR+S had the highest risk of cardiovascular death (HR: 6.34), cardiovascular death or hospitalizations for heart failure (HR: 5.57) and death from any cause or hospitalizations for major adverse cardiovascular events (HR: 4.74) (all P < 0.0001), compared with +CMR-S. An intermediate risk of meeting these endpoints was observed for -CMR, with HRs of 1.51 (P = 0.0726), 1.61 (P = 0.0169) and 1.87 (p = 0.0005), respectively. The +CMR+S group had the highest risk of death from pump failure (HR: 5.40, p < 0.0001) and sudden cardiac death (HR: 4.40, p = 0.0218), in relation to the +CMR-S group. CONCLUSIONS Compared with a conventional implantation approach, the use of LGE-CMR to guide LV lead deployment away from scarred myocardium results in a better clinical outcome after CRT. Pacing scarred myocardium was associated with the worst outcome, in terms of both pump failure and sudden cardiac death.
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Affiliation(s)
- Francisco Leyva
- Centre for Cardiovascular Sciences, Queen Elizabeth Hospital, University of Birmingham, UK
| | - Paul WX Foley
- University of Birmingham, Department of Cardiology, Good Hope Hospital, Sutton Coldfield, UK
| | - Shajil Chalil
- Centre for Cardiovascular Sciences, Queen Elizabeth Hospital, University of Birmingham, UK
| | - Karim Ratib
- University of Birmingham, Department of Cardiology, Good Hope Hospital, Sutton Coldfield, UK
| | - Russell EA Smith
- Centre for Cardiovascular Sciences, Queen Elizabeth Hospital, University of Birmingham, UK
| | - Frits Prinzen
- Departments of Physiology and Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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23
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Cardiac resynchronization therapy guided by late gadolinium-enhancement cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2011. [PMID: 21668964 DOI: 10.1186/1532-492x-13-29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Myocardial scarring at the LV pacing site leads to incomplete resynchronization and a suboptimal symptomatic response to CRT. We sought to determine whether the use of late gadolinium cardiovascular magnetic resonance (LGE-CMR) to guide left ventricular (LV) lead deployment influences the long-term outcome of cardiac resynchronization therapy (CRT). METHODS 559 patients with heart failure (age 70.4 ± 10.7 yrs [mean ± SD]) due to ischemic or non-ischemic cardiomyopathy underwent CRT. Implantations were either guided (+CMR) or not guided (-CMR) by LGE-CMR prior to implantation. Fluoroscopy and LGE-CMR were used to localize the LV lead tip and and myocardial scarring retrospectively. Clinical events were assessed in three groups: +CMR and pacing scar (+CMR+S); CMR and not pacing scar (+CMR-S), and; LV pacing not guided by CMR (-CMR). RESULTS Over a maximum follow-up of 9.1 yrs, +CMR+S had the highest risk of cardiovascular death (HR: 6.34), cardiovascular death or hospitalizations for heart failure (HR: 5.57) and death from any cause or hospitalizations for major adverse cardiovascular events (HR: 4.74) (all P < 0.0001), compared with +CMR-S. An intermediate risk of meeting these endpoints was observed for -CMR, with HRs of 1.51 (P = 0.0726), 1.61 (P = 0.0169) and 1.87 (p = 0.0005), respectively. The +CMR+S group had the highest risk of death from pump failure (HR: 5.40, p < 0.0001) and sudden cardiac death (HR: 4.40, p = 0.0218), in relation to the +CMR-S group. CONCLUSIONS Compared with a conventional implantation approach, the use of LGE-CMR to guide LV lead deployment away from scarred myocardium results in a better clinical outcome after CRT. Pacing scarred myocardium was associated with the worst outcome, in terms of both pump failure and sudden cardiac death.
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24
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Tsvetkova AS, Kibler NA, Nuzhny VP, Shmakov DN, Azarov JE. Acute effects of pacing site on repolarization and haemodynamics of the canine ventricles. Europace 2011; 13:889-96. [PMID: 21421575 DOI: 10.1093/europace/eur053] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
AIMS To determine the repolarization duration gradients in different ventricular regions at atrial and ventricular pacing and to test the hypothesis that acute haemodynamic response to ventricular pacing is related to the lead position with respect to repolarization gradients. METHODS AND RESULTS Repolarization durations estimated as activation-recovery intervals (ARIs) were measured from unipolar electrograms recorded in the subepicardial (Epi), mid-myocardial (Mid), and subendocardial (Endo) layers of the apical and basal parts of the right ventricle (RV) and left ventricle (LV) of 15 healthy dogs under atrial and ventricular pacing. Cardiac haemodynamic variables were measured as well. At atrial pacing, ARIs were shorter in Epi than in the innermost layers (P< 0.05) in the RV apex and LV base, but not in the LV apex and RV base. Activation-recovery intervals increased from apex to base and from base to apex in RV and LV, respectively (P ≤ 0.05). At apical or basal pacing of RV and LV, repolarization gradients decayed. The dispersion of repolarization increased at LV apical pacing and preserved at RV apical pacing. The pump function of a ventricle was altered dramatically at pacing of the area with the shorter ARIs and to a lesser degree at pacing of the area with the longer ARIs (P ≤ 0.051). CONCLUSION The transmural and apicobasal differences in repolarization durations were heterogeneously distributed at atrial pacing. The acute haemodynamic response of the individual ventricle was better with pacing of the region with the longest repolarization suggesting a promising criterion for the lead position selection on the basis of ARIs measurements.
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Affiliation(s)
- Alena S Tsvetkova
- Laboratory of Cardiac Physiology, Institute of Physiology, Komi Science Center, Ural Division, Russian Academy of Sciences, 50 Pervomayskaya St., Syktyvkar, 167982 Russia
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25
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HM DELNOY PETERPAUL, OTTERVANGER JANPAUL, VOS DICKHS, ELVAN ARIF, MISIER ANANDRRAMDAT, BEUKEMA WILLEMP, STEENDIJK PAUL, VAN HEMEL NORBERTM. Upgrading to Biventricular Pacing Guided by Pressure-Volume Loop Analysis During Implantation. J Cardiovasc Electrophysiol 2010; 22:677-83. [DOI: 10.1111/j.1540-8167.2010.01968.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Foley PWX, Leyva F, Frenneaux MP. What is treatment success in cardiac resynchronization therapy? Europace 2010; 11 Suppl 5:v58-65. [PMID: 19861392 PMCID: PMC2768584 DOI: 10.1093/europace/eup308] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is an established treatment for symptomatic patients with heart failure, a prolonged QRS duration, and impaired left ventricular (LV) function. Identification of ‘responders’ and ‘non-responders’ to CRT has attracted considerable attention. The response to CRT can be measured in terms of symptomatic response or clinical outcome, or both. Alternatively, the response to CRT can be measured in terms of changes in surrogate measures of outcome, such as LV volumes, LV ejection fraction, invasive measures of cardiac performance, peak oxygen uptake, and neurohormones. This review explores whether these measures can be used in assessing the symptomatic and prognostic response to CRT. The role of these parameters to the management of individual patients is also discussed.
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Affiliation(s)
- Paul W X Foley
- Centre for Cardiovascular Sciences, University of Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
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27
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Delhaas T, Prinzen FW. Right ventricular or biventricular pacing in repaired tetralogy of Fallot? Heart Rhythm 2009; 7:351-2. [PMID: 20185108 DOI: 10.1016/j.hrthm.2009.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Indexed: 10/20/2022]
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28
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Handoko ML, Lamberts RR, Redout EM, de Man FS, Boer C, Simonides WS, Paulus WJ, Westerhof N, Allaart CP, Vonk-Noordegraaf A. Right ventricular pacing improves right heart function in experimental pulmonary arterial hypertension: a study in the isolated heart. Am J Physiol Heart Circ Physiol 2009; 297:H1752-9. [DOI: 10.1152/ajpheart.00555.2009] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Right heart failure in pulmonary arterial hypertension (PH) is associated with mechanical ventricular dyssynchrony, which leads to impaired right ventricular (RV) function and, by adverse diastolic interaction, to impaired left ventricular (LV) function as well. However, therapies aiming to restore synchrony by pacing are currently not available. In this proof-of-principle study, we determined the acute effects of RV pacing on ventricular dyssynchrony in PH. Chronic PH with right heart failure was induced in rats by injection of monocrotaline (80 mg/kg). To validate for PH-related ventricular dyssynchrony, rats (6 PH, 6 controls) were examined by cardiac magnetic resonance imaging (9.4 T), 23 days after monocrotaline or sham injection. In a second group (10 PH, 4 controls), the effects of RV pacing were studied in detail, using Langendorff-perfused heart preparations. In PH, septum bulging was observed, coinciding with a reversal of the transseptal pressure gradient, as observed in clinical PH. RV pacing improved RV systolic function, compared with unpaced condition (maximal first derivative of RV pressure: +8.5 ± 1.3%, P < 0.001). In addition, RV pacing markedly decreased the pressure-time integral of the transseptal pressure gradient when RV pressure exceeds LV pressure, an index of adverse diastolic interaction (−24 ± 9%, P < 0.01), and RV pacing was able to resynchronize time of RV and LV peak pressure (unpaced: 9.8 ± 1.2 ms vs. paced: 1.7 ± 2.0 ms, P < 0.001). Finally, RV pacing had no detrimental effects on LV function or coronary perfusion, and no LV preexcitation occurred. Taken together, we demonstrate that, in experimental PH, RV pacing improves RV function and diminishes adverse diastolic interaction. These findings provide a strong rationale for further in vivo explorations.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Cornelis P. Allaart
- Cardiology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands
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29
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Friedberg MK, Roche SL, Mohammed AF, Balasingam M, Atenafu EG, Kantor PF. Left ventricular diastolic mechanical dyssynchrony and associated clinical outcomes in children with dilated cardiomyopathy. Circ Cardiovasc Imaging 2009; 1:50-7. [PMID: 19808514 DOI: 10.1161/circimaging.108.782086] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND We investigated diastolic mechanical dyssynchrony and its relation to clinical status in pediatric dilated cardiomyopathy (DCM). METHODS AND RESULTS We calculated a diastolic and systolic dyssynchrony index (standard deviation of time to peak tissue early diastolic/systolic velocity in 12 left ventricular segments) in 33 children with DCM and 46 control subjects. A threshold to diagnose diastolic dyssynchrony was determined, and cardiac function and clinical outcomes were compared between DCM patients with and without diastolic dyssynchrony. Left ventricular wall motion was more synchronized in diastole than in systole. The diastolic dyssynchrony index was significantly higher in children with DCM than in control subjects (28.1+/-18.1 versus 9.1+/-3.8 ms, P<0.0001). A 17-ms threshold indicated the presence of diastolic dyssynchrony. Patients who died or underwent transplantation had greater diastolic dyssynchrony (diastolic dyssynchrony index 37.9+/-20.5 versus 22.1+/-13.8 ms, P=0.01), and the rate of transplant-free survival appeared to be worse for DCM patients with diastolic dyssynchrony than for patients with synchronous DCM (hazard ratio 2.98, P=0.11; hazard ratio adjusted for disease duration 2.95, P=0.17). CONCLUSIONS Left ventricular diastolic mechanical dyssynchrony is common in pediatric DCM, especially in patients who subsequently experience transplantation or death, and may be associated with a decreased length of transplantation-free survival.
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Affiliation(s)
- Mark K Friedberg
- Divisions of Pediatric Cardiology, The Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada.
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30
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Williams LK, Ellery S, Patel K, Leyva F, Bleasdale RA, Phan TT, Stegemann B, Paul V, Steendijk P, Frenneaux M. Short-term hemodynamic effects of cardiac resynchronization therapy in patients with heart failure, a narrow QRS duration, and no dyssynchrony. Circulation 2009; 120:1687-94. [PMID: 19822812 DOI: 10.1161/circulationaha.108.799395] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy produces both short-term hemodynamic and long-term symptomatic/mortality benefits in symptomatic heart failure patients with a QRS duration >120 ms. This is conventionally believed to be due principally to relief of dyssynchrony, although we recently showed that relief of external constraint to left ventricular filling may also play a role. In this study, we evaluated the short-term hemodynamic effects in symptomatic patients with a QRS duration <120 ms and no evidence of dyssynchrony on conventional criteria and assessed the effects on contractility and external constraint. METHODS AND RESULTS Thirty heart failure patients (New York Heart Association class III/IV) with a left ventricular ejection fraction < or =35% who were in sinus rhythm underwent pressure-volume studies at the time of pacemaker implantation. External constraint, left ventricular stroke work, dP/dtmax, and the slope of the preload recruitable stroke work relation were measured from the end-diastolic pressure-volume relation before and during delivery of biventricular and left ventricular pacing. The following changes were observed during delivery of cardiac resynchronization therapy: Cardiac output increased by 25+/-5% (P<0.05), absolute left ventricular stroke work increased by 26+/-5% (P<0.05), the slope of the preload recruitable stroke work relation increased by 51+/-15% (P<0.05), and dP/dtmax increased by 9+/-2% (P<0.05). External constraint was present in 15 patients and was completely abolished by both biventricular and left ventricular pacing (P<0.05). CONCLUSIONS Cardiac resynchronization therapy results in an improvement in short-term hemodynamic variables in patients with a QRS <120 ms related to both contractile improvement and relief of external constraint. These findings provide a potential physiological basis for cardiac resynchronization therapy in this patient population.
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Affiliation(s)
- Lynne K Williams
- Department of Cardiovascular Medicine, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK.
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31
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Delgado V, Tops LF, Trines SA, Zeppenfeld K, Marsan NA, Bertini M, Holman ER, Schalij MJ, Bax JJ. Acute effects of right ventricular apical pacing on left ventricular synchrony and mechanics. Circ Arrhythm Electrophysiol 2009; 2:135-45. [PMID: 19808458 DOI: 10.1161/circep.108.814608] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chronic right ventricular (RV) apical pacing has a detrimental effect on left ventricular (LV) function. However, the acute effects of RV apical pacing on LV mechanics remain unclear. The purpose of the study was to assess the acute impact of RV apical pacing on global LV function, evaluating LV contraction synchrony and LV shortening and twist, using 2D speckle-tracking strain imaging. METHODS AND RESULTS A group of 25 patients with structural normal hearts referred for electrophysiological study were studied. Two-dimensional echocardiography was performed at baseline and during RV apical pacing at the time of the electrophysiological study. Changes in LV synchrony and mechanics (longitudinal shortening and twist) were assessed using speckle-tracking strain imaging. In addition, 25 controls matched by age, sex, and LV function were studied during sinus rhythm. The group of patients (44+/-12 years, 10 men) and the group of controls (48+/-3 years, 8 men) showed comparable LV synchrony, LV longitudinal shortening, and LV twist at baseline. However, during RV apical pacing, a more dyssynchronous LV contraction was observed in the patients (from 21 ms [Q(1):10, Q(3):53] to 91 ms [Q(1):40, Q(3):204], P<0.001) together with an impairment in LV longitudinal shortening (from -18.3+/-3.5% to -11.8+/-3.6%, P<0.001) and in LV twist (from 12.4+/-3.7 degrees to 9.7+/-2.6 degrees , P=0.001). CONCLUSIONS During RV apical pacing, an acute induction of LV dyssynchrony is observed. In addition, LV longitudinal shortening and LV twist are acutely impaired.
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Affiliation(s)
- Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
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Delnoy PPH, Ottervanger JP, Luttikhuis HO, Vos DH, Elvan A, Ramdat Misier AR, Beukema WP, Steendijk P, van Hemel NM. Pressure-volume loop analysis during implantation of biventricular pacemaker/cardiac resynchronization therapy device to optimize right and left ventricular pacing sites. Eur Heart J 2008; 30:797-804. [DOI: 10.1093/eurheartj/ehp011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Tang WHW, Mullens W, Borowski AG, Tong W, Shrestha K, Troughton RW, Martin MG, Kassimatis K, Agler D, Jasper S, Grimm RA, Starling RC, Klein AL. Relation of mechanical dyssynchrony with underlying cardiac structure and performance in chronic systolic heart failure: implications on clinical response to cardiac resynchronization. Europace 2008; 10:1370-4. [DOI: 10.1093/europace/eun296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Kerckhoffs RCP, Lumens J, Vernooy K, Omens JH, Mulligan LJ, Delhaas T, Arts T, McCulloch AD, Prinzen FW. Cardiac resynchronization: insight from experimental and computational models. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 2008; 97:543-61. [PMID: 18417196 DOI: 10.1016/j.pbiomolbio.2008.02.024] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Cardiac resynchronization therapy (CRT) is a promising therapy for heart failure patients with a conduction disturbance, such as left bundle branch block. The aim of CRT is to resynchronize contraction between and within ventricles. However, about 30% of patients do not respond to this therapy. Therefore, a better understanding is needed for the relation between electrical and mechanical activation. In this paper, we focus on to what extent animal experiments and mathematical models can help in order to understand the pathophysiology of asynchrony to further improve CRT.
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Affiliation(s)
- R C P Kerckhoffs
- Department of Bioengineering, The Whitaker Institute for Biomedical Engineering, University of California, San Diego, La Jolla, CA 92093-0412, USA
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Abstract
PURPOSE OF REVIEW Until recently the right ventricle's role in myocardial dynamics has not been fully appreciated. This article provides an overview of the pathophysiology, imaging and management of right ventricular dysfunction. RECENT FINDINGS That levosimendan may promote right ventricular function opens new avenues for treatment. In addition there are existing therapies such as phosphodiesterase inhibitors and nitric oxide, which offer yet further modalities to improve outcome in right ventricular failure. How these drugs are used, in combination or alone, in conjunction with ventilatory and cardiovascular strategies has not been evaluated in multicentred randomized controlled trials. SUMMARY Acute right ventricular dysfunction is relatively common. There is a lack of convincing evidence in favour of any single treatment modality. Imaging methods now permit a more accurate evaluation of the right ventricle and its function. Combining treatments may offer significant advantages and the imaging and monitoring available allows real-time assessment of the response to intervention. This article illustrates how incomplete our knowledge of this condition and its management within the critical care setting is and reinforces previous calls for suitably designed trials to evaluate and develop guidelines for existing strategies and therapeutic agents.
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Affiliation(s)
- Justin Woods
- Department of Anaesthesia and Intensive Care Medicine, St George's Hospital, London, UK
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37
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Liu WH, Chen MC, Chen YL, Guo BF, Pan KL, Yang CH, Chang HW. Right Ventricular Apical Pacing Acutely Impairs Left Ventricular Function and Induces Mechanical Dyssynchrony in Patients with Sick Sinus Syndrome: A Real-time Three-dimensional Echocardiographic Study. J Am Soc Echocardiogr 2008; 21:224-9. [PMID: 17904807 DOI: 10.1016/j.echo.2007.08.045] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic right ventricular apical (RVA) pacing can lead to an increased risk of heart failure. However, assessment of left ventricular mechanical dyssynchrony in the whole left ventricle simultaneously with acute RVA pacing has never been investigated. METHODS AND RESULTS This study included 35 patients with sick sinus syndrome and intact intrinsic atrioventricular conduction. All patients received dual-chamber pacemaker implants with atrial leads placed in the right atrial appendage and right ventricle leads positioned in the RVA. Transthoracic two-dimensional echocardiography, tissue Doppler echocardiography, and real-time three-dimensional echocardiography were performed to determine the chamber size, dyssynchronization index, myocardial performance index, and global left ventricular ejection fraction. The myocardial performance index was significantly higher with RVA pacing (with RVA 0.42 +/- 0.18 vs. without RVA 0.31 +/- 0.14; P = .004), and left ventricular ejection fraction derived by real-time three-dimensional echocardiography was significantly lower with RVA pacing (with RVA 54.4% +/- 7.7% vs. without RVA 56.7% +/- 7.9%; P = .013), indicating deteriorated left ventricular function with RVA pacing. In addition, there was significant difference in the intraventricular delays in favor of without RVA pacing when assessed by the septal-to-posterior wall motion delay on the midventricular level (with RVA 91.9 +/- 52.5 msec vs. without RVA 38.6 +/- 28.9 msec; P < .0001) and when assessed by real-time three-dimensional echocardiography-derived systolic dyssynchrony index (with RVA 7.00% +/- 2.54% vs. without RVA 5.36 +/- 2.17%; P = .0003). CONCLUSION Acute RVA pacing can induce left ventricular mechanical dyssynchrony and impair left ventricular function in patients with sick sinus syndrome.
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Affiliation(s)
- Wen-Hao Liu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China
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Birnie DH, Tang ASL. If It Is Not Broken, Don't Fix It: Avoidance of Right Ventricular Pacing in Cardiac Resynchronization Therapy. J Cardiovasc Electrophysiol 2007; 18:505-6. [PMID: 17403083 DOI: 10.1111/j.1540-8167.2007.00799.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Frenneaux M, Williams L. Ventricular-arterial and ventricular-ventricular interactions and their relevance to diastolic filling. Prog Cardiovasc Dis 2007; 49:252-62. [PMID: 17185113 DOI: 10.1016/j.pcad.2006.08.004] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Chronic heart failure is a common clinical problem, and, until recently, attention has focused predominantly on those patients with reduced left ventricular (LV) systolic function, as evidenced by a reduced LV ejection fraction. However, nearly half of all patients thought clinically to have heart failure have a "preserved" LV ejection fraction, variously defined as greater than 40% to 45% ("heart failure with normal ejection fraction" syndrome). The interaction of the heart with the systemic vasculature, termed ventricular-arterial coupling, is a key determinant of cardiovascular performance. The capacity of the body to augment cardiac output, regulate systemic blood pressure, and respond appropriately to elevations in heart rate and preload depends on both the properties of the heart and the properties of the vasculature into which the heart ejects blood. Although the marked increase of arterial and cardiac stiffness with aging can maintain ventricular-vascular coupling within a normal range, it does have detrimental effects on hemodynamic stability and cardiac reserve. Patients with heart failure with normal ejection fraction have been shown to have both arterial and ventricular stiffening, resulting in enhanced pressure-load dependence and sensitivity of blood pressure to circulating volume and diuretics. There is also indirect evidence to suggest that on exercise, increased external constraint to LV filling (as a result of diastolic ventricular interaction and pericardial constraint) may contribute to impaired use of the Starling mechanism in this group of patients.
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Affiliation(s)
- Michael Frenneaux
- Department of Cardiovascular Medicine, University of Birmingham, Birmingham, United Kingdom
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40
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Waggoner AD, Agler DA, Adams DB. Cardiac Resynchronization Therapy and the Emerging Role of Echocardiography (Part 1): Indications and Results from Current Studies. J Am Soc Echocardiogr 2007; 20:70-5. [PMID: 17218204 DOI: 10.1016/j.echo.2005.10.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2005] [Indexed: 11/23/2022]
Abstract
Cardiac resynchronization therapy (CRT) has been established as an adjunctive treatment for patients with left ventricular systolic dysfunction and medically refractory heart failure with a wide QRS interval. Echocardiography can be used to determine the response in left ventricular structure and function after device implantation and emerging evidence as a method for selection of patients who may derive clinical benefit from CRT. This review discusses the applications of CRT, including results of clinical trials and the current experience using echocardiography. Part 2 will address the practical aspects of obtaining echocardiographic data in patients who are potential candidates for CRT and optimization of pacemaker settings after device implantation.
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Affiliation(s)
- Alan D Waggoner
- Washington University School of Medicine, St Louis, Missouri 63110, USA.
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Kerckhoffs RCP, McCulloch AD, Omens JH, Mulligan LJ. Effect of Pacing Site and Infarct Location on Regional Mechanics and Global Hemodynamics in a Model Based Study of Heart Failure. FUNCTIONAL IMAGING AND MODELING OF THE HEART 2007. [DOI: 10.1007/978-3-540-72907-5_36] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Piccirillo G, Magrì D, di Carlo S, De Laurentis T, Torrini A, Matera S, Magnanti M, Bernardi L, Barillà F, Quaglione R, Ettorre E, Marigliano V. Influence of cardiac-resynchronization therapy on heart rate and blood pressure variability: 1-year follow-up. Eur J Heart Fail 2006; 8:716-22. [PMID: 16513420 DOI: 10.1016/j.ejheart.2006.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2005] [Revised: 11/14/2005] [Accepted: 01/18/2006] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Several studies have shown that cardiac-resynchronization therapy (CRT) improves haemodynamic function, cardiac symptoms, and heart rate variability (HRV) and reduces the risk of mortality and sudden death in subjects with chronic heart failure (CHF). In subjects with CHF, power spectral values for the low-frequency (LF) component of RR variability < or =13 ms2, are associated with an increased risk of sudden death. AIMS AND METHODS To assess whether spectral indexes obtained by power spectral analysis of HRV and systolic blood pressure (SBP) variability could predict malignant ventricular arrhythmias in patients with severe CHF treated with an implantable cardioverter-defibrillator (ICD) alone or with ICD+CRT. In addition, changes in non-invasive spectral indices using short-term power spectral analysis of HRV and SBP variability during controlled breathing in 15 patients with CHF treated with an ICD alone and 16 patients receiving ICD+CRT, were assessed pre-treatment and at 1 year. RESULTS Arrhythmias necessitating an appropriate ICD shock were more frequent in subjects who had low LF power. CRT improved all spectral components, including LF power. CONCLUSIONS Low LF power values predict an increased risk of malignant ventricular arrhythmias; after 1 year of CRT most non-spectral and spectral data, including LF power, improved. Whether these improvements lead to better long-term survival in patients with CHF remains unclear.
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Affiliation(s)
- Gianfranco Piccirillo
- Dipartimento di Scienze dell'Invecchiamento, I Clinica Medica, Policlinico Umberto I, Università La Sapienza, 00161 Rome, Italy.
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Lieberman R, Padeletti L, Schreuder J, Jackson K, Michelucci A, Colella A, Eastman W, Valsecchi S, Hettrick DA. Ventricular Pacing Lead Location Alters Systemic Hemodynamics and Left Ventricular Function in Patients With and Without Reduced Ejection Fraction. J Am Coll Cardiol 2006; 48:1634-41. [PMID: 17045900 DOI: 10.1016/j.jacc.2006.04.099] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2005] [Revised: 04/17/2006] [Accepted: 04/25/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES We compared left ventricular (LV) systolic and diastolic function during right ventricular (RV), LV, and biventricular (BiV) pacing in patients with narrow QRS duration with and without LV dysfunction. BACKGROUND The optimal RV pacing lead location for patients with a standard indication for ventricular pacing remains controversial. METHODS Left ventricular pressure and volume data were determined via conductance catheter during electrophysiology study in 31 patients divided into groups with ejection fraction (EF) > or =40% (n = 17) or EF <40% (n = 14). QRS duration was 91 +/- 18 versus 106 +/- 25 ms, respectively (p = NS). Hemodynamic data were recorded during atrial and dual chamber pacing from the RV apex, RV free wall, RV septum, LV free wall, and BiV. RESULTS In patients with EF > or =40%, RV pacing at 1 or more sites, but not LV free wall or BiV pacing, significantly (p < 0.05) impaired cardiac output (CO), stroke work (SW), EF, and LV relaxation compared with atrial overdrive pacing. Right ventricular pacing also impaired hemodynamics and LV function in patients with EF <40%. However, LV and BiV pacing increased CO, SW, EF, and LV +dP/dt(MAX) in patients with LV dysfunction. Left ventricular and BiV pacing enhanced an index of global LV cycle efficiency in patients with depressed EF. The detrimental hemodynamic effects of RV pacing were attenuated by selecting the optimal RV pacing site. CONCLUSIONS Right ventricular pacing worsens LV function in patients with and without LV dysfunction unless the RV pacing site is optimized. Left ventricular and BiV pacing preserve LV function in patients with EF >40% and improve function in patients with EF <40% despite no clinical indication for BiV pacing.
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Affiliation(s)
- Randy Lieberman
- Department of Cardiology, Harper University Hospital, Detroit, Michigan 48201, USA.
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44
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Miller JD, Smith CA, Hemauer SJ, Dempsey JA. The effects of inspiratory intrathoracic pressure production on the cardiovascular response to submaximal exercise in health and chronic heart failure. Am J Physiol Heart Circ Physiol 2006; 292:H580-92. [PMID: 16997896 DOI: 10.1152/ajpheart.00211.2006] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We sought to determine whether the normal inspiratory intrathoracic pressures (P(ITP)) produced during exercise contribute to the blunted cardiac output and locomotor limb blood flow responses observed in chronic heart failure (CHF). Five chronically instrumented dogs exercised on a treadmill at 2.5 mile/h at 5% grade while healthy or after the induction of tachycardia-induced CHF. We observed several key differences in the cardiovascular responses to changes in the inspiratory P(ITP) excursion between health and CHF; namely, 1) removing approximately 70% of the normally produced inspiratory P(ITP) excursion during exercise (with 15 cmH(2)O inspiratory positive pressure ventilation) significantly reduced stroke volume (SV) in healthy animals by 5 +/- 2% (P < 0.05) but significantly increased SV and cardiac output (Q(TOT)) in animals with CHF by 5 +/- 1% (P < 0.05); 2) doubling the magnitude of the inspiratory P(ITP) excursion had no effect on SV or Q(TOT) in healthy animals but significantly reduced steady-state Q(TOT) and SV in animals with CHF by -4 +/- 3% and -10 +/- 3%, respectively; 3) removing the majority of the normally produced inspiratory P(ITP) excursion had no effect on blood flow distribution in healthy animals but increased hindlimb blood flow (9 +/- 3%, P < 0.05) out of proportion to the increases in Q(TOT); and 4) the only similarity between healthy and CHF animals was that increasing the inspiratory P(ITP) excursion significantly reduced steady-state locomotor limb blood flow by 5 +/- 2% and 6 +/- 3%, respectively (P < 0.05 for both). We conclude that 1) the normally produced inspiratory P(ITP) excursions are required for a maximal SV response to submaximal exercise in healthy animals but detrimental to the SV and Q(TOT) responses to submaximal exercise in CHF, 2) the respiratory muscle ergoreflex tonically restrains locomotor limb blood flow during submaximal exercise in CHF, and 3) excessive inspiratory muscle work further compromises cardiac function and blood flow distribution in both health and CHF.
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Affiliation(s)
- Jordan D Miller
- Univ. of Iowa, 200 Hawkins Dr., 340B Eckstein Medical Research Bldg., Iowa City, IA 52242, USA.
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Ellery S, Williams L, Frenneaux M. Role of resynchronisation therapy and implantable cardioverter defibrillators in heart failure. Postgrad Med J 2006; 82:16-23. [PMID: 16397075 PMCID: PMC2563719 DOI: 10.1136/pgmj.2005.034199] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The worldwide prevalence of heart failure is increasing in part because of an aging population. In the developed world, heart failure affects 1%-2% of the general population, accounting for 5% of adult hospital admissions. There is now convincing evidence supporting the beneficial effects of cardiac resynchronisation therapy for the treatment of heart failure. Numerous observational studies, as well as a series of randomised controlled trials, have shown the safety, efficacy, and long term benefits for patients with chronic systolic heart failure who have broad QRS complexes and refractory symptoms despite optimal medical therapy. These studies have consistently found statistically significant improvements in quality of life, New York Heart Association functional class, exercise tolerance, and left ventricular reverse remodelling. Recent evidence suggests that the benefit may at least in part be because of a reduction in mechanical dysynchrony.
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Affiliation(s)
- S Ellery
- Department of Cardiovascular Medicine, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
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46
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Williams L, Frenneaux M. Diastolic ventricular interaction: from physiology to clinical practice. ACTA ACUST UNITED AC 2006; 3:368-76. [PMID: 16810172 DOI: 10.1038/ncpcardio0584] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2005] [Accepted: 03/30/2006] [Indexed: 11/08/2022]
Abstract
The ventricles share a common septum and, therefore, the filling of one influences the compliance of the other. This phenomenon is known as direct diastolic ventricular interaction. The interaction is noticeably increased when the force exerted by the surrounding pericardium is raised, which is termed pericardial constraint. In healthy individuals, pericardial constraint is minor in the resting state. When right ventricular volume-to-pressure ratio acutely increases, however, such as during exercise, massive pulmonary embolism, or right ventricular infarction, notable diastolic ventricular interaction occurs. In this setting, the measured left ventricular intracavitary diastolic pressure overestimates the true left ventricular filling pressure, because the effect of external forces must be subtracted. Although growth of the pericardium can be a feature of chronic cardiac enlargement, here we review the evidence of the importance of diastolic ventricular interaction in certain acute and chronic disease processes, including heart failure.
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Affiliation(s)
- Lynne Williams
- Department of Cardiovascular Medicine, University of Birmingham, Birmingham, UK.
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Schuster I, Habib G, Jego C, Thuny F, Avierinos JF, Derumeaux G, Beck L, Medail C, Franceschi F, Renard S, Ferracci A, Lefevre J, Luccioni R, Deharo JC, Djiane P. Diastolic asynchrony is more frequent than systolic asynchrony in dilated cardiomyopathy and is less improved by cardiac resynchronization therapy. J Am Coll Cardiol 2006; 46:2250-7. [PMID: 16360054 DOI: 10.1016/j.jacc.2005.02.096] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2004] [Revised: 01/12/2005] [Accepted: 02/14/2005] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To compare the incidence of diastolic and systolic asynchrony, assessed by tissue Doppler imaging (TDI), in patients with congestive heart failure (CHF) and severe left ventricular (LV) dysfunction, and to assess TDI changes induced by cardiac resynchronization therapy (CRT). BACKGROUND Thirty percent of CRT candidates are nonresponders. Besides QRS width, the presence of echographic systolic asynchrony has been used to identify future responders. Little is known about diastolic asynchrony and its change after CRT. METHODS Tissue Doppler imaging was performed in 116 CHF patients (LV ejection fraction 26 +/- 8%). Systolic and diastolic asynchrony was calculated using TDI recordings of right ventricular and LV walls. RESULTS The CHF group consisted of 116 patients. Diastolic asynchrony was more frequent than systolic, concerning both intraventricular (58% vs. 47%; p = 0.0004) and interventricular (72 vs. 45%; p < 0.0001) asynchrony. Systolic and diastolic asynchrony were both present in 41% patients, but one-third had isolated diastolic asynchrony. Although diastolic delays increased with QRS duration, 42% patients with narrow QRS presented with diastolic asynchrony. Conversely, 27% patients with large QRS had no diastolic asynchrony. Forty-two patients underwent CRT. Incidence of systolic intraventricular asynchrony decreased from 71% to 33% after CRT (p < 0.0001), but diastolic asynchrony decreased only from 81% to 55% (p < 0.0002). Cardiac resynchronization therapy induced new diastolic asynchrony in eight patients. CONCLUSIONS Diastolic asynchrony is weakly correlated with QRS duration, is more frequent than systolic asynchrony, and may be observed alone. Diastolic asynchrony is less improved by CRT than systolic. Persistent diastolic asynchrony may explain some cases of lack of improvement after CRT despite good systolic resynchronization.
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Affiliation(s)
- Iris Schuster
- Echocardiography Laboratory, La Timone Hospital, Marseille, France
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Scharf C, Attenhofer Jost CH. Concepts and questions in programming cardiac resynchronization devices. Heart Rhythm 2005; 2:1073-5. [PMID: 16188584 DOI: 10.1016/j.hrthm.2005.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2005] [Indexed: 10/25/2022]
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49
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Kohli SK, Elliott P. Cardiac resynchronization therapy: the procedure and progress so far. Br J Hosp Med (Lond) 2005; 66:469-73. [PMID: 16097528 DOI: 10.12968/hmed.2005.66.8.18513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sanjay K Kohli
- Inherited Cardiovascular Disease Unit, The Heart Hospital, University College London, London W1G 8PH
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50
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Kerckhoffs RCP, Faris OP, Bovendeerd PHM, Prinzen FW, Smits K, McVeigh ER, Arts T. Electromechanics of paced left ventricle simulated by straightforward mathematical model: comparison with experiments. Am J Physiol Heart Circ Physiol 2005; 289:H1889-97. [PMID: 15964924 PMCID: PMC2396318 DOI: 10.1152/ajpheart.00340.2005] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Intraventricular synchrony of cardiac activation is important for efficient pump function. Ventricular pacing restores the beating frequency but induces more asynchronous depolarization and more inhomogeneous contraction than in the normal heart. We investigated whether the increased inhomogeneity in the left ventricle can be described by a relatively simple mathematical model of cardiac electromechanics, containing normal mechanical and impulse conduction properties. Simulations of a normal heartbeat and of pacing at the right ventricular apex (RVA) were performed. All properties in the two simulations were equal, except for the depolarization sequence. Simulation results of RVA pacing on local depolarization time and systolic midwall circumferential strain were compared with those measured in dogs, using an epicardial sock electrode and MRI tagging, respectively. We used the same methods for data processing for simulation and experiment. Model and experiment agreed in the following aspects. 1) Ventricular pacing decreased systolic pressure and ejection fraction relative to natural sinus rhythm. 2) Shortening during ejection and stroke work declined in early depolarized regions and increased in late depolarized regions. 3) The relation between epicardial depolarization time and systolic midwall circumferential strain was linear and similar for the simulation (slope = -3.80 +/- 0.28 s(-1), R2 = 0.87) and the experiments [slopes for 3 animals -2.62 +/- 0.43 s(-1) (R2 = 0.59), -2.97 +/- 0.38 s(-1) (R2 = 0.69), and -4.44 +/- 0.51 s(-1) (R2 = 0.76)]. We conclude that our model of electromechanics is suitable to simulate ventricular pacing and that the apparently complex events observed during pacing are caused by well-known basic physiological processes.
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Affiliation(s)
- R. C. P. Kerckhoffs
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - O. P. Faris
- Laboratory of Cardiac Energetics, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - P. H. M. Bovendeerd
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - F. W. Prinzen
- Department of Physiology, Maastricht University, Maastricht, The Netherlands
| | - K. Smits
- Department of Lead Modeling, Medtronic Bakken Research Center, Maastricht University, Maastricht, The Netherlands
| | - E. R. McVeigh
- Laboratory of Cardiac Energetics, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - T. Arts
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Department of Biophysics, Maastricht University, Maastricht, The Netherlands
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