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Blessberger H, Kammler J, Kellermair J, Kiblboeck D, Nahler A, Hrncic D, Saleh K, Schwarz S, Reiter C, Fellner A, Eppacher C, Sheldon TJ, Steinwender C. Impact of pacing mode and different echocardiographic parameters on cardiac output (PADIAC). Front Cardiovasc Med 2023; 10:1185518. [PMID: 37265566 PMCID: PMC10231674 DOI: 10.3389/fcvm.2023.1185518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/27/2023] [Indexed: 06/03/2023] Open
Abstract
Introduction The extent of the hemodynamic benefit from AV-synchronous pacing in patients with sinus rhythm and AV block is not completely understood. Thus, we systematically investigated the association of an array of echocardiographic and epidemiological parameters with the change in cardiac output depending on the stimulation mode (AV-synchronous or AV-asynchronous pacing). Methods Patients in sinus rhythm after previous dual chamber pacemaker implantation underwent a thorough basic echocardiographic assessment of diastolic and systolic left ventricular function, and atrial function (26 echo parameters, including novel speckle tracking strain measurements). Then, stroke volume was measured with AV-synchronous (DDD) and AV-asynchronous (VVI) pacing. Each patient represented their own control, and the sequence of stroke volume measurements was randomized. Results In this prospective single-center study (NCT04068233, registration August 22nd 2019), we recruited 40 individuals. The stroke volume was higher in all patients when applying AV-synchronous DDD pacing [median increase 12.8 ml (16.9%), P < 0.001]. No echo parameter under investigation was associated with the extent of stroke volume increase in a linear regression model. Of all epidemiological variables, a history of acute myocardial infarction (AMI) was associated with an attenuated stroke volume gain in a univariate and a multivariate regression model that adjusted for confounders. A- and S-wave velocities were reduced in the AMI group. Discussion In our cohort of patients, each subject benefited from AV-synchronous DDD pacing. No single echo parameter could predict the amount of stroke volume increase. The beneficial effect of AV-synchronous pacing on stroke volume was attenuated after prior acute myocardial infarction.ClinicalTrials.gov identifier (NCT number): NCT04068233.
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Affiliation(s)
- Hermann Blessberger
- Department of Cardiology, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Juergen Kammler
- Department of Cardiology, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University, Linz, Austria
- Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Joerg Kellermair
- Department of Cardiology, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Daniel Kiblboeck
- Department of Cardiology, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Alexander Nahler
- Department of Cardiology, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Denis Hrncic
- Department of Cardiology, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Karim Saleh
- Department of Cardiology, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Stefan Schwarz
- Department of Cardiology, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Christian Reiter
- Department of Cardiology, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Alexander Fellner
- Department of Cardiology, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University, Linz, Austria
| | | | | | - Clemens Steinwender
- Department of Cardiology, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University, Linz, Austria
- Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
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Saeed S, Gu H, Rajani R, Chowienczyk P, Chambers JB. First phase ejection fraction in aortic stenosis: A useful new measure of early left ventricular systolic dysfunction. J Clin Ultrasound 2021; 49:932-935. [PMID: 34505640 DOI: 10.1002/jcu.23063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/24/2021] [Accepted: 08/28/2021] [Indexed: 06/13/2023]
Abstract
In aortic stenosis (AS), a left ventricular (LV) ejection fraction (EF) <50% or symptoms are class I indications for aortic valve intervention. However, an EF <50% may be too conservative since subendocardial fibrosis may already have developed. An earlier marker of LV systolic dysfunction is therefore needed and first phase EF (EF1) is a promising new candidate. It is the EF measured over early systole to the point of maximum transaortic blood flow. It may be low in the presence of preserved total LV EF since the heart may compensate by recruiting myosin motors in later systole. The EF1 is inversely related to the grade of AS and directly related to markers of subendocardial fibrosis like late gadolinium enhancement on cardiac magnetic resonance scanning. A reduced EF1 (<25%) predicts adverse clinical events better that total EF and global longitudinal strain. We suggest that it is worth exploring as an indication for surgery in patients with asymptomatic severe AS.
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Affiliation(s)
- Sahrai Saeed
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Haotian Gu
- BHF Centre of Research Excellence, King's College London, London
| | - Ronak Rajani
- Cardiothoracic Centre, Guy's and St. Thomas' Hospitals, London, UK
| | - Phil Chowienczyk
- BHF Centre of Research Excellence, King's College London, London
| | - John B Chambers
- Cardiothoracic Centre, Guy's and St. Thomas' Hospitals, London, UK
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Abstract
INTRODUCTION The heart and arterial system are equally affected by arteriosclerosis/atherosclerosis. There is a constant interaction between the left ventricular (LV) function and the arterial system, termed ventricular-arterial coupling (VAC), which reflects the global cardiovascular efficiency. VAC is traditionally assessed by echocardiography as the ratio of effective arterial elastance (Ea) over end-systolic elastance (Ees) (Ea/Ees). However, the concept of VAC is evolving and new methods have been proposed such as the ratio of pulse wave velocity (PWV) to global longitudinal strain (GLS) and myocardial work index. AREA COVERED This clinical review presents the hemodynamic background of VAC, its clinical implications and the impact of therapeutic interventions to normalize VAC. The review also summarizes the detrimental effects of cardio-metabolic risk factors on the aorta and LV, and provides an update on arterial load and its impact on LV function. The narrative review is based upon a systemic search of the bibliographic database PubMed for publications on VAC. EXPERT OPINION Newer methods such as PWV/GLS-ratio may be a superior marker of VAC than the traditional echocardiographic Ea/Ees in predicting target organ damage and its association with clinical outcomes. Novel anti-diabetic drugs and optimal antihypertensive treatment may normalize VAC in high-risk patients.
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Affiliation(s)
- Sahrai Saeed
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Hannes Holm
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Peter M Nilsson
- Department of Clinical Sciences, Lund University, Skåne University Hospital, Malmö, Sweden
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