Atrioventricular Cross-talk in Biventricular Pacing: A Potential Cause of Ventricular Standstill (original) (raw)
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Echocardiographic Features of Patients With Heart Failure Who May Benefit From Biventricular Pacing
Echocardiography-a Journal of Cardiovascular Ultrasound and Allied Techniques, 2003
BACKGROUND The PARAGON-HF (Prospective Comparison of ARNI With ARB Global Outcomes in HF With Preserved Ejection Fraction) trial tested the efficacy of sacubitril-valsartan in patients with heart failure with preserved ejection fraction (HFpEF). Existing data on cardiac structure and function in patients with HFpEF suggest significant heterogeneity. OBJECTIVES The aim of this study was to characterize cardiac structure and function, quantify their associations with clinical outcomes, and contextualize these findings with other HFpEF studies. METHODS Echocardiography was performed in 1,097 of 4,822 PARAGON-HF patients within 6 months of enrollment. Associations with incident first heart failure hospitalization or cardiovascular death were assessed using Cox proportional hazards models adjusted for age, sex, region of enrollment, randomized treatment, N-terminal pro-brain natriuretic peptide, and clinical risk factors. RESULTS Average age was 74 AE 8 years, 53% of patients were women, median N-terminal pro-brain natriuretic peptide level was 918 pg/ml (interquartile range: 485 to 1,578 pg/ml), 94% had hypertension, and 35% had atrial fibrillation. The mean left ventricular (LV) ejection fraction was 58.6 AE 9.8%, prevalence of LV hypertrophy was 21%, prevalence of left atrial enlargement was 83%, prevalence of elevated E/e 0 ratio was 53%, and prevalence of pulmonary hypertension was 31%. Heart failure hospitalization or cardiovascular death occurred in 288 patients at 2.8-year median follow-up. In fully adjusted models, higher LV mass index (hazard ratio [HR]: 1.05 per 10 g/m 2 ; 95% confidence interval [CI]: 1.00 to 1.10; p ¼ 0.03), E/e 0 ratio (HR: 1.04 per unit; 95% CI: 1.02 to 1.06; p < 0.001), pulmonary artery systolic pressure (HR: 1.51 per 10 mm Hg; 95% CI: 1.29 to 1.76; p < 0.001), and right ventricular end-diastolic area (HR: 1.04 per cm 2 ; 95% CI: 1.01 to 1.07; p ¼ 0.003) were each associated with this composite, while LV ejection fraction and left atrial size were not (p > 0.05 for all). Appreciable differences were observed in cardiac structure compared with other HFpEF clinical trials, despite similar E/e 0 ratio, pulmonary artery systolic pressure, and event rates. CONCLUSIONS Diastolic dysfunction, left atrial enlargement, and pulmonary hypertension were common in PARAGON-HF. LV hypertrophy, elevated left-and right-sided pressures, and right ventricular enlargement were independently predictive of incident heart failure hospitalization or cardiovascular death. Echocardiographic differences among HFpEF trials despite similar clinical event rates highlight the heterogeneity of this syndrome. (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction [PARAGON-HF];
Pace-pacing and Clinical Electrophysiology, 2002
Congestive Heart Failure: Feasibility, Safety, and Early Results in 60 Consecutive Patients. Left bundle branch block worsens congestive heart failure (CHF) in patients with LV dysfunction. Asynchronous LV activation produced by RV apical pacing leads to paradoxical septal motion and inefficient ventricular contraction. Recent studies show improvement in LV function and patient symptoms with biventricular pacing in patients with CHF. The aim of this study was to determine the feasibility, safety, acute efficacy, and early effect on symptoms of the upgrade of a chronically implanted RV pacing system to a biventricular system. Sixty patients with NYHA Class III and IV underwent the upgrade procedure using commercially available leads and adapters. The procedure succeeded in 54 (90%) of 60 patients. Acute LV stimulation thresholds obtained from leads placed along the lateral LV wall via the coronary sinus compare favorably to those reported in current biventricular pacing trials. The complication rate was low (5/60, 8.3%): lead dislodgement (n 5 1), pocket hematoma (n 5 1), and wound infections (n 5 3). During 18 months of follow-up (16.7%) of 60 patients died. Two patients that died failed the initial upgrade attempt. At 3-month follow-up, quality of life scores improved 31 6 28 points (n 5 29), P , 0.0001). NYHA Class improved from 3.4 6 0.5 to 2.4 6 0.7 (P 5 , 0.0001) and ejection fraction increased from 0.23 6 0.8 to 0.29 6 0.11 (P 5 0.0003). Modification of RV pacing to a biventricular system using commercially available leads and adapters can be performed effectively and safely. The early results of this study suggest patients may benefit from this procedure with improved functional status and quality of life. (PACE 2002; 25:1166-1171 biventricular pacing, congestive heart failure
Europace, 2009
It is currently recommended to implant the left ventricular (LV) pacing lead at the lateral wall. However, the optimal right ventricular (RV) pacing lead location for cardiac resynchronization therapy (CRT) remains controversial. We sought to investigate whether optimizing the site for placement of the RV lead could further improve the longterm response to CRT in patients with advanced heart failure. Methods and results Between October 2006 and December 2007, a total of 73 consecutive patients with standard indication for CRT were enrolled. The enrolled patients were divided into two groups based on the RV lead location. There were 50 patients in RV apex (RVA) group and 23 patients in RV high septum (RVHS). The primary study endpoint was a decrease in LV end-systolic volume (LVESV) by .15% at 6-month follow-up. The secondary endpoints were improvement in New York Heart Association (NYHA) class by 1 point and decrease in brain-type natriuretic peptide (BNP) levels by .50% after CRT. At 6-month follow-up, improvement in NYHA class by 1 point (RVA: 72% vs. RVHS: 74%, P ¼ 0.76), decrease in LVESV by 15% (RVA: 65% vs. RVHS: 64%, P ¼ 0.76), and decrease in BNP level by .50% (RVA: 70% vs. RVHS: 69%, P ¼ 0.88) were observed in similar proportion of the two groups. When we separately assessed the significance of RV pacing site in three LV stimulation sites, there were no significant differences in terms of clinical improvement (62 vs. 64%, P ¼ 0.74) and decrease in LVESV by .15% (63 vs. 62%, P ¼ 0.78) between RVA and RVHS pacing when the LV stimulation site was lateral cardiac vein. In anterolateral vein pacing site, the RVA stimulation was associated with higher clinical (88 vs. 47%, P ¼ 0.05), echocardiographic (75 vs. 32%, P ¼ 0.02), and neurohormonal responses (80 vs. 50%, P ¼ 0.04) compared with that in RVHS site. When LV was paced from posterolateral vein, RVHS pacing was superior to RVA in terms of the clinical improvement (85 vs. 35%, P ¼ 0.01), echocardiographic response (72 vs. 30%, P ¼ 0.01), and decrease in BNP levels (75 vs. 50%, P ¼ 0.04). Conclusion The present study did not show any difference between RVA and RVHS pacing sites in terms of overall improvement in clinical outcome and LV reverse remodelling following CRT. However, effect of RV lead location on CRT response varies depending on LV stimulation site.
The American Journal of Cardiology, 2003
S everal groups have studied whether further clinical benefit can be realized by "optimizing" programmed atrioventricular (AV) delay in patients with DDD pacemakers and left ventricular dysfunction, but to date no significant benefit has been clearly demonstrated. 1-10 Various techniques have been used to determine optimal AV delay in patients with DDD pacemakers, including Doppler echocardiography, nuclear techniques, and invasive hemodynamic measurements. 4 -10 We report the results of a double-blind trial in which optimal AV delay was determined using Doppler echocardiography and invasive hemodynamic measurements, and then compared these results with the "out of the box" AV delay in a crossover fashion in patients with dilated cardiomyopathy and permanent DDD pacemakers implanted for symptomatic bradycardia. The purpose of our study was to determine if "optimal" AV delay resulted in a symptomatic and functional benefit greater than that provided by the device's nominal AV delay.
Arquivos Brasileiros De Cardiologia, 2002
Received for publication on Accepted on Purpose -To analyze the influence of biventricular pacing (BP) on clinical behavior, ventricular arrhythmia (VA) prevalence, and left ventricular ejection fraction (LV EF) by gated ventriculography. Methods -Twenty-four patients with left bundle branch block (LBBB) and NYHA class III and IV underwent pacemaker implantation and were randomized either to the conventional or BP group, all receiving BP after 6 months. Results -Sixteen patients were in NYHA class IV (66.6%) and 8 were in class III (33.4%). After 1-year followup, 14 patients were in class II (70%) and 5 were in class III (25%). Two sudden cardiac deaths occurred. A significant reduction in QRS length was found with BP (p=0.006). A significant statistical increase, from a mean of 19.13 ± 5.19% (at baseline) to 25.33 ± 5.90% (with BP) was observed in LVEF Premature ventricular contraction prevalence decreased from a mean of 10,670.00 ± 12,595.39 SD or to a mean of 3,007.00 ± 3,216.63 SD PVC/24 h with BP (p<0.05). Regarding the hospital admission rate over 1 year, we observed a significant reduction from 60. To 16 admissions with BP (p<0.05). Conclusion -Patients with LBBB and severe heart failure experienced, with BP, a significant NYHA class and LVEF improvement. A reduction in the hospital admission rate and VA prevalence also occurred.
Pacemaker associated reduction of left ventricle systolic function
World Journal of Advanced Research and Reviews, 2021
In recent years, data have been accumulated on the negative effect of right ventricular (RV) stimulation, leading to left ventricular (LV) asynchrony, proarrhythmias and progressive heart failure (HF). On the other hand, biventricular pacing has been shown to affect ventricular asynchrony, reduce HF manifestations, and improve prognosis in patients with LV dysfunction and wide QRS complex. The induced asynchrony from apical right ventricular pacing is unequivocally associated with changes in myocardial perfusion, LV dysfunction, and poorer prognosis for patients over time. This has led researchers for decades to look for an alternative position for electrode placement. The incidence of pacemaker-induced cardiomyopathy (PICM) ranges from 5.9 to 39% in patients with RV pacing, depending on the given definition and the limit for the degree of pacing. Upgrading to biventricular pacing has been shown to reverse the cardiomyopathy. Recently, there has been evidence of a positive effect of...
Aims Previous experimental and clinical studies have consistently suggested that right ventricular (RV) apical pacing has important adverse effects. Ventricular pacing (VP), however, is required, and cannot be reduced in many patients with atrioventricular (AV) block. The PREVENT-HF study was an international randomized trial that explored differences in left ventricular (LV) remodelling during RV apical vs. biventricular (BIV) pacing in patients with AV block. Methods and Results Patients with an expected VP prevalence ≥80% were assigned to RV apical or BIV pacing. The primary endpoint was the change in LV end-diastolic volume (EDV) .12 months. Secondary endpoints were LV end-systolic volume (ESV), LV ejection fraction (EF), mitral regurgitation (MR), and a combination of heart failure (HF) events and cardiovascular hospitalizations. Overall, 108 patients were randomized (RV: 58; BIV: 50). Intention to treat and on-treatment analyses revealed no significant differences in any of the outcomes. Analysis of covariance (ANCOVA) difference for treatment according to randomization (in mL): LVEDV 23.92 (218.71 to 10.85), P¼0.6; LVESV 21.38 (212.07 to 9.31), P¼0.80; LVEF 2.47 (23.00 to 7.94), P¼0.37. Analysis of covariance difference for the on-treatment analysis: LVEDV 24.90 (220.02 to 10.22, PP¼0.52; LVESV 26.45 (217.28 to 4.38), P¼0.24, LVEF 2.18 (23.37 to 7.73), P¼0.44. Furthermore, secondary endpoints did not differ significantly. Conclusion This study did not demonstrate significant LV volume differences .12 months between RV apical and BIV pacing for AV block. Thus, BIV pacing cannot be recommended as a routine treatment for AV block in these patients. However, the results encourage and inform the design of subsequent larger trials with higher power for detecting small volume changes. ClinicalTrials.gov Identifier: NCT00170326.