Transvenous biventricular pacing for heart failure: can the obstacles be overcome?

doi:10.1016/S0002-9149(98)01015-7

The American Journal of Cardiology

Volume 83, Issue 5, Supplement 2, 11 March 1999, Pages 136-142

https://doi.org/10.1016/S0002-9149(98)01015-7 Get rights and content

Abstract

Despite increasing evidence of hemodynamic benefit and long-term improvement in clinical status of congestive heart failure (CHF) patients with left ventricular and biventricular pacing, the risks and technical limitations of placing a permanent left ventricular pacing lead have prevented widespread clinical adoption of this therapy. Results of this and other recent investigations suggest it is necessary to target specific sites on the left ventricle to maximize hemodynamic benefit. However, limitations and variations of coronary vein anatomy, as well as patient safety, lead dislodgement, pacing thresholds, lead handling, and ease-of-use issues, present technical challenges for current transvenous permanent pacing lead designs. However, a new transvenous lead system based on an over-the-wire design appears to solve many of these problems and has proved feasible in acute clinical studies.

Section snippets

Does pacing site matter?

Three independent investigations comparing the acute effects of different pacing sites in similar CHF populations have reported corroborating evidence that pacing site is a primary determinant of hemodynamic benefit.8, 12, 14 The patients in these studies had severely impaired functional capacity (New York Heart Association [NYHA] class III–IV), left ventricular systolic dysfunction (ejection fraction <∼35%), and the majority had wide QRS complex (>120 msec) and left bundle branch block. In

Permanent transvenous pacing of the left ventricle

The standard and historic approach to pacing the left ventricle has been to affix an electrode directly to the epicardial surface by means of a subxyphoid, thoracoscopic, or major surgical procedure. All of these methods are well proved and were routine before the advent of transvenous leads designed for endocardial placement. Directly applied epicardial leads are still used occasionally and continue to be manufactured in a variety of lead designs, including stab electrodes, “sew on” or sutured

Coronary venous access

For specific therapy applications, cardiologists have permanently implanted pacing and defibrillation leads in the proximal coronary sinus. To create the proper shape for finding the coronary sinus, physicians manually place a curve in a wire stylet that is then inserted into the lead lumen. Although stylets can be used to access the coronary sinus, they cannot effectively direct a lead further into the distal veins, because they are too stiff to negotiate turns or changes in direction from one

Conclusions

Innovative pacing techniques, a highly promising therapy for CHF patients with severe left ventricular dysfunction and conduction disorders, appears to require permanent pacing leads on the left ventricle. New transvenous lead systems are needed to allow precise placement of pacing electrodes at the most beneficial sites on the left ventricle, which appear to be in mid-lateral to inferior regions for many patients. Lead systems patterned after angioplasty devices provide a familiar and

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Evolving Concepts in Cardiac Physiologic Pacing in the Era of Conduction System Pacing
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Cardiac physiologic pacing (CPP) has become a well-established therapy for patients with cardiomyopathy (left ventricular ejection fraction <35%) in the presence of a left bundle branch block. In addition, CPP can be highly beneficial in patients with pacing-induced cardiomyopathy and patients with existing cardiomyopathy expected to have a right ventricular pacing burden of >40%. The benefits of CPP with traditional biventricular pacing are only realized if adequate resynchronization can be achieved. However, left ventricular lead implantation can be limited by individual anatomic variation within the coronary venous system and can be adversely affected by underlying abnormal myocardial substrate (i.e., scar tissue), especially if located within the basal lateral wall. In the last 7 years the investigation of conduction system pacing (CSP) and its potential salutary benefits are being realized and have led to a rapid evolution in the field of cardiac resynchronization pacing. However, supportive evidence for CSP for patients eligible for cardiac resynchronization remains limited compared with data available for biventricular cardiac resynchronization, mostly derived from leading CSP investigative centers. In this review, we perform an up-to-date comprehensive review of the available literature on CPP.
Cardiac resynchronization therapy and device-based cardiac contractility modulation
2020, Emerging Technologies for Heart Diseases: Volume 1: Treatments for Heart Failure and Valvular Disorders
Heart Failure (HF) is a global epidemic characterized by significant morbidity and mortality. Cardiac resynchronization therapy (CRT) and cardiac contractility modulation (CCM) are two device-based therapies currently available for HF patients. CRT enables favorable remodeling and improves quality of life (QOL) and mortality in HF patients with systolic dysfunction and ventricular dyssynchrony. A significant minority of patients does not benefit from CRT, and considerable research efforts are dedicated to improving CRT response. CCM is an emerging technology which improves left ventricular energy dynamics and remodeling by delivering non-excitatory electrical signals during the absolute refractory period. Initial studies of CCM have shown improvements in QOL and functional capacity in HF patients with systolic dysfunction and intact ventricular synchrony. Larger studies with longer follow-up are required before CCM is adopted into routine practice. This chapter will review current applications of CRT and CCM as well as describe future directions and challenges.
The role of interventricular conduction delay to predict clinical response with cardiac resynchronization therapy
2017, Heart Rhythm
Pacing at sites with late electrical activation or greater interventricular delay is associated with improvement in measures of cardiac resynchronization therapy (CRT) response, primarily reverse remodeling. However, little is known about whether such lead positions improve heart failure (HF) clinical outcomes.
The purpose of this study was to assess the association between interventricular electrical delay and HF clinical outcomes.
The Pacing Evaluation-Atrial SUpport Study was a multicenter randomized trial of patients undergoing CRT-defibrillator implantation. Interventricular delay was measured as the unpaced right ventricle-left ventricle (RV-LV) interval in sinus rhythm. The HF clinical composite score was the primary end point. In addition, the time to first HF hospitalization or death was measured and events were adjudicated by a blinded core laboratory. The cohort was divided at the median RV-LV interval into short (<67 ms) and long (≥67 ms) subgroups. In addition, receiver operating characteristic curves were constructed to identify the optimal cutoff of the RV-LV interval and spline analysis was performed to assess RV-LV interval as a continuous variable.
A total of 1342 patients were included in this study. The clinical composite score at 1 year differed between groups, with more patients improving and fewer patients worsening in the long RV-LV group (P = .014). The time to first HF hospitalization or mortality also differed with a lower risk of an event in the long RV-LV group (hazard ratio 0.62; P = .002). Multivariate analysis showed that RV-LV time (hazard ratio 0.71; P = .038) and sex were independent predictors of this outcome.
Baseline interventricular delay is a strong independent predictor of clinical response to CRT.
Interventricular Electrical Delay Is Predictive of Response to Cardiac Resynchronization Therapy
2016, JACC: Clinical Electrophysiology
This study was conceived to evaluate the relationship between interventricular electrical delay, as measured by the right ventricle-left ventricle (RV-LV) interval, and outcomes in a prospectively designed substudy of the SMART-AV (SMARTDELAY determined AV Optimization) trial.
Despite the well-documented benefit of cardiac resynchronization therapy (CRT), the nonresponder rate remains an important clinical problem. Implanting LV leads by traditional anatomic criteria has limited impact on outcomes. However, pacing at sites with late electrical activation improves CRT response rates. Thus, we hypothesized that interventricular electrical delay is associated with improved CRT outcomes.
This was a multicenter study of patients with advanced heart failure undergoing CRT implantation. In 419 subjects, the unpaced RV-LV interval was measured in sinus rhythm. LV volumes and ejection fraction were measured by echocardiography at baseline and after 6 months of CRT by a blinded core laboratory. Quality of life (QOL) was assessed by a standardized questionnaire.
When separated by quartiles based on interventricular delay, the magnitudes of LV volumes, ejection fraction and the QOL measure increased significantly with prolongation of RV-LV delay (p < 0.05). The LV end-systolic volume response rate increased progressively from 30% to 75% (p < 0.001), and the QOL response rate increased from 50% to 65% (p = 0.08). Patients in the highest quartile of RV-LV had a 5.98-fold increase (p < 0.001) in their odds of a reverse remodeling response, with female sex, ischemic etiology, and baseline LV end-systolic volume being the other independent predictors of response.
Baseline interventricular delay is a potent independent predictor of remodeling and QOL responses with CRT.
Cardiac Resynchronization Therapy
2016, Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy
Cardiac Resynchronization Therapy Programming and Troubleshooting
2016, Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy

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^☆: Supported by a grant from Guidant/CPI, St. Paul, Minnesota.

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Advances in Cardiac Pacing: Special Focus on Pacing for Heart FailureTransvenous biventricular pacing for heart failure: can the obstacles be overcome?☆

Abstract

Section snippets

Does pacing site matter?

Permanent transvenous pacing of the left ventricle

Coronary venous access

Conclusions

Am J Cardiol

Lancet

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Thorac Cardiovasc Surg

Improvement of cardiac function in patients with severe congestive heart failure and coronary disease by dual-chamber pacing with shortened AV delay

PACE Pacing Clin Electrophysiol

Evaluation of different ventricular pacing sites in patients with severe heart failure. Results of an acute hemodynamic study

Circulation

Beneficial effects of biventricular pacing in congestive heart failure

PACE Pacing Clin Electrophysiol

Advances in Cardiac Pacing: Special Focus on Pacing for Heart Failure
Transvenous biventricular pacing for heart failure: can the obstacles be overcome?☆