Acute effects of cardiac resynchronization therapy on left ventricular Doppler indices in patients with congestive heart failure

doi:10.1067/mhj.2002.119616

American Heart Journal

Volume 143, Issue 1, January 2002, Pages 34-44

https://doi.org/10.1067/mhj.2002.119616 Get rights and content

Abstract

Background Patients with heart failure frequently exhibit intraventricular conduction delays, which contribute to asynchronous contraction patterns and impaired hemodynamic performance. Cardiac resynchronization therapy (CRT) with biventricular (BV) and left ventricular (LV) pacing has been shown to improve both hemodynamic and clinical performance. This study investigated the effects of CRT on LV Doppler indices in these patients. Methods and Results Thirty-two patients with advanced heart failure (New York Heart Association class ≥III, QRS >120 milliseconds, PR interval >150 milliseconds) were studied 4 weeks after implantation of a CRT system. Doppler echocardiography was conducted in 3 separate CRT modes, right ventricular, LV, and BV stimulation at 3 different atrioventricular delays. CRT resulted in significant improvement of Doppler parameters such as filling time (FT, 313 ± 111 milliseconds at baseline → 363 ± 154 milliseconds [BV], P <.05), aortic velocity time integral (AO_VTI 23.2 ± 7.4 cm at baseline → 26.8 ± 8.8 cm [LV], P <.05), and the myocardial performance index (MPI, 1.21 ± 0.51 at baseline → 0.85 ± 0.34 [BV], P <.05). The most improvement was observed with LV and BV stimulation at short and intermediate atrioventricular delays (80-120 milliseconds), independent of ischemic or idiopathic origin. Conclusions CRT improves hemodynamic performance in patients with heart failure with intraventricular conduction delays. Doppler echocardiography allows noninvasive evaluation of acute CRT effects in patients with heart failure. In particular, FT, AO_VTI, and MPI are useful parameters for noninvasive follow-up and optimization of pacing parameters. (Am Heart J 2002;143:34-44.)

Section snippets

Study group

The study population consisted of patients from the PATH-CHF trial, a prospective European multicenter single-blinded cross-over study.¹⁴ The study protocol was approved by the local ethics committee at each participating institution. A total of 42 patients were enrolled in the PATH-CHF trial after informed consent was obtained. Inclusion and exclusion criteria, study design, and end points have been reported elsewhere.¹⁴ In brief, patients with dilated cardiomyopathy, irrespective of the

Study group

From the included study population of 41 patients, 2 patients died before the first follow-up examination, both from sudden cardiac death. One patient was excluded from the PATH-CHF trial because of high pacing thresholds, 1 patient refused further follow-up examinations, and 5 patients could not be analyzed because of insufficient transthoracic image quality. Thus Doppler echocardiographic data of 32 patients (17 male, 15 female, mean age 59 ± 6 years) were available for analysis. For every

Discussion

Several recent studies showed beneficial effects of optimized CRT in patients with systolic heart failure and delayed intraventricular conduction by use of invasive measurement techniques. Blanc et al⁶ reported acute improvement in systolic blood pressure, pulmonary capillary wedge pressure, and V-wave amplitude during LV and BV stimulation. Other investigators demonstrated beneficial effects on pulse pressure, LV peak +dP/dt, and LV pressure-volume loops.5, 7

It is desirable to validate

Acknowledgements

We thank all patients who participated in this trial. We deeply acknowledge the help and support of all nurses and colleagues at the participating institutions.

References (40)

HB Xiao et al.
Natural history of abnormal conduction and its relation to prognosis in patients with dilated cardiomyopathy
Int J Cardiol
(1996)
A Evangelista et al.
Cardiac index quantification by Doppler ultrasound in patients without left ventricular outflow tract abnormalities
J Am Coll Cardiol
(1995)
MR Gold et al.
Acute hemodynamic effects of right ventricular pacing site and pacing mode in patients with congestive heart failure secondary to either ischemic or idiopathic dilated cardiomyopathy
Am J Cardiol
(2000)
B Schwaab et al.
Influence of right ventricular stimulation site on left ventricular function in atrial synchronous ventricular pacing
J Am Coll Cardiol
(1999)
F Victor et al.
Optimal right ventricular pacing site in chronically implanted patients: a prospective randomized crossover comparison of apical and outflow tract pacing
J Am Coll Cardiol
(1999)
A Liebold et al.
Short atrioventricular delay dual-chamber pacing early after coronary artery bypass grafting in patients with poor left ventricular function
J Cardiothorac Vasc Anesth
(1998)
M Hochleitner et al.
Usefulness of physiologic dual-chamber pacing in drug-resistant idiopathic dilated cardiomyopathy
Am J Cardiol
(1990)
AC Pearson et al.
Doppler echocardiographic assessment of the effect of varying atrioventricular delay and pacemaker mode on left ventricular filling
Am Heart J
(1988)
MR Gold et al.
Dual-chamber pacing with a short atrioventricular delay in congestive heart failure: a randomized study
J Am Coll Cardiol
(1995)
C Linde et al.
Results of atrioventricular synchronous pacing with optimized delay in patients with severe congestive heart failure
Am J Cardiol
(1995)

S Betocchi et al.

Effects of induced asynchrony on left ventricular diastolic function in patients with coronary artery disease

J Am Coll Cardiol

(1993)

Y Etienne et al.

Evaluation of left ventricular based pacing in patients with congestive heart failure and atrial fibrillation

Am J Cardiol

(1999)

WF Kerwin et al.

Ventricular contraction abnormalities in dilated cardiomyopathy: effect of biventricular pacing to correct interventricular dyssynchrony

J Am Coll Cardiol

(2000)

C Le Rest et al.

Use of left ventricular pacing in heart failure: evaluation by gated blood pool imaging

J Nucl Cardiol

(1999)

C Tei et al.

Noninvasive Doppler-derived myocardial performance index: correlation with simultaneous measurements of cardiac catheterization measurements

J Am Soc Echocardiogr

(1997)

SH Poulsen et al.

The influence of heart rate on the Doppler-derived myocardial performance index

J Am Soc Echocardiogr

(2000)

MJ Garcia et al.

New Doppler echocardiographic applications for the study of diastolic function

J Am Coll Cardiol

(1998)

WJ Stewart et al.

Variable effects of changes in flow rate through the aortic, pulmonary and mitral valves on valve area and flow velocity: impact on quantitative Doppler flow calculations

J Am Coll Cardiol

(1985)

D Farwell et al.

How many people with heart failure are appropriate for biventricular resynchronization?

Eur Heart J

(2000)

H Kuhn et al.

Die Bedeutung des Elektrokardiogramms für die Diagnose und Verlaufsbeobachtung von Patienten mit kongestiver Kardiomyopathie

Z Kardiol

(1974)

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2019, JACC: Cardiovascular Imaging
BRAVO (British Randomized Controlled Trial of AV and VV Optimization) is a multicenter, randomized, crossover, noninferiority trial comparing echocardiographic optimization of atrioventricular (AV) and interventricular delay with a noninvasive blood pressure method.
Cardiac resynchronization therapy including AV delay optimization confers clinical benefit, but the optimization requires time and expertise to perform.
This study randomized patients to echocardiographic optimization or hemodynamic optimization using multiple-replicate beat-by-beat noninvasive blood pressure at baseline; after 6 months, participants were crossed over to the other optimization arm of the trial. The primary outcome was exercise capacity, quantified as peak exercise oxygen uptake. Secondary outcome measures were echocardiographic left ventricular (LV) remodeling, quality-of-life scores, and N-terminal pro–B-type natriuretic peptide.
A total of 401 patients were enrolled, the median age was 69 years, 78% of patients were men, and the New York Heart Association functional class was II in 84% and III in 16%. The primary endpoint, peak oxygen uptake, met the criterion for noninferiority (p_{noninferiority} = 0.0001), with no significant difference between the hemodynamically optimized arm and echocardiographically optimized arm of the trial (mean difference 0.1 ml/kg/min). Secondary endpoints for noninferiority were also met for symptoms (mean difference in Minnesota score 1; p_{noninferiority} = 0.002) and hormonal changes (mean change in N-terminal pro–B-type natriuretic peptide -10 pg/ml; p_{noninferiority} = 0.002). There was no significant difference in LV size (mean change in LV systolic dimension 1 mm; p_{noninferiority} < 0.001; LV diastolic dimension 0 mm; p_{noninferiority} <0.001). In 30% of patients the AV delay identified as optimal was more than 20 ms from the nominal setting of 120 ms.
Optimization of cardiac resynchronization therapy devices by using noninvasive blood pressure is noninferior to echocardiographic optimization. Therefore, noninvasive hemodynamic optimization is an acceptable alternative that has the potential to be automated and thus more easily implemented. (British Randomized Controlled Trial of AV and VV Optimization [BRAVO]; NCT01258829)
Clinical Implications of Complete Left-Sided Reverse Remodeling With Cardiac Resynchronization Therapy: A MADIT-CRT Substudy
2016, Journal of the American College of Cardiology
Clinical implications of complete left-sided reverse remodeling due to cardiac resynchronization therapy with a defibrillator (CRT-D), defined as reduction in both left ventricular end-systolic volume (LVESV) and left atrial volume (LAV), are unknown.
This study aimed to evaluate the rate and predictive value of complete left-sided reverse remodeling on heart failure (HF) and death events in CRT-D patients with left bundle branch block (LBBB) enrolled in MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy).
The study population comprised 533 CRT-D patients with LBBB, 212 (40%) with complete left-sided reverse remodeling (above-median change in both LAV and LVESV), 115 (22%) with discordant reverse remodeling (above-median change in only LAV or LVESV), and 206 (38%) with lesser reverse remodeling (below-median LAV and LVESV change). The primary endpoint was HF or death; secondary endpoints included HF alone and death alone during long-term follow-up.
Patients with complete left-sided reverse remodeling had a significantly lower rate of HF or death than those with discordant reverse remodeling or lesser reverse remodeling (p < 0.001). Multivariate Cox proportional hazard models consistently showed a decreased risk for HF and death in patients with complete reverse remodeling compared with discordant reverse remodeling or lesser reverse remodeling (hazard ratio: 0.66 per each group; 95% CI: 0.50 to 0.85; p = 0.002). This finding was similar for HF alone and death alone.
In MADIT-CRT, >20% of CRT-D patients exhibited discordant reverse remodeling in the left ventricle and the left atrium. CRT-D patients with LBBB and complete left-sided reverse remodeling had a significantly lower risk of HF and death, HF alone, and death alone during long-term follow-up than patients with discordant or lesser reverse remodeling. (MADIT-CRT: Multicenter Automatic Defibrillator Implantation With Cardiac Resynchronization Therapy [MADIT-CRT]; NCT00180271)
Atrioventricular Optimized Direct His Bundle Pacing Improves Acute Hemodynamic Function in Patients with Heart Failure and PR Interval Prolongation Without Left Bundle Branch Block
2015, JACC: Clinical Electrophysiology
Citation Excerpt :
Improvements in cardiac function are likely to be the mechanism for these beneficial effects. The early studies of biventricular pacing in LBBB demonstrated an acute hemodynamic benefit of biventricular pacing (1,39,40). Seeing hemodynamic improvements when another defect, in another part of the conduction system upstream of the bundle branches, is targeted with pacing therapy is encouraging.
The purpose of this study was to investigate whether heart failure patients with narrow QRS duration (or right bundle branch block) but with long PR interval gain acute hemodynamic benefit from atrioventricular (AV) optimization. We tested this with biventricular pacing and (to deliver pure AV shortening) direct His bundle pacing.
Benefits of pacing for heart failure have previously been indicated by acute hemodynamic studies and verified in outcome studies. A new target for pacing in heart failure may be PR interval prolongation, which is associated with 58% higher mortality regardless of QRS duration.
We enrolled 16 consecutive patients with systolic heart failure, PR interval prolongation (mean, 254 ± 62 ms) and narrow QRS duration (n = 13; mean QRS duration: 119 ± 17 ms) or right bundle branch block (n = 3; mean, QRS duration: 156 ± 18 ms). We successfully delivered temporary direct His bundle pacing in 14 patients and temporary biventricular pacing in 14 participants. We performed AV optimization using invasive systolic blood pressure obtaining parabolic responses (mean R²: 0.90 for His, and 0.85 for biventricular pacing).
The mean increment in systolic BP compared with intrinsic ventricular conduction was 4.1 mm Hg (95% confidence interval [CI]: +1.9 to +6.2 mm Hg for His and 4.3 mm Hg [95% CI: +2.0 to +6.5 mm Hg] for biventricular pacing. QRS duration lengthened with biventricular pacing (change = +22 ms [95% CI: +18 to +25 ms]) but not with His pacing (change = +0.5 ms [95% CI: −2.6 to +3.6 ms).
AV-optimized pacing improves acute hemodynamic function in patients with heart failure and long PR interval without left bundle branch block. That it can be achieved by single-site His pacing shows that its mechanism is AV shortening. The improvement is ∼60% of the effect size previously reported for biventricular pacing in left bundle branch block. Randomized, blinded trials are warranted to test for long-term beneficial effects.
Acute echocardiographic optimization of multiple stimulation configurations of cardiac resynchronization therapy through quadripolar left ventricular pacing: A tailored approach
2014, American Heart Journal
Citation Excerpt :
Several studies have demonstrated that acute changes in VTI represent a reasonable surrogate for stroke volume variations during CRT optimization.22 Moreover, MR6 and MPI23,24 measures have been acutely adopted for CRT optimization. In this study, variation in VTI, MPI, MR, and QRSd values was observed between different quadripolar configurations.
Cardiac resynchronization therapy (CRT) is ineffective in approximately 30% of recipients, in part due to sub-optimal left ventricular (LV) pacing location. The Quartet LV lead, with 2 additional electrodes proximal to conventional bipolar lead electrodes, enables 10 different pacing configurations at four independent LV locations. In a CRT patient cohort, we sought to evaluate the spectrum of echocardiographic and electrocardiographic response over these 10 configurations, to select the optimal one in each patient. Moreover, we sought to evaluate the 6-months clinical and echocardiographic response to a “tailored approach” in which the optimal LV pacing configuration for CRT was determined by echocardiographic measures, QRSd and pacing capture thresholds.
Twenty-two consecutive CRT indicated patients were implanted with a quadripolar CRT system (St. Jude Medical). Optimal LV pacing configuration was determined by echocardiographic measures, including velocity time integral (VTI), myocardial performance index (MPI) and mitral regurgitation (MR), and an electrocardiographic measure (QRS duration) during pacing from each of the configurations at pre-discharge. The optimal LV pacing vector was chosen for every patient. Clinical and echocardiographic assessment was repeated after 6 months.
Various configurations provided different VTI, MPI, MR and QRSd values. Conventional bipolar vectors (ie, D1-M2, D1-RVc, M2-RVc) were rarely associated with the best echocardiographic improvements and provided significantly worse VTI, MR, MPI, and QRSd values than the best configuration for every patient (P = .005, P = .05 and P = .03 for VTI; P = .01, P = .005 and P = .001 for MPI; P = .003, P = .01 and P = .005 for MR, P > .5, P = .01 and P = .05 for QRSd) Conversely, “unconventional” proximal configurations (ie, making use of P4 and M3 electrodes) were generally characterized by higher acute VTI, MR and MPI improvements. CRT devices were reprogrammed with an “unconventional” LV pacing configuration in 50% of patients. A significant improvement in New York Heart Association class (81%), LV ejection fraction (76%), end-diastolic and end-systolic volumes was observed after 6 months (P = .02, P < .001, P = .02 and P = .003, respectively).
In this study, conventional bipolar vectors of quadripolar-CRT were rarely associated with the best echocardiographic improvements. Quadripolar CRT utilizing optimal LV pacing configuration was associated with a significant improvement in New York Heart Association class and LV ejection fraction after 6 months.
Usefulness and consequences of cardiac resynchronization therapy in dialysis-dependent patients with heart failure
2013, American Journal of Cardiology
Citation Excerpt :
One potential explanation involves understanding the potential mechanisms by which CRT may exert its therapeutic effects in patients with and without dialysis dependence. Resynchronization of the LV leads to acute and chronic hemodynamic changes11 that lead to reduced LV filling pressures,12 improved myocardial oxygen consumption,13 increased coronary perfusion,14 and increased cardiac output15 with resultant improvements in perfusion of the kidneys and other end organs. Although dialysis-dependent patients should have the potential to benefit by way of a number of these mechanisms, the benefits of augmented renal perfusion is likely limited at best.
Cardiac resynchronization therapy (CRT) is often deferred in dialysis-dependent patients with heart failure (HF) because of a perceived lack of benefit and potentially higher risks, although the outcomes associated with CRT in dialysis have not been reported. We therefore studied our center's experience with CRT in dialysis-dependent patients. We constructed a descriptive assessment of these patients (n = 15) and performed a case-control analysis matching for age, gender, bundle branch morphology, diabetes mellitus, cardiomyopathy origin, and β-blocker and angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker use. Baseline and 6-month echocardiograms were assessed for evidence of reverse remodeling. No periprocedural or long-term complications were observed among dialysis patients. Heterogenous improvement in ejection fraction (+3.1 ± 9.2%) was noted and 2 patients derived absolute improvements of 8% and 22%, respectively. Dialysis patients demonstrated the following 3-year event rates: HF hospitalization, 31%; all-cause hospitalization, 100%; mortality, 73%; and HF hospitalization or death, 82%. In the case-control analysis, controls demonstrated superior reverse remodeling (+9.2 ± 9.5% increase in ejection fraction), decreased mortality (73% vs 44%, p = 0.038), and all-cause hospitalizations (76% vs 100%, p = 0.047), with no difference in HF hospitalizations (p = 0.39), compared with dialysis patients. In conclusion, at our center, the dialysis-dependent patients with HF who underwent CRT implantation did so safely and no serious complications were observed. Certain dialysis patients demonstrated compelling improvement after device implantation. Compared with matched controls, dialysis patients were at increased risk for adverse events and worsened echocardiographic outcomes.
2012 EHRA/HRS expert consensus statement on cardiac resynchronization therapy in heart failure: Implant and follow-up recommendations and management
2012, Heart Rhythm

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^☆: Supported by a grant from the Guidant Corporation, Brussels, Belgium. T. P. and R. S. are employees of Guidant Corporation.

^☆☆: Reprint requests: Christoph Stellbrink, MD, Medizinische Klinik I der RWTH Aachen, Pauwelsstrasse 30, D-52057 Germany. E-mail: [email protected]

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Clinical Investigations: Congestive Heart FailureAcute effects of cardiac resynchronization therapy on left ventricular Doppler indices in patients with congestive heart failure☆,☆☆

Abstract

Section snippets

Study group

Study group

Discussion

Acknowledgements

Int J Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Cardiothorac Vasc Anesth

Am J Cardiol

Am Heart J

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Nucl Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Coll Cardiol

How many people with heart failure are appropriate for biventricular resynchronization?

Eur Heart J

Die Bedeutung des Elektrokardiogramms für die Diagnose und Verlaufsbeobachtung von Patienten mit kongestiver Kardiomyopathie

Z Kardiol

Clinical Investigations: Congestive Heart Failure
Acute effects of cardiac resynchronization therapy on left ventricular Doppler indices in patients with congestive heart failure☆,☆☆