From the Division of Cardiology, Department of Medicine, Johns Hopkins
Medical Institutions, Baltimore, Md, and Medtronic, Inc, Minneapolis, Minn.
Correspondence to Peter H. Pak, MD, Johns Hopkins Hospital, Halsted 500, 600 N Wolfe St, Baltimore, MD 21287-6568. E-mail peterpak{at}welchlink.welch.jhu.edu
Background—Dual-chamber pacing can
improve symptoms in hypertrophic cardiomyopathy
(HCM), but the mechanism remains unclear. We hypothesized that pacing
generates discoordinate contraction and a rightward shift of the
end-systolic pressure-volume relation (ESPVR) and that benefits
from this mechanism do not depend on the presence of resting outflow
pressure gradients or obstruction.
Methods and Results—Eleven patients with NYHA class III
symptoms, 5 with HCM, and 6 with hypertensive hypertrophy
and cavity obliteration, were studied by invasive conductance catheter
methods. No patient had coronary artery or primary
valvular disease. Pressure-volume relations were recorded
before and during VDD pacing by use of a short (75-millisecond) PR
interval to achieve preexcitation. Left ventricular cavity
pressure was simultaneously recorded at basal and
apical sites, with pressure at the basal site used to generate the
ESPVRs. VDD pacing shifted the ESPVR rightward, increasing
end-systolic volume by 45% (range, 17% to 151%;
P=0.002). Resting and provokable gradients declined by
20% (range, -56% to +3%) and 30% (range, -65% to -12%),
respectively (P<0.05). Preload declined by 3% to 10%
because of the short PR interval. Preload-corrected
contractility indexes and myocardial workload declined
by
Conclusions—VDD pacing shifts the ESPVR rightward in HCM patients
with cavity obliteration with or without obstruction, increasing
end-systolic volumes and reducing apical cavity compression and
cardiac work. These effects likely contribute to reduced
metabolic demand and improved symptoms.
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Mechanism of Acute Mechanical Benefit From VDD Pacing in Hypertrophied Heart
Similarity of Responses in Hypertrophic Cardiomyopathy and Hypertensive Heart Disease
10% (P<0.001). Diastolic compliance
and relaxation time were unchanged. Pacing made apical pressure-volume
loops discoordinate, limiting cavity obliteration and reducing distal
systolic pressures. Results in both patient groups were
similar.
Key Words: pacing • cardiomyopathy • hypertrophy • hemodynamics
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