(Circulation. 1999;99:1567-1573.)
© 1999 American Heart Association, Inc.
Clinical Investigation and Reports |
Improved Left Ventricular Mechanics From Acute VDD Pacing in Patients With Dilated Cardiomyopathy and Ventricular Conduction Delay
From the Division of Cardiology, Department of Medicine, the Johns Hopkins Medical Institutions, Baltimore, Md. Dr Chen was a Clinical Research Fellow from the Division of Cardiology, Department of Medicine, Veterans General Hospital Taipei, and National Yang-Ming University, Taiwan, ROC.
Correspondence to David A. Kass, MD, Halsted 500, the Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21287. E-mail dkass{at}eureka.wbme.jhu.edu
Background—Ventricular pacing can improve hemodynamics in heart failure patients, but direct effects on left ventricular (LV) function from varying pacing site and atrioventricular (AV) delay remain unknown. We hypothesized that the magnitude and location of basal intraventricular conduction delay critically influences pacing responses and that single-site pacing in the delay-activated region yields similar or better responses to biventricular pacing.
Methods and Results—Aortic and LV pressures were measured in 18
heart failure patients (mean±SD: LV ejection fraction, 19±7%; LV
end-diastolic pressure, 25±8 mm Hg; QRS duration,
157±36 ms). Data under normal sinus rhythm were compared with
ventricular pacing (VDD) at varying sites and AV delays
(randomized order). Right ventricular (RV) apical or
midseptal pacing had negligible contractile/systolic effects.
However, LV free-wall pacing raised dP/dtmax by
23.7±19.0% and pulse-pressure by 18.0±18.4%
(P<0.01). Biventricular pacing yielded less
change (+12.8±9.3% in dP/dtmax, P<0.05
versus LV). Pressure-volume analysis performed in 11 patients
consistently revealed minimal changes with RV pacing but
increased stroke work and lower end-systolic volumes with LV
pacing. Optimal AV intervals averaged 125±49 ms, and within this
range, AV delay had less influence on LV function than pacing site.
Basal QRS duration positively correlated with %
dP/dtmax
(P<0.005), but pacing efficacy was not associated with
QRS narrowing. Conduction delay pattern generally predicted pacing
sites with most effect.
Conclusions—VDD pacing acutely enhances contractile function in heart failure patients with intraventricular conduction delay. Single-site pacing at the site of greatest delay achieves similar or greater benefits to biventricular pacing in such patients. These data clarify pacing-effect mechanisms and should help in candidate identification for future studies.
Key Words: mechanics • ventricles • pacing • conduction • heart failure
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P. Steendijk, S. A. Tulner, J. J. Bax, P. V. Oemrawsingh, G. B. Bleeker, L. van Erven, H. Putter, H. F. Verwey, E. E. van der Wall, and M. J. Schalij Hemodynamic Effects of Long-Term Cardiac Resynchronization Therapy: Analysis by Pressure-Volume Loops Circulation, March 14, 2006; 113(10): 1295 - 1304. [Abstract] [Full Text] [PDF]
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X. A. A. M. Verbeek, A. Auricchio, Y. Yu, J. Ding, T. Pochet, K. Vernooy, A. Kramer, J. Spinelli, and F. W. Prinzen Tailoring cardiac resynchronization therapy using interventricular asynchrony. Validation of a simple model Am J Physiol Heart Circ Physiol, March 1, 2006; 290(3): H968 - H977. [Abstract] [Full Text] [PDF]
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D. A. Kass Cardiac Resynchronization Therapy and Cardiac Reserve: How You Climb a Staircase May Alter Its Steepness Circulation, February 21, 2006; 113(7): 923 - 925. [Full Text] [PDF]
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M. S. Suffoletto, K. Dohi, M. Cannesson, S. Saba, and J. Gorcsan III Novel Speckle-Tracking Radial Strain From Routine Black-and-White Echocardiographic Images to Quantify Dyssynchrony and Predict Response to Cardiac Resynchronization Therapy Circulation, February 21, 2006; 113(7): 960 - 968. [Abstract] [Full Text] [PDF]
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D. Vollmann, L. Luthje, P. Schott, G. Hasenfuss, and C. Unterberg-Buchwald Biventricular Pacing Improves the Blunted Force-Frequency Relation Present During Univentricular Pacing in Patients With Heart Failure and Conduction Delay Circulation, February 21, 2006; 113(7): 953 - 959. [Abstract] [Full Text] [PDF]
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C. Leclercq, G. Ansalone, F. Gadler, G. Boriani, N. Perez-Castellano, N. Grubb, S. Sack, and E. Boulogne Biventricular vs. left univentricular pacing in heart failure: rationale, design, and endpoints of the B-LEFT HF study. Europace, January 1, 2006; 8(1): 76 - 80. [Abstract] [Full Text] [PDF]
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Z. I. Whinnett, J. E.R. Davies, K. Willson, A. W. Chow, R. A. Foale, D. W. Davies, A. D. Hughes, D. P. Francis, and J. Mayet Determination of optimal atrioventricular delay for cardiac resynchronization therapy using acute non-invasive blood pressure. Europace, January 1, 2006; 8(5): 358 - 366. [Abstract] [Full Text] [PDF]
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J. J. Bax, T. Abraham, S. S. Barold, O. A. Breithardt, J. W.H. Fung, S. Garrigue, J. Gorcsan III, D. L. Hayes, D. A. Kass, J. Knuuti, et al. Cardiac Resynchronization Therapy: Part 2--Issues During and After Device Implantation and Unresolved Questions J. Am. Coll. Cardiol., December 20, 2005; 46(12): 2168 - 2182. [Abstract] [Full Text] [PDF]
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J. M. Aranda Jr, G. W. Woo, R. S. Schofield, E. M. Handberg, J. A. Hill, A. B. Curtis, S. F. Sears, J. S. Goff, D. F. Pauly, and J. B. Conti Management of Heart Failure After Cardiac Resynchronization Therapy: Integrating Advanced Heart Failure Treatment With Optimal Device Function J. Am. Coll. Cardiol., December 20, 2005; 46(12): 2193 - 2198. [Abstract] [Full Text] [PDF]
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A. D. Waggoner, M. N. Faddis, M. J. Gleva, L. de las Fuentes, and V. G. Davila-Roman Improvements in Left Ventricular Diastolic Function After Cardiac Resynchronization Therapy Are Coupled to Response in Systolic Performance J. Am. Coll. Cardiol., December 20, 2005; 46(12): 2244 - 2249. [Abstract] [Full Text] [PDF]
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A. M. Dubin, J. Janousek, E. Rhee, M. J. Strieper, F. Cecchin, I. H. Law, K. M. Shannon, J. Temple, E. Rosenthal, F. J. Zimmerman, et al. Resynchronization Therapy in Pediatric and Congenital Heart Disease Patients: An International MultiCenter Study J. Am. Coll. Cardiol., December 20, 2005; 46(12): 2277 - 2283. [Abstract] [Full Text] [PDF]
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D. E. Gutstein, S. B. Danik, S. Lewitton, D. France, F. Liu, F. L. Chen, J. Zhang, N. Ghodsi, G. E. Morley, and G. I. Fishman Focal gap junction uncoupling and spontaneous ventricular ectopy Am J Physiol Heart Circ Physiol, September 1, 2005; 289(3): H1091 - H1098. [Abstract] [Full Text] [PDF]
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G. Lecoq, C. Leclercq, E. Leray, C. Crocq, C. Alonso, C. d. Place, P. Mabo, and C. Daubert Clinical and electrocardiographic predictors of a positive response to cardiac resynchronization therapy in advanced heart failure Eur. Heart J., June 1, 2005; 26(11): 1094 - 1100. [Abstract] [Full Text] [PDF]
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M. O. Sweeney, A. S. Hellkamp, K. L. Lee, G. A. Lamas, and for the Mode Selection Trial (MOST) Investigators Association of Prolonged QRS Duration With Death in a Clinical Trial of Pacemaker Therapy for Sinus Node Dysfunction Circulation, May 17, 2005; 111(19): 2418 - 2423. [Abstract] [Full Text] [PDF]
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