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Background: Transesophageal left atrial (LA) pacing and transesophageal LA ECG recording are semi-invasive techniques for diagnostic and therapy of supraventricular rhythm disturbance. Cardiac resynchronization therapy (CRT) with right atrial (RA) sensed biventricular pacing is an established therapy for heart failure patients with reduced left ventricular (LV) ejection fraction, sinus rhythm and interventricular electrical desynchronization.
Purpose: The aim of the study was to evaluate electromagnetic and voltage pacing fields of the combination of RA pacing, LA pacing and biventricular pacing in patients with long interatrial and interventricular electrical desynchronization.
Methods: The modelling and electromagnetic simulations of transesophageal LA pacing in combination with RA pacing and biventricular pacing would be staged and analyzed with the CST (Computer Simulation Technology) software. Different electrodes were modelled in order to simulate different types of bipolar pacing in the 3D-CAD Offenburg heart rhythm model: The bipolar Solid S (Biotronik) electrode where modelled for RA pacing and right ventricular (RV) pacing, Attain 4194 (Medtronic) for LV pacing and TO8 (Osypka) multipolar esophageal electrode with hemispheric electrodes for LA pacing.
Results: The pacemaker amplitudes for the electromagnetic pacing simulations were performed with 3 V for RA pacing, 1.5 V for RV pacing, 50 V for LA pacing and 3V for LV pacing with pacing impulse duration of 0.5 ms for RA, RV and LV pacing and 10 ms for LA pacing. The atrioventricular pacing delay after RA pacing was 140 ms. The different pacing modes AAI, VVI, DDD, DDD0V and DDD0D were evaluated for the analysis of the electric pacing field propagation of pacemaker, CRT and LA pacing. The pacing results were compared at minimum (LOW) and maximum (HIGH) parameter settings. While the LOW setting produced fewer tetrahedral and more inaccurate results, the HIGH setting produced many tetrahedral and therefore more accurate results.
Conclusions: The simulation of the combination of transesophageal LA pacing with RA sensed biventricular pacing is possible with the Offenburg heart rhythm model. The new temporary 4-chamber pacing method may be additional useful method in CRT non-responders with long interatrial electrical delay.
Introduction: Cardiac resynchronization therapy (CRT) with biventricular pacing (BV) is an established therapy for heart failure (HF) patients (P) with ventricular desynchronisation, but not all patients improved clinically. Aim of this study was to evaluate electrical intra-left ventricular conduction delay (LVCD) and interventricular conduction delay (IVCD), to better select patients for CRT.
Methods: 65 HF patients (age 63.4 ± 10.6 years; 7 females, 58 males) with New York Heart Association (NYHA) class 3 ± 0.2, 24.4 ± 6.7 % left ventricular (LV) ejection fraction and 167.4 ± 35.6 ms QRSD were included. Esophageal TO Osypka focused hemispherical electrodes catheter was perorally applied in position of maximum LV deflection to measure LVCD between onset and offset of LV deflection and IVCD between earliest onset of QRS in the 12-channel surface ECG and onset of LV deflection in the focused bipolar transesophageal LV electrogram.
Results: There were 50 responders with LVCD of 76.5 ± 20.4 ms, IVCD of 80.5 ± 26.1 ms (P=0.34) and QRSD of 171 ± 37.7 ms. 15 non-responders had longer LVCD of 90 ± 28.5 ms (P = 0.045), shorter IVCD of 50.1 ± 29.1 ms (P < 0.001) and QRSD of 155.3 ± 25 ms (P=0.14). During 21.3 ± 20.3 month BV pacing follow-up, the responder`s NYHA classes improved from 3 ± 0.2 to 2. ± 0.3 (P < 0.001) whereas the non-responders NYHA classes did not improve from 3 ± 0.2 to 2.9 ± 0.3 (P = 0.43) during 15.7 ± 13.9 month BV pacing follow-up (53 Boston, 10 Medtronic and 2 St. Jude CRT devices).
Conclusion: Determination of electrical LVCD and IVCD by focused bipolar transesophageal LV electrogram recording may be an additional useful technique to improve patient selection for CRT.
Introduction: Cardiac resynchronization therapy (CRT) with biventricular pacing is an established therapy for heart failure (HF) patients with sinus rhythm and ventricular desynchronisation. The aim of this study was to evaluate interventricular conduction delay (IVCD) and interatrial conduction delay (IACD) before and after premature ventricular contractions (PVC) in HF patients.
Methods: 13 HF patients (age 68 ± 10 years; 2 females, 11 males) with New York Heart Association functional class 2,8 ± 0.5, left ventricular (LV) ejection fraction 28,6 ± 12,6 %, 154 ± 25 ms QRS duration and PVC were analysed with bipolar transesophageal LV and left atrial electrogram recording and National Instruments LabView 2009 software. The level of significance of the t-test is 0,005.
Results: QRS duration increases during PVC (188 ± 32 ms) in comparison to the beat before (154 ± 25 ms, P = ) and after PVC (152 ± 25 ms,). IVCD increases during PVC up to 65 ± 33 ms (51 ± 19 ms in the beat before PVC, P=0.18, 49 ± 19 ms after PVC, P = 0.12). Intra-LV delay of 90 ± 16 ms is not different in the beat before PVC, 90 ± 14 ms during PVC (P = 0.99) and 94 ± 16 ms in the beat after PVC (P = 0.38). IACD is not significantly PVC influenced (67 ± 12 ms before PVC and 65 ± 13 ms after PVC, P = 0.71). Intra-left atrial conduction delay is not significant longer during PVC (57 ± 28 ms) than in the beat before PVC (54 ± 13 ms, P = 0.51) or after PVC (54 ± 8 ms, P = 0.45). PQ duration increases significantly after PVC (224 ± 95 ms) in comparison to the beat before PVC (176± 29 ms, P =...).
Conclusion: Transesophageal left cardiac electrocardiography with LabView 2009 software can improve evaluation of IVCD and IACD before, during and after PVC in HF patient selection for CRT.
Targeting complex fractionated atrial electrocardiograms by automated algorithms during ablation of persistent atrial fibrillation has produced conflicting outcomes in previous electrophysiological studies and catheter ablation of atrial fibrillation and ventricular tachycardia. The aim of the investigation was to evaluate atrial and ventricular high frequency fractionated electrical signals with signal averaging technique.
Methods: Signal averaging electrocardigraphy allows high resolution ECG technique to eliminate interference noise signals in the recorded ECG. The algorithm use automatic ECG trigger function for signal averaged transthoracic, transesophageal and intra-cardiac ECG signals with novel LabVIEW software.
Results: The analysis in the time domain evaluated fractionated atrial signals at the end of the signal averaged P-wave and fractionated ventricular signals at the end of the QRS complex. We evaluated atrial flutter in the time domain with two-to-one atrioventricular conduction, 212.0 ± 4.1 ms atrial cycle length, 426.0 ± 8.2 ms ventricular cycle length, 58.2 ± 1.8 ms P-wave duration, 119.6 ± 6.4 ms PQ duration, 103.0 ± 2.4 ms QRS duration and 296.4 ± 6.8 ms QT duration. The analysis in the frequency domain evaluated high frequency fractionated atrial signals during the P-wave and high frequency fractionated ventricular signals during QRS complex.
Conclusions: Spectral analysis of signal averaging electrocardiography with novel LabVIEW software can be utilized to evaluate atrial and ventricular conduction delays in patients with atrial fibrillation and ventricular tachycardia. Complex fractionated atrial and ventricular electrocardiograms may be useful parameters to evaluate electrical cardiac bradycardia and tachycardia signals in atrial fibrillation and ventricular tachycardia ablation.
Background: The electrical field (E-field) of the biventricular (BV) stimulation is essential for the success of cardiac resynchronization therapy (CRT) in patients with cardiac insufficiency and widened QRS complex. 3D modeling allows the simulation of CRT and high frequency (HF) ablation.
Purpose: The aim of the study was to model different pacing and ablation electrodes and to integrate them into a heart model for the static and dynamic simulation of BV stimulation and HF ablation in atrial fibrillation (AF).
Methods: The modeling and simulation was carried out using the electromagnetic simulation software. Five multipolar left ventricular (LV) electrodes, one epicardial LV electrode, four bipolar right atrial (RA) electrodes, two right ventricular (RV) electrodes and one HF ablation catheter were modeled. Different models of electrodes were integrated into a heart rhythm model for the electrical field simulation (fig.1). The simulation of an AV node ablation at CRT was performed with RA, RV and LV electrodes and integrated ablation catheter with an 8 mm gold tip.
Results: The RV and LV stimulation were performed simultaneously at amplitude of 3 V at the LV electrode and 1 V at the RV electrode, each with a pulse width of 0.5 ms. The far-field potentials generated by the BV stimulations were perceived by the RA electrode. The far-field potential at the RA electrode tip was 32.86 mV. A far-field potential of 185.97 mV resulted at a distance of 1 mm from the RA electrode tip. AV node ablation was simulated with an applied power of 5 W at 420 kHz at the distal 8 mm ablation electrode. The temperature at the catheter tip was 103.87 ° C after 5 s ablation time, 44.17 ° C from the catheter tip in the myocardium and 37.61 ° C at a distance of 2 mm. After 10 s, the temperature at the three measuring points described above was 107.33 ° C, 50.87 ° C, 40.05 ° C and after 15 seconds 118.42 ° C, 55.75 ° C and 42.13 ° C.
Conclusions: Virtual heart and electrode models as well as the simulations of electrical fields and temperature profiles allow the static and dynamic simulation of atrial synchronous BV stimulation and HF ablation at AF. The 3D simulation of the electrical field and temperature profile may be used to optimize the CRT and AF ablation.
Significance of new electrocardiographic parameters to improve cardiac resynchronization therapy
(2011)
Introduction: Oesophageal left heart electrogram (LHE) is a valuable tool providing electrocardiographic parameters for cardiac resynchronization therapy (CRT). It can be utilized to measure left ventricular (LVCD) and intra-leftventricular conduction delays (ILVCD) in heart failure patients to justify implantation of CRT systems. In the follow-up, LHE enables measurement of implant-related interatrial conduction times (IACT) which are the key intervals defining the hemodynamically optimal AV delay (AVD).
Methods: By TOSlim oesophageal electrode and Rostockfilter (Osypka AG, Rheinfelden, Germany), LHE was recorded in 39 heart failure patients (10f, 29m, 65±8yrs., QRS=163±21ms) after implantation of CRT systems according to guidelines. In position of maximal left ventricular deflection, LVCD and ILVCD were measured and compared with QRS width. In position of maximal left atrial deflection (LA), IACT was determined in VDD and DDD operation as interval As-LA and Ap-LA between atrial sense event (As) or stimulus (Ap), resp., and onset of LA. AVD was individualized using SAV =As-LA + 50ms for VDD and PAV=Ap-LA + 50ms for DDD operation.
Results: The CRT patients were characterized by minimal transoesophageal LVCD of 40ms but 73±20ms, at mean, ILVCD of 90±24ms and QRS/LVCD ratio of 2.4±0.6. The measured As-LA of 39±24ms and Ap-LA of 124±26ms resulted into SAV of 89±24ms and PAV of 174±26ms. In case of empirical AVD programming using 120ms for SAV and 180ms for PAV, the LHE revealed inverse sequences of LA and Vp in 4 patients (10%) during VDD and 13 patients (33%) in DDD pacing. In these patients, Vp preceded LA as IACT exceeded the programmed AVD.
Conclusion: Guideline indication of CRT systems is associated with LVCD of 40ms or more. Therefore, individual LVCD offers the minimal target interval that should be reached during left ventricular electrode placement to increase responder rate. Postoperatively, AV delay optimization respecting implant-related IACTs excludes adverse hemodynamic effects.
Introduction: Cardiac resynchronization therapy (CRT) with left ventricular (LV) pacing is an established therapy for heart failure (HF) patients (P) with ventricular desynchronisation and reduced LV ejection fraction (EF). The aim of this study was to test the utilization of the transesophageal approach to measure arterial pulse pressure (PP) during LV pacing and electrical interventricular conduction delay (IVCD), to better select patients for CRT.
Methods: 32 HF patients (age 64 ± 10 years; 5 females, 27 males) with New York Heart Association (NYHA) class 2.8 ± 0.6, 27 ± 11 % LV EF and 155 ± 35 ms QRS duration were analysed with semi-invasive left cardiac pacing and electrocardiography. Esophageal TO8 Osypka catheter of 10.5 F diameter was perorally applied to the esophagus and placed in the position of maximum left atrial (LA) deflection and maximum LV deflection to measure PP with VAT or D00 pacing modes.
Results: Temporary transesophageal LV pacing was possible with VAT mode (n=16) and D00 mode (n=16) in all patients. In 15 Δ-PP-responders, PP was higher during LV pacing on than LV pacing off (78.3 ± 26.6 versus 65.9 ± 23.7 mmHg, P < 0.001) and NYHA class improved from 3.1 ± 0.35 to 2.1 ± 0.35 (P < 0.001) during 29 ± 26 month biventricular (BV) pacing follow-up (6 Medtronic and 9 Boston BV pacing devices). In 17 Δ-PP-non-responders, PP was not higher during LV pacing on than LV pacing off (61.5 ± 23.9 versus 60.9 ± 23.5 mmHg, P = 0.066). IVCD was significant longer in Δ-PP-responders than in Δ-PP-non-responders (87 ± 33 ms versus 37± 29 ms, P < 0.001).
Conclusion: Semi-invasive transesophageale LA and LV pacing with D00 and VAT mode and LV electrogram recording may be useful techniques to predict CRT improvement.
Semi-invasive electromechanical target interval to guide left ventricular electrode placement
(2011)
Using guideline parameters for indication of cardiac resynchronization therapy (CRT), only about two thirds of the patients improve clinically. Unfortunately both, surface ECG and echo are uncertain to predict CRT response. To better characterize cardiac desynchronization in heart failure, interventricular (IVCD) and intra-leftventricular conduction delays (ILVCD) were measured by esophageal left ventricular electrogram (LVE). Recordings in 43 CRT patients (34m, 9f, age: 64.7 ± 9.5yrs) evidenced only weak correlation between IVCD and QRS of 0.53 and between ILVCD and QRS of 0.33. This demonstrated that QRS duration is not a reliable indicator of desynchronization. Therefore, the study resulted into development of LVE feature for a programmer with implant support device. It can be used interoperatively to guide the left ventricular electrode location in order to increase responder rate in CRT.
Introduction: Patient selection for cardiac resynchronization therapy (CRT) requires quantification of left ventricular conduction delay (LVCD). After implantation of biventricular pacing systems, individual AV delay (AVD) programming is essential to ensure hemodynamic response. To exclude adverse effects, AVD should exceed individual implant-related interatrial conduction times (IACT). As result of a pilot study, we proposed the development of a programmer-based transoesophageal left heart electrogram (LHE) recording to simplify both, LVCD and IACT measurement. This feature was implemented into the Biotronik ICS3000 programmer simultaneously with 3-channel surface ECG.
Methods: A 5F oesophageal electrode was perorally applied in 44 heart failure CRT-D patients (34m, 10f, 65±8 yrs., QRS=162±21ms). In position of maximum left ventricular deflection, oesophageal LVCD was measured between onsets of QRS in surface ECG and oesophageal left ventricular deflection. Then, in position of maximum left atrial deflection (LA), IACT in VDD operation (As-LA) was calculated by difference between programmed AV delay and the measured interval from onset of left atrial deflection to ventricular stimulus in the oesophageal electrogram. IACT in DDD operation (Ap-LA) was measured between atrial stimulus and LA..
Results: LVCD of the CRT patients was characterized by a minimum of 47ms with mean of 69±23ms. As-LA and Ap-LA were found to be 41±23ms and 125±25ms, resp., at mean. In 7 patients (15,9%), IACT measurement in DDD operation uncovered adverse AVD if left in factory settings. In this cases, Ap-LA exceeded the factory AVD. In 6 patients (13,6%), IACT in VDD operation was less than or equal 10ms indicating the need for short AVD.
Conclusion: Response to CRT requires distinct LVCD and AVD optimization. The ICS3000 oesophageal LHE feature can be utilized to measure LVCD in order to justify selection for CRT. IACT measurement simplifies AV delay optimization in patients with CRT systems irrespective of their make and model.