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Hintergrund: Richtung und Stärke des elektrischen Feldes (E-Feld) der biventrikulären (BV) Stimulation und elektrische interventrikuläre Desynchronisation sind bei Patienten mit Herzinsuffizienz und verbreitertem QRS Komplex von Bedeutung für den Erfolg der kardialen Resynchronisationstherapie (CRT). Das 3D Herzrhythmusmodell (HRM) ermöglicht die
Simulation von CRT und Hochfrequenz (HF) Ablation. Das Ziel der Studie besteht in der Integration von Schrittmacher- und Ablationselektroden in das HRM zur E-Feld Simulation der BV Stimulation und thermischen Feld (T-Feld) Simulation der HF Ablation von Vorhofflimmern (AF).
Methoden: Es wurden fünf multipolare linksventrikuläre (LV) Elektroden, eine epikardiale LV Elektrode, vier bipolare rechtsatriale (RA) Elektroden, zwei rechtsventrikuläre (RV) Elektroden und ein HF Ablationskatheter mit CST (Computer Simulation Technology, Darmstadt) modelliert und das HRM (Schalk et al: Clin Res Cardiol 106, Suppl 1, April 2017, P1812) um den Koronarvenensinus (CS) erweitert (HRM-CS). E-Feld Simulationen bei vorhofsynchroner BV Stimulation und bei RA Stimulation mit RV und LV Ableitung erfolgten mit den Elektroden Select Secure 3830, Capsure VDD-2 5038 und Attain OTW 4194 im HRM+CS (Fig.). F-Feld Simulationen der HF Ablation von AF bei CRT wurden mit integriertem Ablationskatheter AlCath G FullCircle (Biotronik) simuliert.
Ergebnisse: HRM-CS ermöglichte 3D E-Feld Simulationen bei vorhofsynchroner bipolarer BV Stimulation und bei bipolarer RA Stimulation mit bipolarer RV und LV Ableitung. RV und LV Stimulation erfolgten zeitgleich bei einer Amplitude von 3 V an der LV Elektrode und 1 V an der RV Elektrode mit einer Impulsbreite von jeweils 0,5 ms. Die von der BV Stimulationen erzeugten Fernpotentiale konnten von der RA Elektrode wahrgenommen werden. Das Fernpotential an der RA Elektrodenspitze betrug 32,86 mV und in 1 mm Abstand von der RA Elektrodenspitze ergab sich ein Fernpotential von 185,97 mV. HRM-CS ermöglichte 3D T-Feld Simulationen der HF Ablation von AF bei CRT. Das T-Feld bei HF Ablation des AV-Knotens wurde mit einer anliegenden Leistung von 5 W bei 420 kHz an der distalen 8 mm Ablationselektrode simuliert. Die Temperatur an der Katheterspitze betrug nach 5 s Ablationsdauer 88,66 °C, in 1 mm Abstand von der Katheterspitze im Myokard 42,17 °C und in 2 mm Abstand 37,49 °C.
Schlussfolgerungen: HRM-CS und Elektrodenmodelle ermöglichen die 3D Simulationen von E-Feldern bei vorhofsynchroner BV Stimulation, RA Stimulation mit RV und LV Wahrnehmung und von T-Feldern bei HF Ablation. E-Feld Simulationen von RA, RV und LV Stimulation und Sensing können möglicherweise zur Vorhersage von CRT Respondern genutzt werden.
Die Simulation komplexer kardialer Strukturen und kardialer Elektroden ist von Bedeutung für die Optimierung langatmiger und kostspieliger klinischer Studien. Das Risiko der Patientengefährdung wird durch diese Methode auf ein Minimum reduziert. Das Ziel der Studie besteht im Entwurf eines anatomisch korrekten 3D CAD Herzrhythmusmodells (HRM) zur Simulation von elektrophysiologischen Untersuchungen (EPU) und Hochfrequenz-(HF-)Ablationen.
Responder-rate in cardiac resynchronization therapy (CRT) of patients in sinus rhythm (SR) or atrial fibrillation (AF) mainly depends on accurat selection, optimal position of the left ventricular electrode and individualization of hemodynamical parameters of the implanted biventricular pacing system during follow-up. High resolution esophageal left heart electrocardiography offers a quick and semi-invasive approach to the electrical activity of left atrium and left ventricle. It was used in 62 heart failure patients in sinus rhythm and 11 in atrial fibrillation after implantation of CRT systems to compare the semi-invasive interventricular conduction delay (IVCDE) with QRS width. In all of the patients, guideline decision for CRT was linked with IVCDE of about 40ms and up. From logical point of view, IVCDE provides the minimal target interval for the left ventricular electrode placement in order to exclude non-responders. Esophageal measurement of interatrial conduction intervals in VDD and DDD pacing was utilized to individualize the AV delay and to exclude adverse hemodynamic effects.
Introduction: Cardiac resynchronisation therapy (CRT) with atrioventricular (AV) and interventricular (VV) optimized biventricular pacing (BV) is an established therapy for heart failure (HF) patients with electrical interventricular conduction delay (IVCD). The aim of the study was to compare AV and VV delay optimization with cardiac output (CO) and acceleration index (ACI) impedance cardiographic (ICG) methods.
Methods: HF patients with IVCD 86.8 ± 33 ms (n=15, age 66 ± 10 years; 2 females, 13 males), New York Heart Association (NYHA) functional class 3.1 ± 0.4, left ventricular (LV) ejection fraction 21.3 ± 7.8 % and QRS duration 176.1 ± 31.7 ms underwent AV and VV delay optimization with CO and ACI methods (Cardioscreen, Medis GmbH, Ilmenau, Germany). After evaluation of optimal AV delay, we evaluated optimal VV delay during simultaneous LV and right ventricular (RV) pacing (LV=RV), LV before RV pacing (LV-RV) and RV before LV pacing (RV-LV).
Results: Optimal VV delay was -12.3 ± 25.9 ms LV-RV pacing with VV delay range from -80 ms LV-RV pacing to +20 ms RV-LV pacing and RV=LV pacing. Optimal AV delay after atrial sensing was 108.6 ± 20.3 ms (n=14) and optimal AV delay after atrial pacing 190 ± 14.1 ms (n=2) with AV delay range from 80 ms to 200 ms. RV versus BV pacing mode resulted in improvement of CO from 3.4 ± 1.2 l/min to 4.4 ± 1.4 l/min (p<0.001) and ACI from 0.667 ± 0.227 1/s² to 0.834 ± 0.282 1/s² (p<0.002). During 34 ± 26 month BV pacing, the NYHA class improved from 3.1 ± 0.4 to 2.1 ± 0.4 (p<0.001).
Conclusion: AV and VV delay optimized BV pacing acutely improve ICG CO and ACI and their NYHA class during long-term follow-up. ICG may be a simple and useful technique to optimize AV and VV delay in CRT.
In-vivo and in-vitro comparison of implant-based CRT optimization - What provide new algorithms?
(2011)
Introduction: In cardiac resynchronization therapy (CRT), individual AV delay (AVD) optimization can effectively increase hemodynamics and reduce non-responder rate. Accurate, automatic and easily comprehensible algorithms for the follow-up are desirable. QuickOpt is the first attempt of a semi-automatic intracardiac electrogram (IEGM) based AVD algorithm. We aimed to compare its accuracy and usefulness by in-vitro and in-vivo studies.
Methods: Using the programmable ARSI-4 four-chamber heart rhythm and IEGM simulator (HKP, Germany), the QuickOpt feature of an Epic HF system (St. Jude, USA) was tested in-vitro by simulated atrial IEGM amplitudes between 0.3 and 3.5mV during both, manual and automatic atrial sensing between 0.2 and 1.0mV. Subsequently, in 21 heart failure patients with implanted biventricular defibrillators, QuickOpt was performed in-vivo. Results of the algorithm for VDD and DDD stimulation were compared with echo AV delay optimization.
Results: In-vitro simulations demonstrated a QuickOpt measuring accuracy of ± 8ms. Depending on atrial IEGM amplitude, the algorithm proposed optimal AVD between 90 and 150ms for VDD and between 140 and 200ms for DDD operation, respectively. In-vivo, QuickOpt difference between individual AVD in DDD and VDD mode was either 50ms (20pts) or 40ms (1pt). QuickOpt and echo AVD differed by 41 ± 25ms (7 – 90ms) in VDD and by 18 ± 24ms (17-50ms) in DDD operation. Individual echo AVD difference between both modes was 73 ± 20ms (30-100ms).
Conclusion: The study demonstrates the value of in-vitro studies. It predicted QuickOpt deficiencies regarding IEGM amplitude dependent AVD proposals constrained to fixed individual differences between DDD and VDD mode. Consequently, in-vivo, the algorithm provided AVD of predominantly longer duration than echo in both modes. Accepting echo individualization as gold standard, QuickOpt should not be used alone to optimize AVD in CRT patients.
Background: Cardiac resynchronization therapy (CRT) with biventricular (BV) pacing is an established therapy for heart failure (HF) patients (P) with sinus rhythm, reduced left ventricular (LV) ejection fraction (EF) and electrical ventricular desynchronization. The aim of the study was to evaluate electrical interventricular delay (IVD) and left ventricular delay (LVD) in right ventricular (RV) pacemaker pacing before upgrading to CRT BV pacing.
Methods: HF P (n=11, age 69.0 ± 7.9 years, 1 female, 10 males) with DDD pacemaker (n=10), DDD defibrillator (n=1), RV pacing, New York Heart Association (NYHA) class 3.0 ± 0.2 and 24.5 ± 4.9 % LVEF were measured by surface ECG and transesophageal bipolar LV ECG before upgrading to CRT defibrillator (n=8) and CRT pacemaker (n=3). IVD was measured between onset of QRS in the surface ECG and onset of LV signal in the transesophageal ECG. LVD was measured between onset and offset of LV signal in the transesophageal ECG. CRT atrioventricular (AV) and BV pacing delay were optimized by impedance cardiography.
Results: Interventricular and intraventricular desynchronization in RV pacemaker pacing were 228.2 ± 44.8 ms QRS duration, 86.5 ± 32.8ms IVD, 94.4 ± 23.8ms LVD, 2.6 ± 0.8 QRS-IVD-ratio with correlation between IVD and QRS-IVD-ratio (r=-0.668 P=0.0248) and 2.3 ± 0.7 QRS-LVD-ratio. The LVEF-IVD-ratio was 0.3 ± 0.1 with correlation between IVD and LVEF-IVD-ratio (r=-0.8063 P=0.00272) and with correlation between QRS duration and LVEF-IVD-ratio (r=-0.7251 P=0.01157). Optimal sensing and pacing AV delay were 128.3 ± 24.8 ms AV delay after atrial sensing (n=6) and 173.3 ± 40.4 ms AV delay after atrial pacing (n=3). Optimal BV pacing delay was -4.3 ± 11.3 ms between LV and RV pacing (n=7). During 30.4 ± 29.6 month CRT follow-up, the NYHA class improved from 3.1 ± 0.2 to 2.2 ± 0.3.
Conclusions: Transesophageal electrical IVD and LVD in RV pacemaker pacing may be additional useful ventricular desynchronization parameters to improve P selection for upgrading RV pacemaker pacing to CRT BV pacing.
Die Pulmonalvenenisolation (PVI) mithilfe von Kryoballonkathetern ist eine anerkannte Methode zur Behandlung von Vorhofflimmern (AF). Diese Methode bietet eine kürzere Behandlungsdauer als die klassische Therapie durch die Hochfrequenz- (HF) Ablation. Ziel dieser Studie war es, verschie-dene Kryoballonkatheter, HF-Ablationskatheter und Ösophaguskatheter in ein Herzrhythmusmodell zu integrieren und mit statischer und dynamischer Simulation elektrische und thermische Felder bei PVI unter Vorhofflimmern zu untersuchen.