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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.
Electrical velocimetry to optimize VV delay in biventricular VVIR and DDD pacing for heart failure
(2011)
Introduction: VV delay (VVD) is the only parameter to hemodynamically optimize cardiac resynchronization therapy (CRT) for patients with atrial fibrillation (AF). Electrical velocimetry (EV) has been established to monitor thoracic electrical conductivity and to calculate hemodynamic surrogate parameters. We compared the response of this method to hemodynamic parameter changes between CRT patients with sinus rhythm (SR) and patients with AF.
Methods: VVD was individualized in 17 CRT patients in SR (12m, 5f, 67.0±7.2yrs.) after echo AV delay optimization and in 11 CRT patients in AF (10m, 1f, 69.8±9.6yrs.) using the Aesculon Cardiovascular Monitor (Osypka Medical, Berlin, Germany). Serial 30s EV recordings were accomplished, decreasing the VVD stepwise by 10ms from +60ms to -60ms between right and left ventricular stimulus. Optimal VVD was determined by the maximum of at least two of the three averaged parameters stroke volume (SV), cardiac output (CO) and cardiac index (CI). The response of SV, CO and CI was tested comparing their values in optimal VVD and suboptimal VVD. Suboptimal VVD was defined by optimal VVD±20ms.
Results: In all 28 patients in SR and AF, EV recordings resulted in optimal VVD. Between suboptimal and optimal mean VVD of 18.6±30.8ms between left and right ventricular stimulus, SV increased by 7.2±6.8%, CO by 7.8±7.2% and CI by 10.0±13.3% (all p<0.02). In the SR group with VVD of 18.8± 29.6ms, SV increased by 4.6±2.9%, CO by 5.0±2.9% and CI by 4.9±2.9% (all p<0.02). In the AF group with VVD of 18.2±4.0ms, SV increased by 10.4±8.9%, CO by 11.3±9.5% and CI by 16.4±18.2% (all p<0.02). Significant differences were not found between optimal VVD in SR and AF patients.
Conclusion: EV is a feasible serial method to individualize VVD in DDD and VVIR pacing for heart failure. Its response to hemodynamic changes demonstrates the value of EV for VVD fine-tuning.
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 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 (BV) pacing is an established therapy for heart failure (HF) patients with ventricular desynchronisation and reduced left ventricular (LV) function. The aim of this study was to evaluate preejection period (PEP) and left ventricular ejection time (LVET) with transthoracic signal averaging impedance and electrocardiography in HF patients with and without BV pacing.
Methods: 10 HF patients (age 68.9 ± 8 years; 2 females, 9 males) with New York Heart Association (NYHA) class 2,9 ± 0.5, 30.9 ± 10.5 % LV ejection fraction and 159.4 ± 22.9 ms QRS duration were analysed with transthoracic impedance and electrocardiography (Cardioscreen Medis, Ilmenau, Germany) and novel National Intruments LabView 2009 signal averaging software. One day after BV pacing device implantation, AV and VV delays were optimized by transthoracic impedance cardiography and stroke volume (SV) and cardiac output (CO) were gained by Cardioscreen.
Results: Transthoracic impedance and electrocardiography AV and VV delay opimization was possible in all HF patients with BV pacing devices (n= 10). PEP was 154 ± 24ms without BV pacing and measured between onset of QRS in the surface electrocardiogram and onset of ventricular deflection in the impedance cardiogram. LVET was 342 ± 65ms without BV pacing and measured between onset and offset of ventricular deflection in the impedance cardiogram. The use of optimal AV and VV delay BV pacing resulted in improvement of SV from 64.1 ± 26.5 ml to 94.1 ± 33.96 ml (P < 0.05) and CO from 4.05 ± 1.36 l/min to 6.44 ± 1.56 l/min (P < 0.05).
Conclusion: PEP and LVET may be useful parameters of ventricular Desynchronisation. AV and VV delay optimized BV pacing improve SV and CO. Impedance and electrocardiography with LabView 2009 signal averaging may be a simple and useful technique to optimize CRT.
Die kardiale Resynchronisationstherapie ist ein großer Segen für viele Patienten mit einer Herzschwäche, die auf einen krankhaften Verlust der synchronen Kontraktion beider Herzkammern zurückzuführen ist. Warum einige von ihnen jedoch nicht darauf ansprechen, wird gegenwärtig erforscht. Als eine neue Methode mit dem Ziel der Effektivitätssteigerung dieser Therapie mit elektronischen Implantaten demonstrieren wir die Nutzbarkeit von durch eine Schluckelektrode aus der Speiseröhre abgeleiteten Elektrokardiogrammen.