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About 20% of those heart failure patients receiving cardiac resynchronization therapy (CRT) are in atrial fibrillation (AF). Current guidelines apply for patients in sinus rhythm only. Recent studies have shown again, that successful resynchronization is closely linked to a pre-existent ventricular desynchronization. In those studies, the interventricular conduction delay (IVCD) was determined prior to device implantation by ultrasound in patients with sinus rhythm (SR)only. In patients with AF this method ́s use is limited.
To implement left-heart electrogram (LHE) into standard programmers and to simplify IVCD measurement in heart failure patients with AF, LHE was recorded in 11 AF patients with heart failure by Biotronik ICS3000 programmer via a15Hz Butterworth high-pass filter. Therefore, TOslim esophageal electrode (Dr. Osypka GmbH, Rheinfelden, Germany) was perorally applied and fixed in position of maximal left ventricular defection. IVCD was measured between onset of QRS in surface ECG and left ventricular defection (LV) in LHE. In addition, intra-left ventricular conduction delay (ILVCD) was measured as duration of LV in LHE.
In all of the 11 AF patients, desynchronization was quantifiable by LHE. Mean QRS of 162 ± 27ms (120-206ms) was linked with IVCD of 62ms ± 27ms (37-98ms) and ILVCD of 110 ± 20ms (80-144ms), at mean. Correlation between IVCD and QRS was 0.39 (n. s.) with IVCD/QRS ratio of 0.38 ± 0.11 (0.22-0.81).
A 15Hz high-pass filtered LHE feature of the Biotronik ICS3000 programmer is feasible to quantify ventricular dyssynchrony in heart failure patients with AF in order to clearly indicate implantation of CRT systems. As relations between QRS duration, IVCD and ILVCD considerably differ interindividually, the predictive values of IVCD, ILVCD and IVCD/QRS ratio for individual CRT response or non-response shall be identified in follow-up studies.
ECG simulators, available on the market, imitate the electric activity of the heart in a simplified manner. Thus, they are suitable for education purposes but not really for testing algorithms to recognize complex arrhythmias needed for pacemakers and implantable defibrillators. Especially certain discrimination between various morphologies of atrial and ventricular fibrillation needs simulators providing native electrograms of different patients’ heart rhythm events. This explains the necessity to develop an ECG simulator providing high-resolution native intracardiac and surface electrograms of in-vivo rhythm events. In this paper we demonstrate an approach for an ECG simulator based on a consumer multichannel soundcard and a corresponding software application for a laptop computer. This Live-ECG Simulator is able to handle invasive electrogram recordings from electrophysiological studies and send the data to a modified external soundcard for subsequent digital to analog conversion. The hardware is completed with an electronic circuit providing level adjustment to adapt the output amplitude to the input conditions of several cardiac implants.
In cardiac resynchronization therapy (CRT) for heart failure, individualization of the AV delay is essential to improve hemodynamics and to minimize non-responder rate. In patients in sinus rhythm having additional disposition to bradycardia, optimization is necessary for both situations, atrial sensing and pacing. Therefore, echo-optimization is the goldstandard but time consuming. Unfortunately, it depends on the particular CRT systems parameter set if the resulting individually optimal AV delays can be programmed or not. Some CRT systems provide a set of AV delays for DDD operation combined with a set of the pace-sense-compensation to optimize the AV delay in DDD and VDD operation. The pace-sense-compensation (PSC) can be defined by the difference of implant-related interatrial conduction intervals in DDD and VDD operation measured in the esophageal left atrial electrogram. In a cohort of 96 CRT patients we found mean PSC of 59-35ms ranging between 0-143ms. As a consequence, allowing 10ms tolerance, AVD optimization is completely impossible in one of the two modes, VDD or DDD operation, in 34 (35%) or 5 (5%) patients with implants restricting the PSC range to 60ms or 100ms, respectively. Thus, we propose companies to provide CRT systems with programmable pace-sense- compensation between 0ms and 150ms.
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.
New frontiers of supraventricular tachycardia and atrial flutter evaluation and catheter ablation
(2012)
Radiofrequency catheter ablation (RFCA) has revolutionized treatment for tachyarrhythmias and has become first-line therapy for some tachycardias. Although developed in the 1980s and widely applied in the 1990s, the technique is still in development. Transesophageal atrial pacing (TAP) can used for initiation and termination of supraventricular tachycardia (SVT).
Methods: The paroxysmal SVT include a wide spectrum of disorders including, in descending order of frequency, atrial flutter, atrioventricular (AV) nodal reentry, Wolff-Parkinson-White syndrome, and atrial tachycardia. While not life-threatening in most cases, they may cause important symptoms, such as palpitations, chest discomfort, breathlessness, anxiety, and syncope, which significantly impair quality of life. Medical therapy has variable efficacy, and most patients are not rendered free of symptoms. Research over the past several decades has revealed fundamental mechanisms involved in the initiation and maintenance of all of these arrhythmias. Knowledge of mechanisms has in turn led to highly effective surgical and catheter-based treatments. The supraventricular arrhythmias and their treatment are described in this report. SVT initiation was analysed with programmed TAP in 49 patients with palpitations (age 47 ± 17 years, 24 females, 25 males).
Results: In comparison to antiarrhythmic drug therapy the radiofrequency catheter ablation in patients suffering from atrial flutter, atrioventricular nodal reentry, atrioventricular reentry and atrial tachycardia is the better choice in most cases. TAP SVT initiation was possible in 23 patients before RFCA. Atrial cycle length of SVT was 320 ± 59 ms. We initiated AV nodal reentrant tachycardia (AVNRT, n=15), atrial tachycardia (AT, n=6) and AV reentrant tachycardia with Kent pathway conduction (AVRT, n=2) before RFCA.
Conclusions: Radiofrequency catheter ablation is a successful and safe method to cure most patients with paroxysmal supraventricular tachycardias. TAP allowed initiation and termination of SVT especially in outpatients.
Cardiac resynchronization therapy (CRT) with biventricular pacing is an established therapy for heart failure (HF) patients (P) with ventricular desynchronization and reduced left ventricular (LV) ejection fraction. The aim of this study was to evaluate electrical right atrial (RA), left atrial (LA), right ventricular (RV) and LV conduction delay with novel telemetric signal averaging electrocardiography (SAECG) in implantable cardioverter defibrillator (ICD) P to better select P for CRT and to improve hemodynamics in cardiac pacing.
Methods: ICD-P (n=8, age 70.8 ± 9.0 years; 2 females, 6 males) with VVI-ICD (n=4), DDD-ICD (n=3) and CRT-ICD (n=1) (Medtronic, Inc., Minneapolis, MN, USA) were analysed with telemetric ECG recording by Medronic programmer 2090, ECG cable 2090AB, PCSU1000 oscilloscope with Pc-Lab2000 software (Velleman®) and novel National Intruments LabView SAECG software.
Results: Electrical RA conduction delay (RACD) was measured between onset and offset of RA deflection in the RAECG. Interatrial conduction delay (IACD) was measured between onset of RA deflection and onset of far-field LA deflection in the RAECG. Interventricular conduction delay (IVCD) was measured between onset of RV deflection in the RVECG and onset of LV deflection in the LVECG. Telemetric SAECG recording was possible in all ICD-P with a mean of 11.7 ± 4.4 SAECG heart beats, 97.6 ± 33.7 ms QRS duration, 81.5 ± 44.6 ms RACD, 62.8 ± 28.4 ms RV conduction delay, 143.7 ± 71.4 ms right cardiac AV delay, 41.5 ms LA conduction delay, 101.6 ms LV conduction delay, 176.8 ms left cardiac AV delay, 53.6 ms IACD and 93 ms IVCD.
Conclusions: Determination of RA, LA, RV and LV conduction delay, IACD, IVCD, right and left cardiac AV delay by telemetric SAECG recording using LabView SAECG technique may be useful parameters of atrial and ventricular desynchronization to improve P selection for CRT and hemodynamics in cardiac pacing.
Cardiac resynchronization therapy with biventricular pacing is an established therapy for heart failure patients with electrical left ventricular desynchronization. The aim of this study was to evaluate left atrial conduction delay, intra left atrial conduction delay, left ventricular conduction delay and intra left ventricular conduction delay in heart failure patients using novel signal averaging transesophageal left heart ECG software.
Methods: 8 heart failure patients with dilated cardiomyopathy (DCM), age 68 ± 9 years, New York Heart Association (NYHA) class 2.9 ± 0.2, 24.8 ± 6.7 % left ventricular ejection fraction, 188.8 ± 15.5 ms QRS duration and 8 heart failure patients with ischaemic cardiomyopathy (ICM), age 67 ± 8 years, NYHA class 2.9 ± 0.3, 32.5 ± 7.4 % left ventricular ejection fraction and 167.6 ± 19.4 ms QRS duration were analysed with transesophageal and transthoracic ECG by Bard LabDuo EP system and novel National Intruments LabView signal averaging ECG software.
Results: The electrical left atrial conduction delay was 71.3 ± 17.6 ms in ICM versus 72.3 ± 12.4 ms in DCM, intra left atrial conduction delay 66.8 ± 8.6 ms in ICM versus 63.4 ± 10.9 ms in DCM and left cardiac AV delay 180.5 ± 32.6 ms in ICM versus 152.4 ± 30.4 ms in DCM. The electrical left ventricular conduction delay was 40.9 ± 7.5 ms in ICM versus 42.6 ± 17 ms in DCM and intra left ventricular conduction delay 105.6 ± 19.3 ms in ICM versus 128.3 ± 24.1 ms in DCM.
Conclusions: Left heart signal averaging ECG can be utilized to analyse left atrial conduction delay, intra left atrial conduction delay, left ventricular conduction delay and intra left ventricular conduction delay to improve patient selection for cardiac resynchronization therapy.