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Currently, QRS width and bundle branch block morphology are used as electrocardiographic guideline criterias to selectheart failure (HF) patients with interventricular desynchronization in sinus rhythm (SR) for cardiac resynchronisationtherapy (CRT). Nevertheless, up to 30% of these patients do not benefit from implantation of CRT systems. Esophagealleft ventricular electrogram (LVE) enables semi-invasive measurement of interventricular conduction delays (IVCD)even in patients with atrial fibrillation (AF). To routinely apply this method, a programmer based semi-invasiveautomatic quantification of IVCD should to be developed. Our aims were todefine interventricular conduction delaysby analyzing fractionated left ventricular (LV) deflections in the esophageal left ventricular electrogram of HF patientsin SR or AF.
In 66 HF patients (49 male,17 female, age 65 ± 10 years) a 5F TOslim electrode (Osypka AG, Germany) was perorallyapplied. Using BARD EP Lab, cardiac desynchronization was quantified as interval IVCD between onset of QRS insurface ECG and the investigator-determined onset of the left ventricular deflection in LVE. IVCD was compared withthe intervals between QRS onset and the first maximum (IVCDm1) and between QRS onset and the second maximum(IVCDm2) of the LV complex.
QRS of 173 ± 26 ms was linked with empirical IVCD of 75 ± 25 ms, at mean. First and second LV maximum could beascertained beyond doubt in all patients. Significant correlations of the p<0,01 level were found between IVCD and theIVCDm1 of 96 ± 28 ms as well as between IVCD and the IVCDm2 of 147 ± 31 ms, at mean. To standardize automatic measurement of interventricular conduction delays with respect to patients with fractionatedLV complexes, the first maximum of the LV deflection should be utilized to qualify the IVCD of HF patients with sinusrhythm and atrial fibrillation.
Cardiac resynchronization therapy (CRT) with biventricular (BV) pacing is an established therapy in approximately two-thirds of symptomatic heart failure (HF) patients (P) with left bundle branch block (LBBB). The aim of this study was to evaluate left atrial (LA) conduction delay (LACD) and left ventricular (LV) conduction delay (LVCD) using pre-implantational transesophageal electrocardiography (ECG) in sinus rhythm (SR) CRT responder (R) and non-responder (NR).
Methods: SR HF P (n=52, age 63.6±10.4 years; 6 females, 46 males) with New York Heart Association (NYHA) class 3.0±0.2, 24.4±7.1 % LV ejection fraction and 171.2±37.6 ms QRS duration (QRSD) were measured by bipolar filtered transesophageal LA and LV ECG recording with hemispherical electrodes (HE) TO catheter (Osypka AG, Rheinfelden, Germany). LACD was measured between onset of P-wave in the surface ECG and onset of LA deflection in the LA ECG. LVCD was measured between onset of QRS in the surface ECG and onset of LV deflection in the LV ECG.
Results: There were 78.8 % SR CRT R (n=41) with 171.2±36.9 ms QRSD, 73.3±25.7 ms LACD, 80.0±24.0 ms LVCD and 2.3±0.5 QRSD-LVCD-ratio. SR CRT R QRSD correlated with LACD (r=0.688, P<0.001) and LVCD (r=0.699, P<0.001). There were 21.2 % SR CRT NR (n=11) with 153.4±22.4 ms QRSD (P=0.133), 69.8±24.8 ms LACD (n=6, P=0.767), 54.2±31.0 ms LVCD (P<0.0046) and 3.9±2.5 QRSD-LVCD-ratio (P<0.001). SR CRT NR QRSD not corre-lated with IACD (r=-0.218, P=0.678) and IVCD (r=0.042, P=0.903). During a 22.8±21.3 month CRT follow-up, the CRT R NYHA class improved from 3.1±0.3 to 1.9±0.3 (P<0.001). In CRT NR, NYHA class not improved (2.9±0.4 to 2.9±0.2, P=1) during 11.2±9.8 months BV pacing.
Conclusions: Transesophageal LA and LV ECG with HE can be utilized to analyse LACD and LVCD in HF P. Pre-implantational LVCD and QRSD-LVCD-ratio may be additional useful parameters to improve P selection for SR CRT.
Capture threshold (CT) for transesophageal left atrial (LA) pacing (TLAP) and transesophageal left ventricular (LV) pacing (TLVP) with conventional cylindrical electrodes (CE) are higher than TLAP feeling threshold (FT). Purpose of the study was to evaluate focused TLAP CT and FT for supraventricular tachycardia (SVT) initiation and focused TLVP CT for cardiac resynchronisation therapy (CRT) simulation.
Methods: SVT initiation in patients (P) with palpitations (n=49, age 47 ± 17 years) was analysed during spontaneous rhythm and during focused bipolar TLAP with atrial constant current stimulus output, distal CE and three or seven 6 mm hemispherical electrodes (HE) (TO, Osypka AG, Rheinfelden, Germany). CRT simulation in heart failure P (n=75, age 62 ± 11 years) was evaluated by focused bipolar TLAP and/or TLVP with ventricular constant voltage stimulus output and different pacing mode.
Results: Focused electrical pacing field between CE and HE (n=28) allowed low threshold TLAP with 8.0 ± 2.6 mA CT at 9.9 ms stimulus duration (SD) which was lower than 9.2 ± 4.5 mA FT at 9.9 ms SD. Focused electrical pacing field between HE and HE (n=21) allowed low threshold TLAP with 8.1 ± 2.2 mA CT at 9.9 ms SD which was lower than 9.8 ± 5.0 mA FT at 9.9 ms SD. SVT initiation by programmed AAI TLAP was possible in 23 P and not possible in 26 P. CRT simulation was evaluated with TLAP and TLVP with VAT, D00 and V00 pacing mode and 95.5 ± 10.9 V TLVP CT at 4.0 ms SD.
Conclusions: Programmed focused AAI TLAP allowed initiation of SVT with very low CT and high FT and focused electrical pacing field between CE-HE and HE-HE.CRT simulation with focused TLAP and/or TLVP with VAT, D00 and V00 pacing mode may be a useful technique to detect responders to CRT.