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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.
Cardiac resynchronization therapy (CRT) is an established class I level A biventricular pacing therapy in chronic heart failure patients with left bundle branch block and reduced left ventricular ejection fraction, but not all patients improved clinically. Purpose of the study was to evaluate electrical interatrial conduction delay (IACD) to interventricular conduction delay (IVCD) ratio with focused transesophageal left atrial and left ventricular electrocardiography.
Methods: Thirty eight chronic heart failure patients (age 63.4±10.2 years; 3 females, 35 males) with New York Heart Association (NYHA) functional class 3.0±0.2 and 171.71±36.17ms QRS duration were analysed using posterior left atrial and left ventricular transesophageal electrocardiography with hemispherical electrodes before CRT. Electrical IACD was measured between onset of P-wave in the surface ECG and onset of left atrial signal. Electrical IVCD was measured between onset of QRS complex in the surface ECG and onset of left ventricular signal.
Results: Electrical IACD and IVCD could be evaluated by transesophageal left atrial and left ventricular electrocardiography in all heart failure patients with correlation to 1.18±0.92 IACD-IVCD-ratio (r=-0.57, P<0.001; r=0.66, P<0.001). There were 32 CRT responder with reduction of NYHA class from 3.0±0.22 to 1.97±0.31 (P<0.001) during 16.5±18.9 month CRT with 75.19±33.49ms IACD, 78.91±24.73ms IVCD, 1.04±0.66 IACD-IVCD-ratio and correlation between IACD and IACDIVCD- ratio (r=0.84, P<0.001). There were 6 CRT nonresponder with no reduction of NYHA class from 3.0±0.3 to 2.9±0.5 during 14.3±13.7 month biventricular pacing, 50.0±28.26ms IVCD (P=0.014), 1.92±1.65 IACD-IVCD-ratio (P=0,029) and correlation between 67.0±24.9ms IACD and IACD-IVCD-ratio (r=0.85, P=0.031).
Conclusions: Focused transesophageal left atrial and left ventricular electrocardiography can be utilized to analyse electrical IACD and IVCD in heart failure patients. IACDIVDC- ratio may be a useful parameter to evaluate electrical left cardiac desynchronization in heart failure patients.
Cardiac resynchronization therapy (CRT) is an established biventricular pacing therapy in heart failure patients with left bundle branch block and reduced left ventricular ejection fraction, but not all patients improved clinically as CRT responder. Purpose of the study was to evaluate electrical left atrial conduction delay (LACD) with focused transesophageal electrocardiography in CRT responder and CRT non-responder.
Methods: Twenty heart failure patients (age 66.6±8.2 years; 2 females, 18 males) with New York Heart Association functional class 3.0±0.3 and 174.2±40.2ms QRS duration were analysed using posterior left atrial transesophageal electrocardiography with hemispherical electrodes. Electrical LACD was measured between onset and offset of transesophageal left atrial signal before implantation of CRT devices.
Results: Electrical LACD could be evaluated by bipolar transesophageal left atrial electrocardiography using TO Osypka electrode in all heart failure patients with negative correlation between 54.7±18.1ms LACD and 24.9±6.4% left ventricular ejection fraction (r=-0.65, P=0.002). There were 16 CRT responders with reduction of New York Heart Association functional class from 3.0±0.29 to 2.1±0.2 (r=0.522, P=0.038) during 9.41±10.96 month biventricular pacing and negative correlation between 49.6±14.2ms LACD and 26.0±6.2% left ventricular ejection fraction (r=-0.533, P=0.034). There were 4 CRT non-responders with no reduction of New York Heart Association functional class from 3.0±0.4 to 2.8±0.5 (r=0.816, P=0.184) during with 13.88±16.39 month biventricular pacing and no correlation between 75.25±19.17ms LACD and 20.75±6.4% left ventricular ejection fraction (r=-0.831, P=0.169).
Conclusions: Focused transesophageal left atrial electrocardiography can be utilized to analyse electrical LACD in heart failure patients. LACD correlated negative with left ventricular ejection fraction in CRT responders. LACD may be a useful parameter to evaluate electrical left atrial desynchronization in heart failure patients.
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.
Cardiac resynchronization therapy (CRT) with hemodynamic optimized biventricular pacing is an established therapy for heart failure patients with sinus rhythm, reduced left ventricular ejection fraction and wide QRS complex. The aim of the study was to evaluate electrical right and left cardiac atrioventricular delay and left atrial delay in CRT responder and non-responder with sinus rhythm.
Methods: Heart failure patients with New York Heart Association class 3.0 ± 0.3, sinus rhythm and 27.7 ± 6.1% left ventricular ejection fraction were measured by surface ECG and transesophageal bipolar left atrial and left ventricular ECG before implantation of CRT devices. Electrical right cardiac atrioventricular delay was measured between onset of P wave and onset of QRS complex in the surface ECG, left cardiac atrioventricular delay between onset of left atrial signal and onset of left ventricular signal in the transesophageal ECG and left atrial delay between onset and offset of left atrial signal in the transesophageal ECG.
Results: Electrical atrioventricular and left atrial delay were 196.9 ± 38.7 ms right and 194.5 ± 44.9 ms left cardiac atrioventricular delay, and 47.7 ± 13.9 ms left atrial delay. There were positive correlation between right and left cardiac atrioventricular delay (r = 0.803 P < 0.001) and negative correlation between left atrial delay and left ventricular ejection fraction (r = −0.694 P = 0.026) with 67% CRT responder.
Conclusions: Transesophageal electrical left cardiac atrioventricular delay and left atrial delay may be useful preoperative atrial desynchronization parameters to improve CRT optimization.
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.
Introduction: To simplify AV delay (AVD) optimization in cardiac resynchronization therapy (CRT), we reported that the hemodynamically optimal AVD for VDD and DDD mode CRT pacing can be approximated by individually measuring implant-related interatrial conduction intervals (IACT) in oesophageal electrogram (LAE) and adding about 50ms. The programmer-based St Jude QuickOpt algorithm is utilizing this finding. By automatically measuring IACT in VDD operation, it predicts the sensed AVD by adding either 30ms or 60ms. Paced AVD is strictly 50ms longer than sensed AVD. As consequence of those variations, several studies identified distinct inaccuracies of QuickOpt. Therefore, we aimed to seek for better approaches to automate AVD optimization.
Methods: In a study of 35 heart failure patients (27m, 8f, age: 67±8y) with Insync III Marquis CRT-D systems we recorded telemetric electrograms between left ventricular electrode and superior vena cava shock coil (LVtip/SVC = LVCE) simultaneously with LAE. By LVCE we measured intervals As-Pe in VDD and Ap-Pe in DDD operation between right atrial sense-event (As) or atrial stimulus (Ap), resp., and end of the atrial activity (Pe). As-Pe and Ap-Pe were compared with As-LA an Ap-LA in LAE, respectively.
Results: End of the left atrial activity in LVCE could clearly be recognized in 35/35 patients in VDD and 29/35 patients in DDD operation. We found mean intervals As-LA of 40.2±24.5ms and Ap-LA of 124.3±20.6ms. As-Pe was 94.8±24.1ms and Ap-Pe was 181.1±17.8ms. Analyzing the sums of As-LA + 50ms with duration of As-Pe and Ap-LA + 50ms with duration of Ap-Pe, the differences were 4.7±9.2ms and 4.2±8.6ms, resp., only. Thus, hemodynamically optimal timing of the ventricular stimulus can be triggered by automatically detecting Pe in LVCE.
Conclusion: Based on minimal deviations between LAE and LVCE approach, we proposed companies to utilize the LVCE in order to automate individual AVD optimization in CRT pacing.
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.
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.
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.