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Termination of atrial flutter (AFL) is not possible in all AFL patients (P) with transesophageal left atrial pacing (TLAP) with undirected electrical pacing field (EPF) and high atrial pacing threshold. Purpose of the study was to evaluate bipo-lar transesophageal left atrial electrocardiography (TLAE) and TLAP with directed EPF for evaluation and termination of AFL with and without simultaneous transesophageal echocardiography (TEE).
Methods: AFL P were analysed using either a TO electrode with one cylindrical (CE) and three or seven hemispherical electrodes (HE) or TEE electrode with four HE (Osypka, Rheinfelden, Germany). Burst TLAP cycle length was between 200msand 50ms.
Results: AFL cycle length was 233±30 ms with mean ventricular cycle length of 540±149 ms. AFL could be terminated by rapid bipolar TLAP with directed EPF using HE-HE and CE-HE with induction of atrial fibrillation (AF), induction of AF and spontaneous conversion to sinus rhythm and direct conversion to sinus rhythm. Directed EPF was simulated with finite element method.
Conclusions: AFL can be evaluated by bipolar TLAE. AFL can be terminated with rapid TLAP with directed EPF with and without simultaneous TEE. Bipolar TLAE with rapid TLAP is a safe, simple and useful method for evaluation and termination of AFL.
Cardiac resynchronisation therapy (CRT) with biventricular pacing (BV) is an established therapy for heart failure (HF) patients with interventricular conduction delay (IVCD). The aim of the study was to evaluate transesophageal IVCD and left ventricular (LV) pacing with directed electrical pacing field (EPF) in HF patients.
Methods: HF patients were analysed with bipolar transesophageal LV electrocardiogram recording and LV pacing with constant voltage stimulus output, 4 ms stimulus duration, distal cylindrical electrode (CE) and seven 6 mm hemispherical electrodes (HE) with 15 mm electrode distance (TO, Dr. Osypka, Rheinfelden, Germany).
Results: LV electrocardiogram recording with HE-HE and CE-HE evaluated a mean IVCD of 79.9 ± 36.7 ms. Directed EPF with CE-HE and HE-HE allowed LV VAT (n=12) and LV D00 pacing (n=5) with a mean effective capture output of 97.35 ± 6.64 V. In 15 responders with IVCD of 87 ± 33 ms arterial pulse pressure (PP) increased from 65 ± 24 mmHg to 79 ± 27 mmHg (p < 0.001). EPF was simulated with finite element method.
Conclusions: Transesophageal LV electrocardiography and directed EPF pacing with CE and HE allowed the evaluation of IVCD and PP to select patients for BV pacing.
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.
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.
Cardiac resynchronization therapy is an established therapy for heart failure patients with sinus rhythm, reduced left ventricular ejection fraction and prolongation of QRS duration. The aim of the study was to evaluate ventricular desynchronization with electrical interventricular delay (IVD) to left ventricular delay (LVD) ratio in atrial fibrillation heart failure patients. IVD and LVD were measured by transesophageal posterior left ventricular ECG recording. In atrial fibrillation heart failure patients with prolonged QRS duration, the mean IVD-to-LVD-ratio was 0.84 +/- 0.42 with a range from 0.17 to 2.2 IVD-to-LVD-ratio. IVD-to-LVD-ratio correlated with QRS duration. IVD-to-LVD-ratio may be a useful parameter to evaluate electrical ventricular desynchronization in atrial fibrillation heart failure patients.
Das Ausmaß der elektrischen ventrikulären Desynchronisation bei reduzierter linksventrikulärer Funktion ist von Bedeutung für den Erfolg der Resynchronisationstherapie der Herzinsuffizienz mit biventrikulärer Stimulation. Das Ziel der Untersuchung besteht in der nichtinvasiven Messung der elektrischen inter-ventrikulären Desynchronisation mit und ohne ischämische Herzerkrankung bei kardialen Resynchronisationstherapie Respondern. Bei Patienten mit 25,3 ± 7,3 % reduzierter linksventrikulärer Ejektionsfraktion und 166,9 ± 38,5 ms QRS-Dauer wurde das transösophageale linksventrikuläre EKG abgeleitet. Die QRS-Dauer korrelierte mit dem interventrikulären und links-ventrikulären Delay bei Resynchronisationstherapie Respondern mit nicht-ischämischer Herzerkrankung.
Transösophageales interventrikuläres Delay bei Vorhofflimmern und kardialer Resynchronisation
(2013)
Die transösophageale linksventrikuläre Elektrokardiographie ermöglicht die Evaluierung der elektrischen ventrikulären Desynchronisation im Rahmen der kardialen Resynchronisationstherapie der Herzinsuffizienz. Das Ziel der Untersuchung besteht in der präoperativen Abschätzung des transösophagealen interventrikulären Delays bei Vorhofflimmern und kardialer Resynchronisationstherapie. Bei Patienten mit Vorhofflimmern, Herzinsuffizienz New York Heart Association Klasse 3,0 ± 0,2 und QRS-Dauer 159,6 ± 23,9 ms wurde das fokusierte transösophageale linksventrikuläre EKG abgeleitet. Die kardiale Resynchronisationstherapie Responder QRS-Dauer korrelierte mit dem transösophagealen interventrikulären Delay bei Vorhofflimmern.
Cardiac resynchronization therapy is an established therapy for heart failure patients. The aim of the study was to evaluate electrical left cardiac atrioventricular delay and interventricular desynchronization in sinus rhythm cardiac resynchronization therapy responder and non-responder. Cardiac electrical desynchronization were measured by surface ECG and focused transesophageal bipolar left atrial and left ventricular ECG before implantation of cardiac resynchronization therapy defibrillators. Preoperative electrical cardiac desynchronization was 195.7 ± 46.7 ms left cardiac atrioventricular delay and 74.8 ± 24.5 ms interventricular delay in cardiac resynchronization therapy responder. Cardiac resynchronization therapy responder New York Heart Association class improved during long term biventricular pacing. Transesophageal left cardiac atrioventricular delay and interventricular delay may be additional useful parameters to improve patient selection for cardiac resynchronization therapy.
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.
A disturbed synchronization of the ventricular contraction can cause a highly developed systolic heart failure in affected patients with reduction of the left ventricular ejection fraction, which can often be explained by a diseased left bundle branch block (LBBB). If medication remains unresponsive, the concerned patients will be treated with a cardiac resynchronization therapy (CRT) system. The aim of this study was to integrate His-bundle pacing into the Offenburg heart rhythm model in order to visualize the electrical pacing field generated by His-Bundle-Pacing. Modelling and electrical field simulation activities were performed with the software CST (Computer Simulation Technology) from Dessault Systèms. CRT with biventricular pacing is to be achieved by an apical right ventricular electrode and an additional left ventricular electrode, which is floated into the coronary vein sinus. The non-responder rate of the CRT therapy is about one third of the CRT patients. His- Bundle-Pacing represents a physiological alternative to conventional cardiac pacing and cardiac resynchronization. An electrode implanted in the His-bundle emits a stronger electrical pacing field than the electrical pacing field of conventional cardiac pacemakers. The pacing of the Hisbundle was performed by the Medtronic Select Secure 3830 electrode with pacing voltage amplitudes of 3 V, 2 V and 1,5 V in combination with a pacing pulse duration of 1 ms. Compared to conventional pacemaker pacing, His-bundle pacing is capable of bridging LBBB conduction disorders in the left ventricle. The His-bundle pacing electrical field is able to spread via the physiological pathway in the right and left ventricles for CRT with a narrow QRS-complex in the surface ECG.