Barbara Lamp

Long-term survival in patients undergoing cardiac resynchronization therapy: the importance of performing atrio-ventricular junction ablation in patients with permanent atrial fibrillation

Aims To investigate the effects of cardiac resynchronization therapy (CRT) on survival in heart failure (HF) patients with permanent atrial fibrillation (AF) and the role of atrio-ventricular junction (AVJ) ablation in these patients. Methods and results Data from 1285 consecutive patients implanted with CRT devices are presented: 1042 patients were in sinus rhythm (SR) and 243 (19%) in AF. Rate control in AF was achieved by either ablating the AVJ in 118 patients (AVJ-abl) or prescribing negative chronotropic drugs (AF-Drugs). Compared with SR, patients with AF were significantly older, more likely to be non-ischaemic, with higher ejection fraction, shorter QRS duration, and less often received ICD back-up. During a median follow-up of 34 months, 170/1042 patients in SR and 39/243 in AF died (mortality: 8.4 and 8.9 per 100 person-year, respectively). Adjusted hazard ratios were similar for all-cause and cardiac mortality [0.9 (0.57–1.42), P = 0.64 and 1.00 (0.60–1.66) P = 0.99, respectively]. Among AF patients, only 11/118 AVJ-abl patients died vs. 28/125 AF-Drugs patients (mortality: 4.3 and 15.2 per 100 person-year, respectively, P < 0.001). Adjusted hazard ratios of AVJ-abl vs. AF-Drugs was 0.26 [95% confidence interval (CI) 0.09–0.73, P = 0.010] for all-cause mortality, 0.31 (95% CI 0.10–0.99, P = 0.048) for cardiac mortality, and 0.15 (95% CI 0.03–0.70, P = 0.016) for HF mortality. Conclusion Patients with HF and AF treated with CRT have similar mortality compared with patients in SR. In AF, AVJ ablation in addition to CRT significantly improves overall survival compared with CRT alone, primarily by reducing HF death.

Adaptive servoventilation improves cardiac function in patients with chronic heart failure and Cheyne-Stokes respiration.

Sleep disordered breathing (SDB), especially Cheyne–Stokes respiration (CSR) is common in patients with chronic heart failure (CHF). Adaptive servoventilation (ASV) was recently introduced to treat CSR in CHF. The aim of this study was to investigate the effects of ASV on CSR and CHF parameters.

Left heart pacing--experience with several types of coronary vein leads.

Our experience with 121 coronary vein (CV) leads in 116 patients shows that CV leads are the leads of choice for pacing the left ventricle (LV). The information gained from pre-operative venous angiography permits individual selection of the most appropriate lead model for each case. The use of steerable electrophysiology catheters facilitates guide catheter cannulation of the coronary sinus (CS) when the anatomy is difficult and reduces the risk of complications. By selecting the CV lead model most suitable for each individual patient, we achieved successful implantation in 99.1% of patients. In this day and age, epicardial electrodes should be restricted to cases with CS anomalies which make CS cannulation impossible, and to LV lead implantation during heart surgery.

Electrocardiographic remodeling in patients paced for heart failure

Congestive heart failure due to advanced coronary artery disease or dilated cardiomyopathy is often associated with intraventricular conduction delays. Electrical resynchronization is an evolving method to improve clinical and functional status. To evaluate whether pacing-induced changes in the electrocardiogram are related to hemodynamic changes, we analyzed electrocardiograms of patients enrolled in the Pacing Therapies in Congestive Heart Failure trial. The study population consisted of 42 patients, New York Heart Association functional class III-IV with a baseline QRS complex of 175 +/- 32 msec and a PR interval of 196 +/- 33 msec. The mean left ventricular ejection fraction was 0.23. Using high-resolution computer scans, we measured QRS duration of intrinsic and paced electrocardiographs at different times during the study. Results of the electrocardiographic measurements were correlated with functional results. During the crossover period, 34 episodes of biventricular pacing, 27 episodes of left ventricular pacing, and 5 episodes of right ventricular pacing occurred, each at an individual optimized atrioventricular (AV) delay. The only significant difference was that right ventricular pacing increased the QRS width by 40 msec as compared with baseline or biventricular pacing. Functional benefit, as indicated by relative increase of peak oxygen uptake (VO2) compared with baseline, was significantly correlated with shortening of paced QRS width (correlation coefficient, r = 0.55; p <0.05). After 12-month follow-up of 28 patients, we saw a slight, nonsignificant decrease of intrinsic QRS width. With regard to the underlying disease, intrinsic QRS width at baseline and at 12 months was also not significantly different between patients with coronary artery disease and dilated cardiomyopathy. This study found that right ventricular pacing causes an increase in QRS duration in patients with left bundle-branch block, whereas in left ventricular and biventricular pacing, QRS width remains unchanged. Shortening of QRS width is correlated with a pronounced relative increase of peak VO2, and thus may become a noninvasive marker of clinical efficacy. There is no evidence of remodeling of the intrinsic electrocardiogram after 12 months of pacing.

Coronary vein balloon angioplasty forleft ventricular pacemaker lead implantation

OBJECTIVES Retrospective analysis of five cases of coronary vein balloon angioplasty performed to allow insertion of left ventricular pacing leads. BACKGROUND Coronary vein stenoses or an insufficient vessel caliber can preclude transvenous placement of coronary vein leads. METHODS We compared our total patient population (n = 218), in whom we implanted coronary vein leads, to those five patients who required coronary vein angioplasty to allow lead placement. Standard over-the-wire coronary artery balloon angioplasty catheters were used to dilate the vessel to 2.5 mm (n = 3) or 3.5 mm (n = 2). RESULTS Transvenous lead placement succeeds in >99% of patients. Four cases of target vein stenoses and one case of a vein of insufficient caliber were successfully treated by balloon angioplasty. There were no complications. CONCLUSIONS Coronary vein angioplasty is an effective and safe technique to permit transvenous left ventricular pacing lead insertion in cases of target vein stenoses or insufficient target vein caliber.

Implantation of Active Fixation Leads in Coronary Veins for Left Ventricular Stimulation: Report of Five Cases

Background: Securing transvenous left ventricular (LV) pacing leads without an active fixation mechanism in proximal coronary vein (CV) segments is usually challenging and frequently impossible. We investigated how active fixation leads can be safely implanted in this location, how to avoid perforating the free wall of the CV, and how to recognize and respond to perforations.

Absolute survival after cardiac resynchronization therapy according to baseline QRS duration: A multinational 10-year experience: Data from the Multicenter International CRT Study

BACKGROUND In the major trials of cardiac resynchronization therapy (CRT), the survival benefit of the therapy, relative to control subjects, increases with QRS duration. In the non-CRT heart failure population, however, a wide QRS duration is associated with a shorter survival. Relative survival benefit from a therapy, however, is not synonymous with a longer absolute survival. We sought to determine whether baseline QRS duration relates to the absolute survival after CRT. METHODS AND RESULTS In this prospective, longitudinal, observational study, 3,319 consecutive patients undergoing CRT (QRS 120-149 ms 26%, QRS 150-199 ms 58%, and QRS ≥200 ms 16%) were assessed in relation to mortality over 10 years. Overall mortality rates (per 100 patient-years) were 9.2%, 9.3%, and 13.3% in the 3 groups, respectively (all P < .001). Cardiac mortality rates were 6.2, 6.0, and 9.9 per 100 patient-years, respectively (all P < .001). Compared with the QRS 120-149 ms group, cardiac mortality was highest in the QRS ≥200 ms group (hazard ratio [HR] 1.72 [95% CI 1.35-2.19], P < .001), independent of age, gender, New York Heart Association class, presence of atrial fibrillation, heart failure etiology, and left ventricular ejection fraction. Median survival after CRT was longest in patients with a width of QRS 120-149 ms and shortest in patients with a QRS ≥200 ms (P < .001). In multivariable analyses, a QRS ≥200 ms emerged as a powerful independent predictor of both overall (HR 1.44 [95% CI 1.07-1.94], P = .017) and cardiac mortality (HR 1.59 [95% CI 1.14-2.24], P = .007). CONCLUSIONS At long-term follow-up, absolute overall and cardiac survival after CRT is similar in patients with a preimplant QRS duration of 120 to 149 ms and 150 to 199 ms but markedly shorter in patients with a QRS ≥200 ms.

[Analysis of inter- and intraventricular asynchrony by tissue Doppler echocardiography].

Cardiac resynchronization therapy (CRT) is a promising non-pharmacological treatment option for patients (pts) with severe severe heart failure (CHF), systolic left ventricular (LV) dysfunction, and ventricular conduction abnormalities (VCA). Pt selection for CRT, however, is still controversial. Tissue Doppler echocardiography (TDE) can be used to analyze regional wall motion with high temporal resolution. In 33 CHF pts with VCA (QRS width ≥140 ms) and 20 normal probands, left and right ventricular (RV) filling and emptying were analyzed by flow and tissue Doppler to assess regional (anterior, lateral, inferior, and septal) asynchrony within the LV as well as asynchrony between the RVand LV. All time measurements were corrected for a heart rate of 60 bpm. Results Maximum interventricular and segmental intraventricular delay was 30 ms in the normals. LV asynchrony, defined as a regional delay of ≥40 ms, was found in 29/33 (88%) of the CHF pts, in 4 cases there was synchronous LV contraction despite VCA. In the pts with LV asynchrony, 22 (67%) showed the maximum delay in the lateral wall, 7 (21%) in the septum. Inter- and intra-ventricular asynchrony correlated weakly. In many CHF pts with VCA, there is a delay both between the two ventricles, and among different LV regions. Predominantly but not exclusively, the LV lateral wall shows the maximum intra-LV delay. Some CHF pts, however, seem to have a synchronous LV contraction despite VCA. TDE thus adds important information for pt selection with respect to CRT. Die kardiale Resynchronisationstherapie (CRT) ist eine vielversprechende nichtmedikamentöse Therapieoption für Patienten (Pat.) mit schwerer Herzinsuffizienz (CHF), systolischer linksventrikulärer (LV-)Pumpfunktionsstörung und gestörter Erregungsausbreitung (EAS). Die Präzision der Patientenselektion für die CRT ist jedoch noch nicht befriedigend. Mittels Gewebe-Dopplerechokardiographie (TDE) ist die regionale Analyse des LV-Kontraktionsablaufs mit hoher zeitlicher Auflösung möglich. Wir überprüfen bei 33 CHF-Pat. mit EAS (Breite des QRS-Komplexes ≥140 ms) und 20 Normalpersonen Parameter der rechts-(RV-) und linksventrikulären Füllung und Entleerung mittels Fluss- und Gewebe-Doppler mit dem Ziel, eine mechanische Asynchronie innerhalb des LV (anteriore, laterale, inferiore und septale Region) bzw. eine interventrikuläre (RV-LV-)Asynchronie zu charakterisieren. Alle Zeitmessungen wurden auf eine Frequenz von 60/min korrigiert. Ergebnisse Die maximale inter- bzw. intraventrikuläre Asynchronie betrug bei den Normalpersonen 30 ms. Eine LV-Asynchronie, definiert als eine regionale Verzögerung um ≥40 ms, fand sich bei 29/33 (88%) der CHF-Pat., in 4 Fällen kontrahierte der LV jedoch trotz EAS synchron. Bei den Pat. mit LV-Asynchronie wies in 22 Fällen (67%) die laterale Wand, in 7 Fällen (21%) das Septum die maximale Verzögerung auf. Zwischen inter- und intraventrikulärer Asynchronie bestand nur eine schwache Korrelation. Bei CHF-Pat. mit EAS besteht vielfach eine zeitliche Latenz sowohl zwischen LV- und RVAuswurf als auch zwischen verschiedenen LV-Regionen. Vorwiegend, aber nicht ausschließlich betrifft die maximale Kontraktionsverzögerung die laterale Wand. Einige CHF-Pat. zeigen trotz EAS eine mechanisch synchrone Kontraktion. Die TDE kann somit wertvolle Informationen zur Selektion von CHF-Pat. liefern, die von der CRT profitieren könnten.

Left ventricular pacing and CRT. What CV lead fits into which vein

SummaryThe experience of 579 patients with left ventricular pacing specific characteristics of various leads and lead types for left ventricular stimulation are reported. After describing the advantages of coronary vein (CV) leads versus epicardial lead usage for left ventricular stimulation, commercially available CV leads are introduced and discussed. Since there is no universally applicable CV lead, the individual optimal lead choice and the sequelae of erroneous lead choice are described in typical clinical examples.ZusammenfassungBasierend auf der Erfahrung von 579 Patienten mit linksventrikulärer Stimulation werden die unterschiedlichen Elektrodentypen zur Stimulation des linken Ventrikels und ihre spezifischen Charakteristika vorgestellt. Neben der Beschreibung der Vorteile von Koronarvenen(CV)-Elektroden gegenüber epikardialen Elektroden bei der Stimulation des linken Ventrikels erfolgt die Vorstellung der verwendeten CV-Elektroden. Da bislang keine universell implantierbare CV-Elektrode verfügbar ist, wird anhand typischer klinischer Beispiele die optimale individuelle Elektrodenauswahl und die Folgen einer falschen Elektrodenwahl beschrieben.

Analyse der inter- und intraventrikulären Asynchronie mittels Fluss- und Gewebe-Dopplerechokardiographie

Cardiac resynchronization therapy (CRT) is a promising non-pharmacological treatment option for patients (pts) with severe severe heart failure (CHF), systolic left ventricular (LV) dysfunction, and ventricular conduction abnormalities (VCA). Pt selection for CRT, however, is still controversial. Tissue Doppler echocardiography (TDE) can be used to analyze regional wall motion with high temporal resolution. In 33 CHF pts with VCA (QRS width ≥140 ms) and 20 normal probands, left and right ventricular (RV) filling and emptying were analyzed by flow and tissue Doppler to assess regional (anterior, lateral, inferior, and septal) asynchrony within the LV as well as asynchrony between the RVand LV. All time measurements were corrected for a heart rate of 60 bpm. Results Maximum interventricular and segmental intraventricular delay was 30 ms in the normals. LV asynchrony, defined as a regional delay of ≥40 ms, was found in 29/33 (88%) of the CHF pts, in 4 cases there was synchronous LV contraction despite VCA. In the pts with LV asynchrony, 22 (67%) showed the maximum delay in the lateral wall, 7 (21%) in the septum. Inter- and intra-ventricular asynchrony correlated weakly. In many CHF pts with VCA, there is a delay both between the two ventricles, and among different LV regions. Predominantly but not exclusively, the LV lateral wall shows the maximum intra-LV delay. Some CHF pts, however, seem to have a synchronous LV contraction despite VCA. TDE thus adds important information for pt selection with respect to CRT. Die kardiale Resynchronisationstherapie (CRT) ist eine vielversprechende nichtmedikamentöse Therapieoption für Patienten (Pat.) mit schwerer Herzinsuffizienz (CHF), systolischer linksventrikulärer (LV-)Pumpfunktionsstörung und gestörter Erregungsausbreitung (EAS). Die Präzision der Patientenselektion für die CRT ist jedoch noch nicht befriedigend. Mittels Gewebe-Dopplerechokardiographie (TDE) ist die regionale Analyse des LV-Kontraktionsablaufs mit hoher zeitlicher Auflösung möglich. Wir überprüfen bei 33 CHF-Pat. mit EAS (Breite des QRS-Komplexes ≥140 ms) und 20 Normalpersonen Parameter der rechts-(RV-) und linksventrikulären Füllung und Entleerung mittels Fluss- und Gewebe-Doppler mit dem Ziel, eine mechanische Asynchronie innerhalb des LV (anteriore, laterale, inferiore und septale Region) bzw. eine interventrikuläre (RV-LV-)Asynchronie zu charakterisieren. Alle Zeitmessungen wurden auf eine Frequenz von 60/min korrigiert. Ergebnisse Die maximale inter- bzw. intraventrikuläre Asynchronie betrug bei den Normalpersonen 30 ms. Eine LV-Asynchronie, definiert als eine regionale Verzögerung um ≥40 ms, fand sich bei 29/33 (88%) der CHF-Pat., in 4 Fällen kontrahierte der LV jedoch trotz EAS synchron. Bei den Pat. mit LV-Asynchronie wies in 22 Fällen (67%) die laterale Wand, in 7 Fällen (21%) das Septum die maximale Verzögerung auf. Zwischen inter- und intraventrikulärer Asynchronie bestand nur eine schwache Korrelation. Bei CHF-Pat. mit EAS besteht vielfach eine zeitliche Latenz sowohl zwischen LV- und RVAuswurf als auch zwischen verschiedenen LV-Regionen. Vorwiegend, aber nicht ausschließlich betrifft die maximale Kontraktionsverzögerung die laterale Wand. Einige CHF-Pat. zeigen trotz EAS eine mechanisch synchrone Kontraktion. Die TDE kann somit wertvolle Informationen zur Selektion von CHF-Pat. liefern, die von der CRT profitieren könnten.