Svein Faerestrand

2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy: the task force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA).

2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy : The Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA)

2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy

### Abbreviations 1st AV : First-degree atrioventricular block AF : atrial fibrillation AT : atrial tachyarrhythmia ATP : Anti-tachycardia pacing AV : atrioventricular BBB : bundle branch block CHF : congestive heart failure CI : confidence interval CPG : Committee for Practice Guidelines CRT : cardiac resynchronization therapy CRT-D : cardiac resynchronization therapy and defibrillator CRT-P : cardiac resynchronization therapy and pacemaker ECG : electrocardiogram EDMD : Emery-Dreifuss muscular dystrophy EF : ejection fraction EPS : electrophysiological study ESC : European Society of Cardiology HCM : hypertrophic cardiomyopathy HF : heart failure HR : hazard ratio HV : His-ventricular ICD : implantable cardioverter defibrillator ILR : implantable loop recorder IVCD : intraventricular conduction delay LBBB : left bundle branch block LQTS : long QT syndrome LV : left ventricular LVEF : left ventricular ejection fraction LVSD : left ventricular systolic dysfunction MR : mitral regurgitation MRI : magnetic resonance imaging NYHA : New York Heart Association PM : pacemaker OR : odds ratio QALY : quality-adjusted life year RBBB : right bundle branch block RCT : randomized controlled trial RV : right ventricular SB : sinus bradycardia SNRT : sinus node recovery time SR : sinus rhythm SSS : sick sinus syndrome TAVI : transcatheter aortic valve implantation VF : ventricular fibrillation VT : ventricular tachycardia VV : interventricular (delay) ### Acronyms of the trials referenced in the recommendations or reported in the tables ADEPT : ADvanced Elements of Pacing Randomized Controlled Trial ADOPT : Atrial Dynamic Overdrive Pacing Trial AOPS : Atrial Overdrive Pacing Study APAF : Ablate and Pace in Atrial Fibrillation ASSERT : ASymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial ATTEST : ATrial Therapy Efficacy and Safety Trial AVAIL CLS/CRT : AV Node Ablation with CLS and CRT Pacing Therapies for Treatment of AF trial B4 : Bradycardia detection in Bundle Branch Block BELIEVE : Bi vs. Left Ventricular Pacing: an International Pilot Evaluation on Heart Failure Patients with Ventricular Arrhythmias BIOPACE : Biventricular pacing for atrioventricular block to prevent cardiac desynchronization BLOCK-HF : Biventricular versus right ventricular pacing in patients with AV block B-LEFT : Biventricular versus LEFT Univentricular Pacing with ICD Back-up in Heart Failure Patients CARE-HF : CArdiac REsynchronization in Heart Failure CLEAR : CLinical Evaluation on Advanced Resynchronization COMBAT : COnventional vs. Biventricular Pacing in Heart Failure and Bradyarrhythmia COMPANION : COmparison of Medical Therapy, Pacing and Defibrillation in Heart Failure DANPACE : DANish Multicenter Randomized Trial on Single Lead Atrial PACing vs. Dual Chamber Pacing in Sick Sinus Syndrome DECREASE-HF : The Device Evaluation of CONTAK RENEWAL 2 and EASYTRAK 2: Assessment of Safety and Effectiveness in Heart Failure FREEDOM : Optimization Study Using the QuickOpt Method GREATER-EARTH : Evaluation of Resynchronization Therapy for Heart Failure in Patients with a QRS Duration GREATER Than 120 ms LESSER-EARTH : Evaluation of Resynchronization Therapy for Heart Failure in Patients with a QRS Duration Lower Than 120 ms HOBIPACE : HOmburg BIventricular PACing Evaluation IN-CHF : Italian Network on Congestive Heart Failure ISSUE : International Study on Syncope of Unexplained Etiology MADIT : Multicenter Automatic Defibrillator Trial MIRACLE : Multicenter InSync RAndomized CLinical Evaluation MOST : MOde Selection Trial in Sinus-Node Dysfunction MUSTIC : MUltisite STimulation In Cardiomyopathies OPSITE : Optimal Pacing SITE PACE : Pacing to Avoid Cardiac Enlargement PAVE : Left Ventricular-Based Cardiac Stimulation Post AV Nodal Ablation Evaluation PATH-CHF : PAcing THerapies in Congestive Heart Failure II Study Group PIPAF : Pacing In Prevention of Atrial Fibrillation Study PIRAT : Prevention of Immediate Reinitiation of Atrial Tachyarrhythmias POT : Prevention Or Termination Study PREVENT-HF : PREventing VENTricular Dysfunction in Pacemaker Patients Without Advanced Heart Failure PROSPECT : PRedictors Of Response to Cardiac Resynchronization Therapy RAFT : Resynchronization–Defibrillation for Ambulatory Heart Failure Trial RethinQ : Cardiac REsynchronization THerapy IN Patients with Heart Failure and Narrow QRS REVERSE : REsynchronization reVErses Remodelling in Systolic left vEntricular dysfunction SAFARI : Study of Atrial Fibrillation Reduction SCD HeFT : Sudden Cardiac Death in Heart Failure Trial SMART-AV : The SMARTDelay Determined AV Optimization: a Comparison with Other AV Delay Methods Used in Cardiac Resynchronization Therapy SYDIT : The SYncope DIagnosis and Treatment SYNPACE : Vasovagal SYNcope and PACing TARGET : TARgeted Left Ventricular Lead Placement to Guide Cardiac Resynchronization Therapy THEOPACE : Effects of Oral THEOphylline and of Permanent PACEmaker on the Symptoms and Complications of Sick Sinus Syndrome VASIS-PM : VAsovagal Syncope International Study on PaceMaker therapy V-HeFT : Vasodilator in HEart Failure Trial VPSII : Second Vasovagal Pacemaker Study (VPS II) Additional references are mentioned with ‘w’ in the main text and can be found on the online addenda along with 5 figures (1, 6, 7, 9, 11, 12) and 10 tables (3, 4, 5, 9, 11, 12, 19, 21, 22, 23). They are available on the ESC website only at http://www.escardio.org/guidelines-surveys/esc-guidelines/Pages/cardiac-pacing-and-cardiac-resynchronisation-therapy.aspx Guidelines summarize and evaluate all available evidence, at the time of the writing process, on a particular issue, with the …

A time-related study of the hemodynamic benefit of atrioventricular synchronous pacing evaluated by Doppler echocardiography.

We have used Doppler echocardiography to estimate the stroke volume (SV) in a study of 13 patients equipped with DDD pacemakers. SV was measured both during DDD and WI pacing after observation times of 1,3, 6, and 12 months of DDD pacing. SV was also measured at seven atrioventricular (AV) intervals (75–250 ms) in the search for optimal AV intervals. Mitral flow velocity was investigated to see if DDD pacing resulted in synchronous atrial contraction, and if mitral insufficiency existed at any of the pacing modes. Compared with the VVI mode, DDD pacing resulted in a mean increase in SV of 21 ± 2% for the four observation periods. Two patients with severe left ventricular failure had no significanl increase in SV during DDD vs VVI pacing. In each patient, an optimal AV inlerval ranging between 100–250 ms for the SV was found. Velocity profiles of mitral flow showed synchronous atrial contraction during DDD pacing, but not during VVI pacing. Mitral insufficiency was not seen in any pacing mode. DDD pacing resulted in a reduction in SV during the first 6 months, and was constant thereafter. Doppler echocardiography can be used repeatedly to evaluate the hemodynamic response of DDD pacing vs VVI pacing, and to find which AV interval gives the highest SV in the individual patient. Our study further shows that the hemodynamic benefit of DDD pacing is present after short‐term as well as after long‐term DDD pacing.

Colour tissue velocity imaging can show resynchronisation of longitudinal left ventricular contraction pattern by biventricular pacing in patients with severe heart failure

Objective: To quantify ventricular resynchronisation by biventricular pacing using colour tissue Doppler velocity imaging (c-TVI). Design and patients: c-TVI shows regional tissue velocity profiles with a very high time resolution (10 ms). Eighteen patients were studied from an apical four chamber view at baseline and after a one month follow up of biventricular pacing. Regional left ventricular peak tissue velocities and regional time differences during the cardiac cycle were compared in the basal and mid interventricular septal segments of the left ventricle, and in the corresponding segments in the left ventricular free wall. Results: From baseline to follow up, mean peak tissue velocities changed only during isovolumic contraction in the basal interventricular septum and the left ventricular free wall. At baseline the peak main systolic tissue velocities in the left ventricular free wall were typically delayed by an average of 42 ms in the basal left ventricular site and by 14 ms in the mid left ventricular site compared with the corresponding sites in the interventricular septum. After resynchronisation by biventricular pacing those regional movements were separated by an average of only 7 ms at the basal site, but there was still a 21 ms earlier movement of the left ventricular free wall in the mid left ventricular site. The diastolic movement pattern remained unchanged from baseline to follow up. Conclusions: c-TVI showed a significant asynchronous regional longitudinal movement of basal left ventricular sites at baseline. A change to a more synchronous longitudinal left ventricular movement pattern during biventricular pacing was demonstrated.

A randomized study of haemodynamic effects and left ventricular dyssynchrony in right ventricular apical vs. high posterior septal pacing in cardiac resynchronization therapy

The effect on left ventricular (LV) systolic function and LV dyssynchrony by alternative right ventricular (RV) lead position in cardiac resynchronization therapy (CRT) is unclear. In the present study, RV apical (RV‐A) was compared with RV high posterior septal (RV‐HS) lead position in CRT.

Color Doppler tissue velocity imaging can disclose systolic left ventricular asynchrony independent of the QRS morphology in patients with severe heart failure.

A QRS width greater than 120 ms is assumed to be a marker of inter‐ and intraventricular asynchrony in severe heart failure (HF) patients. Color Doppler tissue velocity imaging (c‐TVI) with a time resolution of 10 ms was used to study regional left ventricular (LV) longitudinal systolic contraction pattern in HF patients with left and right bundle branch block (LBBB and RBBB) and in patients with normal QRS width. We studied 12 women and 23 men with severe HF, with a mean age of 66 ± 11 years in New York Heart Association functional Class 2.9 ± 0.6. Twenty patients had LBBB and 10 of those were accepted for cardiac resynchronization therapy by biventricular pacing (CRT). Ten patients had normal QRS width, and five had RBBB. In the echocardiographic apical four chamber view, regional peak LV tissue velocities and regional LV time differences of peak tissue velocities were compared at basal and mid‐LV segments. There were no significant differences in regional mean peak tissue velocities among the patient groups. In patients with LBBB accepted for CRT, the LV lateral free‐wall movement at basal LV was 29 ms delayed during main systole, almost significantly different from LBBB patients not accepted for CRT (P = 0.075). Even in HF patients with normal QRS width or RBBB, significant asynchronous longitudinal LV contraction was observed. Conclusions: For the detection of regional longitudinal LV contraction asynchrony in patients with severe HF, supplementary methods to the surface ECG, such as c‐TVI, are strongly recommended. (PACE 2004; 27:460–467)

Long‐Term Clinical Performance of a Central Venous Oxygen Saturation Sensor for Rate Adaptive Cardiac Pacing

Rate adaptive ventricular pacemakers using central venous oxygen saturation (O2Sat) to control the pacing rate have been implanted in 14 patients (mean age 71 years), with a mean follow‐up period of 44 months (range 2–63 months). In eight patients the pacemakers were replaced due to signs of battery depletion after an implant duration of 39–58 months. During bicycle exercise testing the O2Sat decreased on average from 61%± 4% at rest to 36%± 4% (P < 0,0001) at peak exercise, and the maximum pacing rate was 122 ± 5 beats/min. The time delay until the O2Sat bad dropped 10%, 65%, and 90% of the total reduction during exercise was 4.8 ± 0.9 seconds, 39.8 ± 3.8 seconds, and 71.3 ± 7.5 seconds, respectively. The O2Sat decreased 9.4%± 2% (P <0.005) from resting supine to resting sitting. Oxygen breathing increased the telemetered O2Sat from the pacemaker by 8.4 %± 1 % (P < 0.001). During follow‐up the O2Sats were relatively stable in 50% of the patients, but demonstrated significant fluctuations in the others. At 1‐year invasive follow‐up O2Sat measured by the pacemaker decreased 22%± 2%, and in blood samples from the right ventricle 22%± 2% from rest to 3 minutes exercise at 25 watts. There was a significant correlation between O2Sat measured by the pacemaker and in blood samples from right ventricle (n = 105; r = 0.73; P < 0.001). In two patients the O2Sat dropped significantly during pneumonia. In another patient episodes of angina pectoris was associated with low O2Sat and a concomitant fast pacing rate.

Cardiovascular and urological dysfunction in spinal cord injury

Hagen EM, Faerestrand S, Hoff JM, Rekand T, Gronning M. Cardiovascular and urological dysfunction in spinal cord injury.
Acta Neurol Scand: 2011: 124 (Suppl. 191): 71–78.
© 2011 John Wiley & Sons A/S.

Clinical implication of right ventricular to left ventricular interlead sensed electrical delay in cardiac resynchronization therapy

AIMS To evaluate the clinical implication of right ventricular (RV) to left ventricular (LV) interlead sensed electrical delay (RV-LVs) and the relation to ventricular lead position in cardiac resynchronization therapy (CRT). METHODS AND RESULTS Eighty-five consecutive CRT patients (mean age 66 ± 11 years) received LV lead prospectively targeted to the latest mechanical activated segment (concordant), assessed by two-dimensional speckle tracking radial strain (ST-RS) echocardiography. The RV lead was randomized to RV apex (n= 43) or RV high posterior septum (n= 42). Right ventricular to left ventricular interlead sensed electrical delay was obtained during the CRT implant procedure. Intraventricular dyssynchrony was evaluated by ST-RS echocardiography. Interventricular mechanical delay (IVMD) was measured by using pulse-wave Doppler. Separated by the median RV-LVs (82 ms), a long RV-LVs demonstrated more LV end-systolic volume (LVESV) reduction than a short RV-LVs (-27 ± 20 vs. -16 ± 22%; P= 0.02), 6 months after CRT (6FU). Right ventricular to left ventricular interlead sensed electrical delay correlated to IVMD (r = 0.50; P< 0.001) and intraventricular dyssynchrony (r = 0.25; P= 0.02) at baseline. Concordant LV leads (n= 61) demonstrated superior reduction of LVESV (P= 0.005) 6 months after CRT; however, both RV lead positions had similar effects. Right ventricular to left ventricular interlead sensed electrical delay was irrespective to LV lead concordance and RV lead position (P= ns). Independent predictors to reverse remodelling (reduction of LVESV ≥ 15%) at 6FU were concordant LV lead (odds ratio, 3.210; P= 0.029) and IVMD (odds ratio, 1.028; P= 0.026). CONCLUSION Right ventricular to left ventricular interlead sensed electrical delay was not predictive to LV reverse remodelling affected by CRT at 6FU. Concordant LV leads demonstrated superior LV reverse remodelling at 6FU. Right ventricular to left ventricular interlead sensed electrical delay was irrespective of ventricular lead position and might be insufficient to target optimal LV lead position in CRT. TRIAL REGISTRATION http://clinicaltrials.gov. Unique identifier: NCT01035489.

Atrial Synchronous Ventricular Pacing with a Single Lead: Reliability of Atrial Sensing During Physical Activities, and Long-term Stability of Atrial Sensing

A VDD pacing system with bipolar single‐pass leads, were implanted in 36 consecutive patients (average age 72 ± 2years) with high degree atrioventricular block and normal sinus node function. At implant the atrial signal amplitude was 2.6 ± 0.2mV measured by a pacing system analyser (PSA), 1.8 ± 0.1mV measured peak‐to‐peak from the telemetered calibrated electrogram, and 1.3 ± 0.1mV measured from the sensing threshold. At one month follow‐up the peak‐to‐peak amplitudes (mV) of the telemetered atrial electrograms were not significantly different measured continuously during resting supine with quiet breathing (1.4 ± 0.1), sitting (1.6 ± 0.2). standing (1.5 ± 0.1), arm swinging (1.4 ± 0.2), hyperventilation (1.3 ± 0.1), Vaisalva manoeuvre (1.4 ± 0.1), and treadmill exercise (1.9 ± 0.6). The telemetered atrial electrogram amplitude and the atrial sensing threshold varied between 1.2 ± 0.09mV and 1.8 ± 0.1mV, and between 0.95 ± 0.07mV and 1.3 ± 0.01mV, respectively at 0.5, 1, 3, 6 and 12 months follow‐up, but the changes were statistically nonsignificant. The Event Summary showed sensing of 98% to 99% of the atrial events at the different follow‐up periods.