Tobias Heinke

Termination of atrial flutter by directed transesophageal atrial pacing during transesophageal echocardiography / Terminierung von Vorhofflattern mit gerichteter transösophagealer Vorhofstimulation bei transösophagealer Echokardiographie

Abstract Introduction: The purpose of this study was to evaluate termination of atrial flutter (AFL) by directed rapid transesophageal atrial pacing (TAP) with and without simultaneous transesophageal echocardiography (TEE) performed using a novel TEE tube electrode. Materials and methods, and Results: A total of 16 AFL patients (age 63±12 years; 13 males) with mean AFL cycle length of 224±24 ms (n=12) and mean ventricular cycle length of 448±47 ms (n=12) were analyzed using either an esophageal TO electrode (n=10) or a novel TEE tube electrode consisting of a tube with four hemispherical electrodes that is pulled over the echo probe (n=6). AFL could be terminated by directed rapid TAP using an esophageal TO electrode, leading to induction of atrial fibrillation (AF) (n=6), induction of AF and spontaneous conversion to sinus rhythm (SR) (n=3), and with conversion to SR (n=1). AFL could also be terminated by directed rapid TAP using the TEE tube electrode, with induction of AF (n=3) or induction of AF and spontaneous conversion to SR (n=3). Conclusion: AFL can be terminated by directed rapid TAP with hemispherical electrodes with and without simultaneous TEE. TAP with the directed TEE tube electrode is a safe, simple, and useful method for terminating AFL. Zusammenfassung Einleitung: Die Terminierung von Vorhofflattern (AFL) mit gerichteter hochfrequenter transösophagealer Vorhofstimulation (TAP) wurde mit und ohne simultane transösophageale Echokardiographie (TEE) mit einer neuen TEE-Schlauchelektrode evaluiert. Material und Methode und Ergebnisse: 16 AFL Patienten (Alter 63±12 Jahre; 13 Männer) mit einer mittleren AFL-Periodendauer von 224±24 ms (n=12) und einer mittleren ventrikulären Periodendauer von 448±47 ms (n=12) wurden mittels Ösophaguselektrode „TO” (n=10) oder neuer „TEE-Schlauchelektrode”, die aus einem Schlauch mit 4 halbkugelförmigen Elektroden besteht und über die Echokardiographiesonde gezogen wird (n=6), analysiert. AFL konnte mit gerichteter hochfrequenter TAP und TO-Elektrode durch Induktion von Vorhofflimmern (AF) (n=6), Induktion von AF mit spontaner Konversion in den Sinusrhythmus (SR) (n=3) und Konversion in den SR (n=1) terminiert werden. AFL konnte mit gerichteter hochfrequenter TAP und TEE-Schlauchelektrode durch Induktion von AF (n=3) und Induktion von AF mit spontaner Konversion in den SR (n=3) terminiert werden. Schlussfolgerung: AFL kann durch gerichtete hochfrequente TAP mit halbkugelförmigen Elektroden mit und ohne simultane TEE terminiert werden. TAP mit der gerichteten TEE-Schlauchelektrode ist eine sichere, einfache und praktikable Methode zur Terminierung von AFL.

Electrical Right and Left Cardiac Atrioventricular and Left Atrial Delay in Cardiac Resynchronization Therapy Responder and Non-responder with Sinus Rhythm

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.

Electrical interventricular delay and left ventricular delay in right ventricular pacemaker pacing before upgrading to cardiac resynchronization therapy

Abstract Cardiac resynchronization therapy with biventricular pacing is an established therapy for heart failure patients with sinus rhythm, reduced left ventricular ejection fraction and electrical ventricular desynchronization. The aim of the study was to evaluate electrical interventricular delay and left ventricular delay in right ventricular pacemaker pacing before upgrading to cardiac resynchronization therapy. Heart failure patients with right ventricular pacing, DDD pacemaker, DDD defibrillator and 24.5 ± 4.9 % left ventricular ejection fraction were measured by surface ECG and transesophageal bipolar left ventricular ECG before upgrading to cardiac resynchronization therapy. Interventricular and intraventricular desynchronization in right ventricular pacemaker pacing were 228.2 ± 44.8ms QRS duration, 86.5 ± 32.8ms interventricular delay and 94.4 ± 23.8ms left ventricular delay. Cardiac resynchronization therapy was optimized by impedance cardiography. Transesophageal electrical interventricular delay and left ventricular delay in right ventricular pacemaker pacing may be additional useful ventricular desynchronization parameters to improve patient selection for upgrading right ventricular pacemaker pacing to cardiac resynchronization therapy.

Left cardiac atrioventricular delay and inter-ventricular delay in cardiac resynchronization therapy responder and non-responder

Abstract 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.

Electrical Interatrial to Interventricular Conduction Delay Ratio with Focused Transesophageal Electrocardiography in Cardiac Resynchronization Therapy

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.

Electrical Left Atrial Conduction Delay with Focused Transesophageal Electrocardiography in Cardiac Resynchronization Therapy

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.

Transösophageales Interventrikuläres Delay bei Vorhofflimmern und Kardialer Resynchronisation

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.

Ventrikuläre Desynchronisation mit und ohne Ischämische Herzerkrankung bei Resynchronisationsrespondern.

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 interventrikulären 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 QRSDauer korrelierte mit dem interventrikulären und linksventrikulären Delay bei Resynchronisationstherapie Respondern mit nicht-ischämischer Herzerkrankung.

Left atrial and left ventricular conduction delay by transesophageal electrocardiography with hemispherical electrodes in sinus rhythm cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) with biventricular (BV) pacing is an established therapy in approximately twothirds 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 preimplantational 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 correlated 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. Preimplantational LVCD and QRSD-LVCD-ratio may be additional useful parameters to improve P selection for SR CRT.

Focused transesophageal left atrial and left ventricular pacing with different pacing mode for supraventricular tachycardia initiation and cardiac resynchronization therapy simulation

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.