Yves Etienne

Evaluation of Different Ventricular Pacing Sites in Patients With Severe Heart Failure Results of an Acute Hemodynamic Study

BACKGROUND Multisite ventricular pacing has recently been proposed as an additional treatment for patients with severe congestive heart failure. To further assess the potential value of this technique, we compared the acute hemodynamic changes associated with pacing the right ventricular apex (RVA) or outflow tract (RVOT) alone, the left ventricle (LV) alone, or biventricular (BIV) pacing of the RVA and LV together. METHODS AND RESULTS Acute hemodynamic findings were measured in 27 patients with severe heart failure despite optimal therapy and either first-degree AV block and/or an intraventricular conduction defect. In the 23 patients with a high pulmonary capillary wedge pressure (PCWP) (>15 mm Hg), data were collected after transvenous pacing at different ventricular sites in either the VDD mode (AV delay=100 ms) or the VVI mode in patients with atrial fibrillation (n=6). The mean baseline cardiac index was 1.82 L x min(-1) x m(-2). Mean+/-SD baseline systolic blood pressure (SBP) (118.5+/-15.2 mm Hg), PCWP (26.4+/-6.6 mm Hg), and V-wave amplitude (39.1+/-14.6 mm Hg) were similar before and after either RVA or RVOT pacing. In contrast, LV-based pacing (either LV alone or BIV pacing) resulted in higher SBP (P<.03) and lower PCWP (P<.01) and V-wave amplitude (P<.001) than either baseline or RV pacing measurements. With LV pacing alone, SBP, PCWP, and V waves were 126.5+/-15.1, 20.7+/-5.9, and 25.5+/-8.1 mm Hg, respectively. The results with LV pacing alone were similar to those obtained with BIV pacing. CONCLUSIONS In patients with severe congestive heart failure, both LV pacing alone and BIV pacing resulted in a similar and significant acute improvement in SBP, PCWP, and V-wave amplitude compared with baseline measurements and RV pacing alone. These results provide a strong basis for initiating long-term studies examining the chronic effects of LV-based pacing in patients with medically refractory congestive heart failure.

Long-term left ventricular pacing: assessment and comparison with biventricular pacing in patients with severe congestive heart failure.

OBJECTIVE The purpose of this study is to report prospectively the results of six-month follow-up of permanent left ventricular (LV) based pacing in patients with severe congestive heart failure (CHF) and left bundle branch block (LBBB). BACKGROUND Left ventricular pacing alone has been demonstrated to result in identical improvement compared to biventricular pacing (BiV) during acute hemodynamic evaluation in patients with advanced CHF and LBBB. However, to our knowledge, the clinical outcome during permanent LV pacing alone versus BiV pacing mode has not been evaluated. METHODS Pacing configuration (LV or BiV) was selected according to the physicians preference. Patient evaluation was performed at baseline and at six months. RESULTS Thirty-three patients with advanced CHF and LBBB were included. Baseline characteristics of LV (18 patients) and BiV (15 patients) pacing groups were similar. During the six-month follow-up period, seven patients died three BiV and four LV). In the surviving patients at 6 months, 8 of 14 patients in the LV group and 9 of 12 in the BiV group were in New York Heart Association class I or II (p = 0.39). No significant difference was observed between the two groups in terms of objective parameters except for LV end-diastolic diameter decrease (-4.4 mm in BiV group vs. -0.7 mm in LV group; p = 0.04). CONCLUSION At six-month follow-up, a trend toward improvement was observed in objective parameters in patients with severe CHF and LBBB following LV-based pacing. The two pacing modes (LV and BiV) were associated with almost equivalent improvement of subjective and objective parameters.

Evaluation of left ventricular based pacing in patients with congestive heart failure and atrial fibrillation

Acute hemodynamic data of left ventricular based pacing were assessed in 2 groups of patients with severe cardiac failure: 11 patients with atrial fibrillation and 17 patients with sinus rhythm. Both biventricular and left ventricular pacing significantly improved acute hemodynamic findings to a similar degree in both groups, suggesting that left ventricular based pacing may be beneficial in patients with severe cardiac failure regardless of whether or not they are in sinus rhythm.

Angiographic Anatomy of the Coronary Sinus and Its Tributaries

Permanent left ventricular pacing has been shown to imporve the hemodynamic and clinical status of patients with severe heart failure. To pace the left ventricle, the electrode is implanted in tributaries of the coronary sinus (CS). However, the anatomy of cardiac veins with this purpose in mind has not been described in detail. Methods: One hundred consecutive patients admitted for coronary angiography had a simultaneous coronary venography performed after the injection of 8 to 10 mL of contrast material into the left coronary artery. Cardiac veins were analyzed in antero‐posterior, left anterior oblique 60±, and right anterior oblique 30± views by three different observers. The number, dimension, angulation, and position of the coronary sinus and of its tributaries were studied. Results: Two veins are consistently present: the middle cardiac vein (mean diameter 2.62 ± 1.26 mm) and the great cardiac vein (mean diameter 3.55 ± 1.24 mm). The left posterior vein(s) (LPV) (mean diameter 2.25 ± 1.2 mm) is (are) variable in number (ranging from 0 to 3), size, and angulation. The absence of LPV limits the ability to pace the left ventricle endovenously. The diameter of the vein (< 2 mm) and its angulation may also complicate the insertion of the lead. Conclusion: Angiographic analysis of dimensions, tortuosity, number, and angulation of venous tributaries of the CS seems to allow the insertion of commercially available pacing leads in approximately 85% of cases. An increase in this percentage hinges on the development of new, dedicated leads.

Midterm Benefits of Left Univentricular Pacing in Patients With Congestive Heart Failure

Background—Resynchronization therapy by simultaneous pacing of the right and left ventricles has gained wide acceptance as a useful treatment for patients with severe congestive heart failure. Several short-term hemodynamic studies in humans and animals failed to demonstrate any benefit of biventricular pacing over left univentricular pacing, but long-term studies on this pacing mode are lacking. The objective of this study was to assess the outcome over a 1-year period of patients paced exclusively in the left ventricle. Methods and Results—Clinical, angiographic, echocardiographic, and ergometric data were collected at baseline and after 12 months in 22 patients (age, 69.3±6.5 years) with NYHA class III or IV (10 patients), sinus rhythm, left bundle-branch block, and no bradycardia indication for pacing. After 12 months, compared with baseline values, NYHA class improved significantly by 40% (P <0.0001), 6-minute walk distance by 30% (P =0.01), peak &OV0312;O2 by 26% (P =0.01), left ventricular enddiastolic diameter by 5% (P = 0.02), ejection fraction by 22% (P = 0.07), mitral regurgitation area by 40% (P = 0.01), and norepinephrine level by 37% (P = 0.04). Conclusions—In patients with severe congestive heart failure, sinus rhythm, and left bundle-branch block despite optimal pharmacological treatment, left univentricular pacing is feasible and results in significant midterm benefit in exercise tolerance and left ventricular function.

Long-Term Prognosis in Patients With Alcoholic Cardiomyopathy and Severe Heart Failure After Total Abstinence

We prospectively evaluated the long-term prognosis of 14 patients with alcoholic cardiomyopathy and severe end-stage congestive heart failure after total abstinence. Improvement was very significant after 6 months of follow-up in most patients, and continued thereafter.

A METHOD FOR PERMANENT TRANSVENOUS LEFT VENTRICULAR PACING

LV‐based pacing has recently been reported to be of benefit in patients with severe cardiac failure and left bundle branch block. LV permanent pacing has been reported using epicardial leads but the surgical mortality is excessive. A transvenous approach is now favored. In this regard, cannulation of the coronary sinus and of one of its tributaries using only the permanent electrode is feasible but technically challenging. We describe a “long guiding sheath” method using catheterization, and a long radiopaque and peelable sheath. Once the coronaiy sinus is cannulated with the electrophysiological catheter, the long sheath is advanced to the mid‐part of the coronary sinus. The permanent pacing electrode is then placed through the sheath and into a tributary of the coronary sinus. This method has been attempted in 10 patients and was successful in 8, with an average lead insertion time of 21 ± 5.5 minutes and an average fluoroscopic time of 11 ± 5.5 minutes. In conclusion, although transvenous left ventricular pacing remains a challenge, the “long guiding sheath” approach appears to facilitate this procedure with both a high success rate and an acceptable procedure time.

Left ventricular-based pacing in patients with chronic heart failure: Comparison of acute hemodynamic benefits according to underlying heart disease

Acute left ventricular‐based pacing has been shown to improve hemodynamics in patients with severe heart failure and left bundle branch block (LBBB). However, it is not known whether the cause of the underlying heart disease influences the potential effect of left ventricular‐based pacing.

Use of left ventricular pacing in heart failure: Evaluation by gated blood pool imaging

BackgroundLeft ventricular (LV) pacing has been suggested to complement other forms of therapy in patients with heart failure.Methods and ResultsWe investigated 17 patients (15 men, 2 women, aged 68±6 years, 10 ischemic and 7 primary dilated cardiomyopathy) with heart failure (13 were in New York Heart Association class IV and 4 in class III). One month after LV pacer implantation, 12 patients reported clinical improvement (mean class 3.7 before pacing vs 2.6 with LV pacing; P=.001). We report the results of 3 equilibrium-gated blood pool studies performed in each patient, 1 before pacing and 2 after pacer implantation (1 with pacing on, and 1 after turning off the pacer). LV pacing did not modify LV ejection fraction. Phase analysis demonstrated a significant decrease of the interventricular phase shift (Δπ) with LV pacing (no pacing, Δπ=8.99°±19.05°; Δπ=−0.97°±27.85° with LV pacing). Clinical improvement was observed in patients with an initial positive Δπ that decreased with pacing and/or an initial LV phase standard deviation >50° that decreased with pacing.ConclusionLV pacing induces interventricular and intraventricular synchronization. A decrease of the interventricular phase shift seems to be the most important predictor of functional recovery for paced patients with heart failure.

Primary failure of cardiac resynchronization therapy: what are the causes and is it worth considering a second attempt? A single-centre experience.

AIMS Cardiac resynchronization therapy (CRT) has been validated as an effective treatment for patients with drug-refractory congestive heart failure and left bundle branch block. Failure of implantation of the left ventricular (LV) lead has been reported in 10-15% of patients. The goal of our study was to determine the causes of failure and the success rate following a repeat procedure by the same operators. METHODS AND RESULTS We reviewed our last 100 consecutive cases of CRT before July 2007. The procedure was considered as unsuccessful if it had to be interrupted before the placement of the LV lead in an appropriate position, because of patients haemodynamic status or if the procedure duration exceeded 3 h. Cardiac resynchronization therapy was unsuccessful in 10 patients (5 men, mean age: 72 +/- 11 years). The causes of failure of CRT were as follows: no target vein other than the great cardiac vein (n = 5), coronary sinus dissection (n = 1), and a lateral vein too small to provide a stable location for the LV lead (n = 4). A second procedure was attempted in four patients and was successful in all cases. CONCLUSION In our study results, failure of CRT was observed in 10% of the patients. A second procedure can be attempted in a selected group of patients and is associated with a high success rate.