Comparison of stimulation sites within left ventricular veins on the acute hemodynamic effects of cardiac resynchronization therapy

Gold, Michael R.; Auricchio, Angelo; Hummel, John D.; Giudici, Michael; Ding, Jiang; Tockman, Bruce; Spinelli, Julio

doi:10.1016/j.hrthm.2004.12.025

Cited by 88 publications

(51 citation statements)

References 19 publications

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“…[2][3][4] However, in patients receiving biventricular pacing, LV lead positioning varies randomly on account of contingencies, unpredictable anatomic conditions, or technical reasons.…”

Section: Clinical Perspective On P 467mentioning

confidence: 99%

Acute Hemodynamic Effect of Left Ventricular Endocardial Pacing in Cardiac Resynchronization Therapy

Padeletti

Pieragnoli

Ricciardi

et al. 2012

Circ: Arrhythmia and Electrophysiology

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During cardiac resynchronization therapy (CRT) device implantation, left ventricular (LV) lead placement is usually performed by means of a transvenous approach using the tributaries of the coronary sinus (CS). The feasibility of transvenous lead positioning depends on many factors, including venous anatomy, accessibility of the vein, pacing threshold, lead stability, and the absence of phrenic nerve stimulation. 1 Clinical Perspective on p 467Several authors have reported variable individual responses to CRT and have indicated the LV pacing site as a major determinant of the hemodynamic response.2-4 However, in patients receiving biventricular pacing, LV lead positioning varies randomly on account of contingencies, unpredictable anatomic conditions, or technical reasons.Transvenous LV endocardial pacing via transseptal puncture has been implemented in the rare circumstance in which neither the transvenous CS epicardial nor the surgical option is feasible. Indeed, this technique enables the limitations of CS venous anatomy to be overcome and may constitute an alternative method of optimizing lead positioning and improving outcome. Initial experience in early studies with transvenous LV endocardial pacing has yielded promising results. [5][6][7] In the present study, we evaluated the acute hemodynamic effects of CRT through transvenous LV endocardial pacing in heart failure patients by analyzing LV pressure-volume relationships. Methods Patient Selection and ProcedureWe enrolled 12 consecutive heart failure patients with indications for CRT. The Institutional Review Board approved the protocol, and all patients gave written informed consent.Exclusion criteria were the presence of a previously implanted device, valvular insufficiency, or stenosis. The atrial and right ventricular leads were placed in the right atrium and at the apex of the right ventricle, respectively, in patients who were lightly sedated. The LV lead was positioned in the CS and advanced into the lateral or posterolateral vein in accordance with standard procedure. Background-During cardiac resynchronization therapy (CRT) device implantation, the pacing lead is usually positioned in the coronary sinus (CS) to stimulate the left ventricular (LV) epicardium. Transvenous LV endocardial pacing via transseptal puncture has been proposed as an alternative method. In the present study, we evaluated the acute hemodynamic effects of CRT through LV endocardial pacing in heart failure patients by analyzing LV pressure-volume relationships. Methods and Results-LV pressure and volume data were determined via conductance catheter during CRT device implantation in 10 patients. In addition to the standard epicardial CS pacing, the following endocardial LV sites were systematically assessed: the site transmural to the CS lead, the LV apex, the septal midwall, the basal lateral free wall, and the midlateral free wall. Four atrioventricular delays were tested. There was a significant improvement of systolic function with CRT in all LV pacing configurations, wherea...

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“…[2][3][4] However, in patients receiving biventricular pacing, LV lead positioning varies randomly on account of contingencies, unpredictable anatomic conditions, or technical reasons.…”

Section: Clinical Perspective On P 467mentioning

confidence: 99%

Acute Hemodynamic Effect of Left Ventricular Endocardial Pacing in Cardiac Resynchronization Therapy

Padeletti

Pieragnoli

Ricciardi

et al. 2012

Circ: Arrhythmia and Electrophysiology

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“…Other clinical studies in patients with heart failure and dyssynchrony have yet to corroborate these observations. 18 One possibility is that smaller hearts (ie, those in children and dogs) may yield somewhat different contraction/excitation patterns that favor more apical placement over what is observed in much lager adult human hearts. The benefit of more apical versus basal stimulation may relate to faster radial dispersion (anterior-posterior), followed by apex-base activation based on fiber architecture 19,20 to provide faster activation synchrony and better LV function.…”

Section: Optimal Crt Pacing Region: the Sweet Spotmentioning

confidence: 99%

Three-Dimensional Mapping of Optimal Left Ventricular Pacing Site for Cardiac Resynchronization

et al. 2007

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Background-The efficacy of cardiac resynchronization therapy (CRT) depends on placement of the left ventricular lead within the late-activated territory. The geographic extent and 3-dimensional distribution of left ventricular (LV) locations yielding optimal CRT remain unknown. Methods and Results-Normal or tachypacing-induced failing canine hearts made dyssynchronous by right ventricular free wall pacing or chronic left bundle-branch ablation were acutely instrumented with a nonconstraining epicardial elastic sock containing 128 electrodes interfaced with a computer-controlled stimulation/recording system. Biventricular CRT was performed using a fixed right ventricular site and randomly selected LV sites covering the entire free wall. For each LV site, global cardiac function (conductance catheter) and mechanical synchrony (magnetic resonance imaging tagging) were determined to yield 3-dimensional maps reflecting CRT impact. Optimal CRT was achieved from LV lateral wall sites, slightly more anterior than posterior and more apical than basal. LV sites yielding Ն70% of the maximal dP/dtmax increase covered Ϸ43% of the LV free wall. This distribution and size were similar in both normal and failing hearts. The region was similar for various systolic and diastolic parameters and correlated with 3-dimensional maps based on mechanical synchrony from magnetic resonance imaging strain analysis. Conclusions-In hearts with delayed lateral contraction, optimized CRT is achieved over a fairly broad area of LV lateral wall in both nonfailing and failing hearts, with modest anterior or posterior deviation still capable of providing effective CRT. Sites selected to achieve the most mechanical synchrony are generally similar to those that most improve global function, confirming a key assumption underlying the use of wall motion analysis to optimize CRT.

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“…19,131,132 LV stimulation at these sites improves acute contractile response, functional capacity, and possibly mortality compared with anterior sites. [133][134][135][136][137] LV stimulation at anterior sites may even worsen contractile response in some patients by exaggerating intraventricular dyssynchrony. A posterior or posterolateral basal site was obtained in only 67% to 77% of patients in RCTs of CRT, 123,138 and it is likely that inadequate LV stimulation sites contribute significantly to CRT nonresponse.…”

Section: Crt Responders and Nonrespondersmentioning

confidence: 99%

Ventricular Pump Function and Pacing

Sweeney

Prinzen

2008

Circ: Arrhythmia and Electrophysiology

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O ptimal cardiac pump function depends on ordered mechanical events that are orchestrated by electrical timing. This electromechanical coupling occurs at multiple anatomic levels: within atria, between atria and ventricles, between ventricles, and especially within the left ventricle (LV). Such disruptions to proper electrical timing result in disordered mechanical events (desynchronization, or "dyssynchrony"), can occur spontaneously or be induced in isolation or in various combinations at any level, and degrade cardiac pump function. These disruptions to normal mechanical ordering occur because of fixed or functional conduction blocks and can be generated by myocardial disease or can be induced by cardiac pacing. The adverse effects of disruption of proper electromechanical coupling at all levels with particular attention to the effects of ventricular conduction delay due to conventional (usually right ventricular apical, RVA) pacing and left bundle-branch block (LBBB) are discussed later. Subsequently, remedies for prevention or treatment are discussed along the same lines. Consequences of Uncoupling atVarious Levels Uncoupling at the Atrial LevelThe right atrium and left atrium are activated nearly simultaneously (within 50 to 80 ms) during sinus rhythm. Preferential sites of interatrial conduction exist at the posteriorsuperior interatrial septum (Bachmann's bundle region), fossa ovalis, and coronary sinus ostium. 1,2 Significant interatrial conduction delays (up to 200 ms or greater) can occur in myopathic atria. Similar conduction delays can be also be induced, or exacerbated, by right atrial pacing. Delayed left atrial contraction can disrupt optimal left-sided atrioventricular (AV) coupling. Severe atrial decoupling and delayed left atrial contraction reverses the left-sided AV contraction sequence, resulting in atrial transport block. 3 This causes increased left atrial pressures, retrograde flow in the pulmonary veins, and counterphysiological neurohormonal responses termed "pseudopacemaker syndrome." 4 -6 Uncoupling at Atrioventricular LevelOptimal AV coupling contributes to ventricular pump function. The normal AV interval results in atrial contraction just before the pre-ejection (isovolumic) period of ventricular contraction that maximizes LV filling (LV end-diastolic pressure, or preload) and cardiac output by the Starling mechanism. This optimal timing relationship maximizes diastolic filling time, reduces diastolic mitral regurgitation (MR), and maintains mean left atrium pressure at low levels. Delayed AV coupling due to conduction delay in the AV node displaces atrial contraction earlier in diastole, which may occur immediately after or even within the preceding ventricular contraction. Atrial contraction before completion of venous return reduces preload and contractile force. A late diastolic LVϾleft atrium pressure gradient may occur, causing diastolic MR and partial closure of the mitral valve, which shortens diastolic filling time. Delayed AV coupling may be worsened or induced by atrial...

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Comparison of stimulation sites within left ventricular veins on the acute hemodynamic effects of cardiac resynchronization therapy

Cited by 88 publications

References 19 publications

Acute Hemodynamic Effect of Left Ventricular Endocardial Pacing in Cardiac Resynchronization Therapy

Acute Hemodynamic Effect of Left Ventricular Endocardial Pacing in Cardiac Resynchronization Therapy

Three-Dimensional Mapping of Optimal Left Ventricular Pacing Site for Cardiac Resynchronization

Ventricular Pump Function and Pacing

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