Effect of biventricular pacing on metabolism and perfusion in patients affected by dilated cardiomyopathy and left bundle branch block: evaluation by positron emission tomography

Neri, G; Zanco, Pierluigi; Zanon, Francesco; Buchberger, R

doi:10.1053/eupc.2002.0272

Cited by 50 publications

(49 citation statements)

References 9 publications

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“…170 By reduction of the inefficiency of dyscoordinate ventricular contractions, cardiac resynchronization therapy increases glucose metabolism and reduces IR 171,172 to improve cardiac efficiency and cardiac energetics. [173][174][175][176] Statins lessen the incidence of new diabetes in patients with metabolic syndrome, 175 improve glucose tolerance, 177,178 and improve HF.…”

Section: Other Potential Therapiesmentioning

confidence: 99%

Metabolic Mechanisms in Heart Failure

Ashrafian

Frenneaux

Opie³

2007

Circulation

457

301

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Abstract-Although neurohumoral antagonism has successfully reduced heart failure morbidity and mortality, the residual disability and death rate remains unacceptably high. Though abnormalities of myocardial metabolism are associated with heart failure, recent data suggest that heart failure may itself promote metabolic changes such as insulin resistance, in part through neurohumoral activation. A detrimental self-perpetuating cycle (heart failure 3 altered metabolism 3 heart failure) that promotes the progression of heart failure may thus be postulated. Accordingly, we review the cellular mechanisms and pathophysiology of altered metabolism and insulin resistance in heart failure. It is hypothesized that the ensuing detrimental myocardial energetic perturbations result from neurohumoral activation, increased adverse free fatty acid metabolism, decreased protective glucose metabolism, and in some cases insulin resistance. The result is depletion of myocardial ATP, phosphocreatine, and creatine kinase with decreased efficiency of mechanical work. On the basis of the mechanisms outlined, appropriate therapies to mitigate aberrant metabolism include intense neurohumoral antagonism, limitation of diuretics, correction of hypokalemia, exercise, and diet. We also discuss more novel mechanistic-based therapies to ameliorate metabolism and insulin resistance in heart failure. For example, metabolic modulators may optimize myocardial substrate utilization to improve cardiac function and exercise performance beyond standard care. The ultimate success of metabolic-based therapy will be manifest by its capacity further to lessen the residual mortality in heart failure. Key Words: fatty acids Ⅲ glucose Ⅲ heart failure Ⅲ insulin resistance D espite significant therapeutic advances, heart failure (HF) remains a leading cause of morbidity and mortality in developed 1 and increasingly in developing countries, 2 with a 5-year mortality rate of Ϸ50%, which rivals or exceeds that of many cancers. 3 This unacceptably high residual mortality and morbidity has mandated a reevaluation of cardiac biology with the aim to identify novel therapeutic strategies for HF. Because the daily turnover of ATP (Ϸ6 to 35 kg) is very many times that of the myocardial ATP pool, and even the healthy heart only extracts Ϸ25% of energy derivable from substrates, 4 it is not surprising that even subtle variations in the efficiency of energy generation or utilization may have a profound cumulative impact on cellular energy levels. 5 Thus cardiac energetics in particular and metabolism in general represent promising targets for HF therapy. 6 Correspondingly, numerous studies have identified decreased cardiac energy levels and flux as a consistent feature of HF. 6,7 These observations have been reinforced by genomic studies 8 and have focused considerable attention on metabolic modulation as a therapy for HF. 6 Specifically, altered myocardial carbohydrate metabolism and the related state of myocardial insulin resistance (IR), in which given concentrations of...

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Section: Other Potential Therapiesmentioning

confidence: 99%

Metabolic Mechanisms in Heart Failure

Ashrafian

Frenneaux

Opie³

2007

Circulation

457

301

View full text Add to dashboard Cite

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“…22,23 Nowak et al suggested that restoration of septal glucose uptake after CRT, as reflected by FDG uptake, was in accordance with an increase of GLUT-4 because of the increase in workload. 19 In a previous report, 24 glucose metabolism in the septum improved with less alteration in perfusion subsequent to CRT, so the restoration of glucose metabolism after CRT may be caused by an alteration in septal workload, and not by restoration of perfusion. The mechanism of the reverse mismatch in LBBB may be the result of reduced septal workload with reduced expression of GLUT-4.…”

Section: Discussionmentioning

confidence: 99%

Reverse Perfusion-Metabolism Mismatch Predicts Good Prognosis in Patients Undergoing Cardiac Resynchronization Therapy A Pilot Study

Inoue

Takahashi

Ishikawa

et al. 2007

Circ J

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t is now accepted that cardiac resynchronization therapy (CRT) improves cardiac function in patients with heart failure, and thus reduces morbidity and mortality. 1,2 However, cardiac function does not improve in all patients who undergo CRT. Some studies have revealed the predictive ability of the response to CRT. 3,4 Patients with left ventricular (LV) systolic dysfunction and dilatation frequently have ventricular conduction delay, such as left bundle branch block (LBBB), which is associated with delayed contraction of the lateral LV wall, causing early contraction of the septum, resulting in paradoxical movement. The abnormal activation sequence induced by spontaneous LBBB 5,6 or by right ventricular (RV) pacing-induced LBBB influences both the perfusion and glucose metabolism of the septum. 7,8 Simultaneous perfusion imaging with a tracer, such as technetium metoxy-isobutyl isonitrile (Tc-MIBI) or NH3, and fluorodeoxyglucose (FDG)-positron emission tomography (PET) has been used to identify myocardial viability and high-risk patients who are likely to benefit from revascularization therapy. Correct interpretation of the patterns of flow and metabolism, such as match, mismatch and reversed mismatch, is important. A mismatch pattern is observed in ischemic, hibernating but viable myocardium, 9 whereas a reverse mismatch pattern is often observed in patients with a recent myocardial infarction, 10 chronic stable coronary artery disease or LBBB. It was recently demonstrated that a reverse mismatch pattern is a sign of reversible myocardial dysfunction. 11,12 Both spontaneous and induced LBBB show a reverse mismatch pattern in the septal myocardium, 7,8 but the significance of this pattern as a predictor of prognosis in patients who subsequently undergo CRT is unknown. In this pilot study we used FDG-PET and metoxy-isobutyl isonitrile (MIBI)-single photon emission computed tomography (SPECT) to investigate whether the patterns of flow and glucose metabolism were related to prognosis in patients who underwent CRT. Background Cardiac resynchronization therapy (CRT) improves glucose metabolism in the septum of patients with heart failure, so in the present study the predictive value of combined fluorodeoxyglucose (FDG)-positron emission tomography (PET) and metoxy-isobutyl isonitrile (MIBI)-single photon emission computed tomography (SPECT) for the prognosis of patients undergoing CRT was investigated. Methods and ResultsFourteen patients (70.3±8.2 years) who underwent FDG-PET and MIBI-SPECT before implantation of a biventricular pacemaker were enrolled. The total number of matches, mismatches, reverse mismatches, summed difference score (SDS: sum total of FDG -MIBI scores) and SDS per segment (%SDS) in each of 5 areas of myocardium (septum, anterior, lateral, inferior area, apex) was calculated and compared between the survival groups (all survival: survival group; survival without ischemic heart disease (IHD): non-IHD survival group) and non-survival group. Both the number of reverse mismatch segments and the %SD...

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“…Although several studies characterized global MVO 2 and MBF in cardiomyopathy with PET, they failed to discriminate between LBBB and non-LBBB patients [17][18][19][20][21]. Recent studies that focused on regional aspects of LBBB on a semiquantitative or quantitative basis mostly of the septal and the lateral walls included only a small number of patients [22][23][24][25][26]. To our knowledge, the present study is the first one to quantitatively investigate both global and regional MVO 2 as well as global and regional MBF in a larger DCM population.…”

Section: Discussionmentioning

confidence: 99%

“…The rationale is to reduce the LBBB associated intraventricular dyssynchrony in DCM patients by synchronous biventricular pacing. Correspondingly, PET investigations revealed that regional inhomogeneities of glucose metabolism, MVO 2 and MBF were balanced [22][23][24][25][26].…”

Section: Regional Mvo 2 and Mbf In Dcm Patients With And Without Lbbbmentioning

confidence: 99%

Global and regional myocardial oxygen consumption and blood flow in severe cardiomyopathy with left bundle branch block

Lindner

Vogt

Baller

et al. 2005

European Journal of Heart Failure

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Objective: In patients with dilated cardiomyopathy (DCM), left bundle branch block (LBBB) is a common finding. The characteristic feature is an asynchronous septal wall motion and most frequently a delay of the lateral and/or posterior wall segments. With the onset of cardiac resynchronization therapy, there is a focus on the specific pathophysiology of a LBBB. However, quantitative data on regional myocardial oxygen consumption (MVO 2 ) and blood flow (MBF) are missing. Methods: We studied 31 patients with severe DCM and LBBB (ejection fraction 22.1F7.1%) and 14 patients with mild to moderate DCM without LBBB (ejection fraction 46.7F7.9%). Global and regional MVO 2 as well as MBF were determined from a dynamic 11 C-acetate positron emission tomography (PET) study. Results: Global MVO 2 and MBF were lower in the DCM group with LBBB than in the control group ( Pb0.05). Regionally, the LBBB group revealed a higher ( Pb0.05) MVO 2 and MBF in the lateral wall than in the other walls. The control group did not show significant differences between the myocardial walls and demonstrated a smaller variability of the parameters. Conclusion: DCM patients with LBBB exhibit a more heterogeneous distribution of MVO 2 and MBF among the myocardial walls than DCM patients without LBBB. Due to the LBBB associated electromechanical alterations, the highest regional values of MVO 2 and MBF are found in the lateral wall.

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Effect of biventricular pacing on metabolism and perfusion in patients affected by dilated cardiomyopathy and left bundle branch block: evaluation by positron emission tomography

Abstract: Our results suggest that, in patients affected by DC and LBBB, BIVP improves the septal glucose metabolism without significant changes in myocardial perfusion.

Cited by 50 publications

References 9 publications

Metabolic Mechanisms in Heart Failure

Metabolic Mechanisms in Heart Failure

Reverse Perfusion-Metabolism Mismatch Predicts Good Prognosis in Patients Undergoing Cardiac Resynchronization Therapy A Pilot Study

Global and regional myocardial oxygen consumption and blood flow in severe cardiomyopathy with left bundle branch block

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