Immediate and chronic effects of AV-delay optimization in patients with cardiac resynchronization therapy

Hardt, Stefan E.; Yazdi, Said Hashem Fani; Bauer, Alexander; Filusch, Arthur; Korosoglou, Grigorios; Hansen, Alexander; Bekeredjian, Raffi; Ehlermann, Philipp; Remppis, Andrew; Katus, Hugo A.; Kuecherer, Helmut F.

doi:10.1016/j.ijcard.2006.03.015

Cited by 51 publications

(30 citation statements)

References 40 publications

(40 reference statements)

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“…Therefore, we believe that our results better reflect the 'true' haemodynamic response to AVD adjustments. The relatively small CO response to AVD adjustments is in contrast with other studies reporting changes in the range of 10-16% using the aortic time-velocity integral 29,30 or thoracic bioimpedance. 31 Riedlbauchova et al 20 reported a non-significant 32% change in CO using similar AVD changes as in the present study.…”

Section: Methodological Aspectscontrasting

confidence: 93%

Cardiac output response to changes of the atrioventricular delay in different body positions and during exercise in patients receiving cardiac resynchronization therapy

et al. 2009

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AimsThe aim of this study was to study the haemodynamic effect of atrioventricular delay (AVD) modifications within a narrow range in different body positions and during exercise in patients receiving cardiac resynchronization therapy (CRT). MethodsThe previously optimized AVD was shortened and prolonged by 40 ms in 27 CRT patients and 9 controls without heart failure. Cardiac output (CO) was measured by inert gas rebreathing (Innocor) as the average over different body positions (left-lateral, supine, sitting, standing, and exercise). In eight CRT patients with an implantable haemodynamic monitor, the estimated pulmonary artery diastolic pressure (ePAD) was analysed. ResultsThe magnitude of CO response to AVD changes was greater in CRT patients than in controls (0.25 vs. 0.20 L/min, P , 0.05), varied substantially between individuals (range: 0.12-0.56 L/min), and correlated with left atrial size (r ¼ 0.61, P , 0.001). On average, AVD shortening decreased CO slightly (0.07 + 0.17 L/min) and increased ePAD (1.1 + 0.8 mmHg, both P , 0.05), whereas prolongation had no significant effect. ConclusionThe haemodynamic response to AVD modifications within a narrow range is larger in CRT patients than in normal controls and varies substantially between individuals. These findings suggest that optimal AVD tuning is clinically important in selected patients.--

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Section: Methodological Aspectscontrasting

confidence: 93%

Cardiac output response to changes of the atrioventricular delay in different body positions and during exercise in patients receiving cardiac resynchronization therapy

et al. 2009

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“…However, even though many trials have shown acute benefits of AV optimization, 3,4,6,13,22 only limited data exist to suggest that systematic AV interval optimization results in long-term improvement in clinical outcomes. 20,[23][24][25][26][27] On the other hand, AV optimization by echocardiography is time-consuming and costly, and it would be desirable to avoid the procedure or, at the very least, to replace it with a simpler yet equally effective technique. 28 Previous large-scale, multicenter, randomized clinical trials of CRT have been inconsistent in their approach to AV optimization.…”

Section: Discussionmentioning

confidence: 99%

Primary Results From the SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in Cardiac Resynchronization Therapy (SMART-AV) Trial

Ellenbogen

Gold

Meyer³

et al. 2010

Circulation

368

123

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Background-One variable that may influence cardiac resynchronization therapy response is the programmed atrioventricular (AV) delay. The SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in Cardiac Resynchronization Therapy (SMART-AV) Trial prospectively randomized patients to a fixed empirical AV delay (120 milliseconds), echocardiographically optimized AV delay, or AV delay optimized with SmartDelay, an electrogram-based algorithm. Methods and Results-A total of 1014 patients (68% men; mean age, 66Ϯ11 years; mean left ventricular ejection fraction, 25Ϯ7%) who met enrollment criteria received a cardiac resynchronization therapy defibrillator, and 980 patients were randomized in a 1:1:1 ratio. All patients were programmed (DDD-60 or DDDR-60) and evaluated after implantation and 3 and 6 months later. The primary end point was left ventricular end-systolic volume. Secondary end points included New York Heart Association class, quality-of-life score, 6-minute walk distance, left ventricular end-diastolic volume, and left ventricular ejection fraction. The medians (quartiles 1 and 3) for change in left ventricular end-systolic volume at 6 months for the SmartDelay, echocardiography, and fixed arms were Ϫ21 mL (Ϫ45 and 6 mL), Ϫ19 mL (Ϫ45 and 6 mL), and Ϫ15 mL (Ϫ41 and 6 mL), respectively. No difference in improvement in left ventricular end-systolic volume at 6 months was observed between the SmartDelay and echocardiography arms (Pϭ0.52) or the SmartDelay and fixed arms (Pϭ0.66). Secondary end points, including structural (left ventricular end-diastolic volume and left ventricular ejection fraction) and functional (6-minute walk, quality of life, and New York Heart Association classification) measures, were not significantly different between arms. Conclusions-Neither SmartDelay nor echocardiography was superior to a fixed AV delay of 120 milliseconds. The routine use of AV optimization techniques assessed in this trial is not warranted. However, these data do not exclude possible utility in selected patients who do not respond to cardiac resynchronization therapy. Clinical Perspective on p 2668Achieving the optimal outcome from CRT may be dependent on proper programming of the optimal atrioventricular (AV) delay. 13,14 Suboptimal AV delay programming can result in as much as a 10% to 15% decline in cardiac output. 15,16 However, the large-scale randomized clinical trials establishing the overall efficacy of CRT have differed widely in their approach to AV optimization. In the CONTAK CD trial, there was no AV optimization. 6 In contrast, the Cardiac Resynchronization-Heart Failure (CARE-HF) and Multicenter InSync Randomized Clinical Evaluation (MIRACLE) investigators used Doppler echocardiography of transmitral flow to select the optimal AV delay, 2,3,13,14,17 an approach endorsed by the American Society of Echocardiography. 18 In further contrast, the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) investigators used an algorithm based on the i...

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“…In various preliminary studies, optimization of the AV delay has been demonstrated to significantly increase hemodynamic response, New York Heart Association (NYHA) class, LVEF and B-type natriuretic peptide level in the short-time follow-up [10][11][12][13][14]. In contrast, the recently published SmartDelay determined AV Optimization: A comparison to Other AV Delay Methods Used in Cardiac Resynchronization Therapy (SMART-AV) trial implied otherwise.…”

Section: Av Delay Optimization and Qrs Fusionmentioning

confidence: 99%

Comprehensive cardiac resynchronization therapy optimization in the real world

et al. 2014

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Background: Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in patients suffering from chronic heart failure (CHF (17.5% and 28.4% for sAV and pAV, respectively). In contrast, interventricular delay (VV delay) was rarely changed (11.9%). Conclusions: In our "real world" cohort, a substantial proportion of patients presented to their first post-operative consultation with suboptimal device settings. Our data indicate that the opportunity to optimize device settings is frequently wasted in the "real world", underlining the necessity for expert device follow-up to deliver optimal care to this challenging group of heart failure patients. (Cardiol J 2014; 21, 3: 316-324)

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Immediate and chronic effects of AV-delay optimization in patients with cardiac resynchronization therapy

Cited by 51 publications

References 40 publications

Cardiac output response to changes of the atrioventricular delay in different body positions and during exercise in patients receiving cardiac resynchronization therapy

Cardiac output response to changes of the atrioventricular delay in different body positions and during exercise in patients receiving cardiac resynchronization therapy

Primary Results From the SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in Cardiac Resynchronization Therapy (SMART-AV) Trial

Comprehensive cardiac resynchronization therapy optimization in the real world

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