Resynchronization pacing is a useful adjunct to the management of acute heart failure after surgery for congenital heart defects

Janoušek, Jan; Vojtovič, Pavel; Hučín, B; Tláskal, T; Gebauer, Roman; Matějka, Tomáš; Marek, Jan; Reich, Oleg

doi:10.1016/s0002-9149(01)01609-5

Cited by 126 publications

(78 citation statements)

References 22 publications

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“…Electrical resynchronization with RV pacing has been shown to acutely increase arterial systolic and pulse pressure (23), as well as cardiac index and RV dP/dt max (15), in patients with congenital heart disease. BiVP has been shown to acutely increase the aortic velocity-time integral and RV dP/dt max , and to decrease the RV-LV preejection period in patients with systemic RV failure (22), and to increase RV ejection fraction in a single patient with previous Mustard repair (11).…”

Section: Discussionmentioning

confidence: 99%

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Effects of sequential biventricular pacing during acute right ventricular pressure overload

Quinn

Berberian

Cabreriza

et al. 2006

American Journal of Physiology-Heart and Circulatory Physiology

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-Temporary sequential biventricular pacing (BiVP) is a promising treatment for postoperative cardiac dysfunction, but the mechanism for improvement in right ventricular (RV) dysfunction is not understood. In the present study, cardiac output (CO) was optimized by sequential BiVP in six anesthetized, open-chest pigs during control and acute RV pressure overload (RVPO). Ventricular contractility was assessed by the maximum rate of increase of ventricular pressure (dP/dt max). Mechanical interventricular synchrony was measured by the area of the normalized RV-left ventricular (LV) pressure diagram (A PP ). Positive A PP indicates RV pressure preceding LV pressure, whereas zero indicates complete synchrony. In the control state, CO was maximized with nearly simultaneous stimulation of the RV and LV, which increased RV (P ϭ 0.006) and LV dP/dt max (P ϭ 0.002). During RVPO, CO was maximized with RV-first pacing, which increased RV dP/dt max (P ϭ 0.007), but did not affect LV dP/dtmax, and decreased the left-to-right, end-diastolic pressure gradient (P ϭ 0.023). Percent increase of RV dP/dt max was greater than LV dP/dtmax (P ϭ 0.014). There were no increases in end-diastolic pressure to account for increases in dP/dt max. In control and RVPO, RV dP/dtmax was linearly related to A PP (r ϭ 0.779, P Ͻ 0.001). The relation of CO to APP was curvilinear, with a peak in CO with positive A PP in the control state (P ϭ 0.004) and with A PP approaching zero during RVPO (P ϭ 0.001). These observations imply that, in our model, BiVP optimization improves CO by augmenting RV contractility. This is mediated by changes in mechanical interventricular synchrony. Afterload increases during RVPO exaggerate this effect, making CO critically dependent on simultaneous pressure generation in the RV and LV, with support of RV contractility by transmission of LV pressure across the interventricular septum. ventricular mechanics; interventricular synchrony; cardiac output; perioperative pacing; cardiac resynchronization therapy BIVENTRICULAR PACING (BiVP), or cardiac resynchronization therapy, is an important evolving therapeutic modality for congestive heart failure, reversing intraventricular conduction delay and left ventricular (LV) dysfunction intrinsic to dilated cardiomyopathy (2). In addition to long-term benefits for cardiac function and geometry in patients with various forms of chronic heart failure, BiVP is associated with acute improvements in ventricular systolic and diastolic function, inter-and intraventricular synchrony, and cardiac output (CO), with no cost to energy consumption (2). These acute benefits of BiVP suggest its possible value as an adjunct to the treatment of LV or right ventricular (RV) dysfunction after cardiac surgery. Although its use for perioperative management has not been carefully evaluated, initial studies have shown the utility of temporary BiVP after surgery for acquired (19, 56) and congenital (27, 40, 47) heart disease.Studies investigating sequential BiVP by alteration of the interventricular pacin...

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Section: Discussionmentioning

confidence: 99%

“…Little work has been done using pacing to treat RV dysfunction. Preliminary studies have demonstrated improvement in CO with improvement in RV contractility and mechanical interventricular synchrony (11,15,22,23). The same mechanisms may explain improvements in CO with optimized BiVP in acute RVPO.…”

mentioning

confidence: 93%

Effects of sequential biventricular pacing during acute right ventricular pressure overload

Quinn

Berberian

Cabreriza

et al. 2006

American Journal of Physiology-Heart and Circulatory Physiology

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“…Superior hemodynamic performance during LV pacing compared with RV pacing probably is caused by a more favorable balance between interventricular synchrony [13], intraventricular synchrony [36], and the sequence of electrical ventricular activation [26] during LV pacing. The idea that the sequence of activation is an important determinant of cardiac pump function is supported by other studies as well [25,26].…”

Section: Relation Between Pacing Site and LV Functionmentioning

confidence: 99%

“…Cardiac resynchronization therapy with biventricular pacing increases cardiac function after surgery for patients with congenital heart disease compared with intrinsic activation [13,42]. Experience with chronic biventricular pacing in children is sparse, but a multicenter study showed promising results with regard to cardiac function after 4 months of resynchronization therapy [11], and biventricular pacing proved effective in the treatment of six children with RV pacing-induced heart failure [20].…”

Section: Relation Between Pacing Site and LV Functionmentioning

confidence: 99%

Chronic Left Ventricular Pacing Preserves Left Ventricular Function in Children

et al. 2008

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Chronic right ventricular (RV) pacing can induce structural and functional cardiac deterioration. Because animal studies showed a benefit of left ventricular (LV) over RV pacing, this study compared the effects of chronic RV and LV pacing in children. Retrospectively, echocardiographic data were evaluated from 18 healthy children (control subjects) and from children undergoing chronic epicardial RV pacing (7 RVP) or LV pacing (7 LVP). Assessment included LV end-diastolic wall thickness (LVEDWT) and end-systolic wall thickness (LVESWT) as well as LV end-diastolic diameter (LVEDD) and end-systolic diameter (LVESD). The shortening fraction and eccentricity index (LV diameter/2 9 LV wall thickness) were calculated as measures of LV function and eccentricity, respectively. Duration of QRS and septal posterior wall motion delay (SPWMD) were used as measures of electrical and mechanical dyssynchrony, respectively. A p value less than 0.05 determined significance. As the findings showed, LVEDD, LVESD, LVEDWT, and LVESWT were not significantly different between the groups. The shortening fraction was significantly lower in the RVP (21.7% ± 6.0%) than in the LVP (32.2% ± 5.2%) or control (29.3% ± 4.3%) children. The systolic LV eccentricity index was significantly larger in the RVP (1.8 ± 0.2) than in the LVP (1.4 ± 0.1) or control (1.4 ± 0.2) children. The SPWMD was significantly larger in the RVP (338 ± 20 ms) than in the LVP (-16 ± 14 ms) or control (-5 ± 35 ms) group, whereas QRS duration was similarly longer in the RVP (157 ± 10 ms) and LVP (158 ± 22 ms) groups compared than in the control group (69 ± 7 ms). The authors conclude that LV function in children is preserved by chronic pacing at the LV lateral wall.Keywords Cardiac function Á Children Á Dyssynchrony Á Pacing Á Site Á Ventricular In children and adults with congenital or acquired atrioventricular (AV) block, the ventricular pacing lead is traditionally positioned at the right ventricle (RV) [16,19]. However, RV apex pacing causes an acute decrease in left ventricular (LV) function in animals [26], adults [6] and children [14,36]. During chronic RV pacing in children, LV function, morphology [30,31], and histology [15] are at risk for deterioration over time (for review see Karpawich [16]). Chronic RV pacing can eventually result in cardiac failure, which occurs in 6% to 7% of children [17,20,38]. Also, in adults, chronic RV apex pacing has deleterious effects (for review see Manolis [19]) and increases the risk of heart failure [1,28].Recognition of the possible harmful effects from RV apex pacing initiated the search for alternative ventricular pacing sites including the RV outflow tract, His bundle, LV wall, and biventricular pacing. Pacing at the His bundle is likely the superior approach [8], but appears to be

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“…[61][62][63] In 2001, Janousek et al 61 used temporary epicardial pacing wires in 7 postoperative CHD patients with 2-ventricle anatomy and RBBB. Intraventricular resynchronization was successfully achieved with atrial synchronous RV pacing from the lateral RV wall.…”

Section: Crt For the Failing Rvmentioning

confidence: 99%

Cardiac Resynchronization Therapy for Pediatric Patients With Heart Failure and Congenital Heart Disease

Motonaga

Dubin

2014

Circulation

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1879C ardiac resynchronization therapy (CRT) is an effective treatment for adult patients with left ventricular (LV) failure. Large prospective, randomized, controlled trials have demonstrated that CRT results in improvement in cardiac function, LV reverse remodeling, decreased hospitalizations for heart failure (HF), improved quality of life, and decreased overall mortality.1-5 However, 30% of adult patients are nonresponders to CRT, spurring further evaluation of electromechanical dyssynchrony to determine optimal pacing sites and to improve CRT selection criteria for maximal response. 1,6 The positive response in adult HF prompted exploration of the use of CRT in pediatric HF patients. However, the effectiveness of CRT in the pediatric population is difficult to evaluate because of the complex anatomic substrates of congenital heart disease (CHD) and scar formation from multiple cardiac surgeries with a higher proportion of right bundle-branch block (RBBB) and right ventricular (RV) failure than in the adult population. The typical adult HF scenario of an LV ejection fraction (EF) ≤35% with a left bundle-branch block (LBBB) is uncommon in children; therefore, the adult selection criteria for CRT cannot be easily translated to pediatric patients. Furthermore, a small heterogeneous pediatric patient population hinders a systematic assessment of long-term benefit from CRT. Principles of CRTIn the normal heart, ventricular electrical activation spreads through the His-Purkinje system, which has unique rapid propagation properties and widespread distribution. This allows highly coordinated electrical activation between distant regions of both ventricles, resulting in highly synchronous mechanical contraction. Given the strong relationship between electrical excitation and mechanical contraction in the myocardium, it is not surprising that abnormal electrical activation results in abnormal mechanical contraction. 7,8 During a spontaneous or pacing-induced bundle-branch block, ventricular activation spreads primarily cell to cell through the surrounding myocardium, which can be up to 4 times slower than the specialized His-Purkinje system. 9,10 This results in asynchronous electrical activation and thus asynchronous mechanical contraction in which opposing regions of the ventricular wall become out of phase with each other. Energy generated by contraction of early activated regions is dissipated by relaxation of late-activated regions, leading to decreased energy efficiency, depressed pump function, and deleterious ventricular remodeling. 11-14Approximately 25% of adults with HF exhibit a LBBB with mechanical dyssynchrony. CRT has traditionally targeted this electrical and mechanical dyssynchrony with biventricular pacing.15 By simultaneously pacing both ventricles, CRT uniformly prolongs the time to maximum contraction in each ventricle as the activation wave fronts from both ventricles merge. 16,17 This results in a more coordinated contraction pattern, more homogeneous distribution of regional loading conditions ...

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Resynchronization pacing is a useful adjunct to the management of acute heart failure after surgery for congenital heart defects

Cited by 126 publications

References 22 publications

Effects of sequential biventricular pacing during acute right ventricular pressure overload

Effects of sequential biventricular pacing during acute right ventricular pressure overload

Chronic Left Ventricular Pacing Preserves Left Ventricular Function in Children

Cardiac Resynchronization Therapy for Pediatric Patients With Heart Failure and Congenital Heart Disease

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