Temporary biventricular pacing decreases the vasoactive-inotropic score after cardiac surgery: A substudy of a randomized clinical trial

Nguyen, Huy; Havalad, Vinod; Aponte-Patel, Linda; A, Murata; Wang, Daniel; Rusanov, Alexander; Cheng, Bin; Cabreriza, Santos E.; Spotnitz, Henry M.

doi:10.1016/j.jtcvs.2012.07.020

Cited by 44 publications

(40 citation statements)

References 22 publications

(26 reference statements)

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“…We have previously demonstrated decreasing vasoactive inotropic score and increased urine output with BiVP during phases I and II [33]. As yet unpublished observations of decreasing intrinsic heart rate in the BiVP group further suggest that pacing might suppress atrial and ventricular arrhythmias in the postoperative period.…”

Section: Commentmentioning

confidence: 83%

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Primary Endpoints of the Biventricular Pacing After Cardiac Surgery Trial

Spotnitz¹,

Cabreriza²,

Wang³

et al. 2013

The Annals of Thoracic Surgery

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Background To determine whether optimized biventricular pacing increases cardiac index in patients at risk of left ventricular dysfunction after cardiopulmonary bypass. Procedures included coronary artery bypass, aortic or mitral surgery and combinations. This trial was approved by the Columbia University Institutional Review Board and was conducted under an Investigational Device Exemption. Methods Screening of 6,346 patients yielded 47 endpoints. With informed consent, 61 patients were randomized to pacing or control groups. Atrioventricular and interventricular delays were optimized one (Phase I), two (Phase II), and 12–24 hours (Phase III) after bypass in all patients. Cardiac index was measured by thermal dilution in triplicate. Two-sample t-test assessed differences between groups and subgroups. Results Cardiac index was 12% higher (2.83±0.16 (S.E.M.) vs. 2.52±0.13 liters/minute/square meter) in the paced group, less than predicted and not statistically significant (p=0.14). However, when aortic and aortic/mitral surgery groups were combined, cardiac index increased 29% in the paced group (2.90±0.19, n=14) vs. controls (2.24±0.15, n=11) (p=0.0138). Using a linear mixed effects model, t-test revealed that mean arterial pressure increased with pacing vs. no pacing at all optimization points (Phase I 79.2±1.7 vs. 74.5±1.6 mmHg, p=0.008, Phase II 75.9±1.5 vs. 73.6±1.8, p=0.006, Phase III 81.9±2.8 vs. 79.5±2.7, p=0.002) Conclusions Cardiac index did not increase significantly overall but increased 29% after aortic valve surgery. Mean arterial pressure increased with pacing at three time points. Additional studies are needed to distinguish rate from resynchronization effects, emphasize atrioventricular delay optimization, and examine clinical benefits of temporary postoperative pacing.

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Section: Commentmentioning

confidence: 83%

“…Optimization was similar to phase I, with testing intervals increased to 20 seconds [4]. The newly optimized protocol was then applied to BiVP patients [4,33] until phase III on the first postoperative day. The clinical endpoint, cardiac index, was measured by thermal dilution immediately prior to phase III testing.…”

Section: Methodsmentioning

confidence: 99%

Primary Endpoints of the Biventricular Pacing After Cardiac Surgery Trial

Spotnitz¹,

Cabreriza²,

Wang³

et al. 2013

The Annals of Thoracic Surgery

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“…At our center, clinical trials conducted with adult patients at risk for left ventricular dysfunction showed that temporary BiVP increased urine output and reduced the vasoactive-inotropic score (VIS) during 3 h immediately after cardiopulmonary bypass (CPB) [11]. Our trial also demonstrated the hemodynamic benefits of atrioventricular delay (AVD) and interventricular delay optimization [14, 17].…”

Section: Introductionmentioning

confidence: 75%

Optimized Multisite Ventricular Pacing in Postoperative Single-Ventricle Patients

et al. 2014

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Ventricular dyssynchrony is associated with morbidity and mortality after palliation of a single ventricle. The authors hypothesized that resynchronization with optimized temporary multisite pacing postoperatively would be safe, feasible, and effective. Pacing was assessed in the intensive care unit within the first 24 h after surgery. Two unipolar atrial pacing leads and four bipolar ventricular pacing leads were placed at standardized sites intraoperatively. Pacing was optimized to maximize mean arterial pressure. The protocol tested 11 combinations of the 4 different ventricular lead sites, 6 atrioventricular delays (50–150 ms), and 14 intraventricular delays. Optimal pacing settings were thus determined and ultimately compared in four configurations: bipolar, unipolar, single-site atrioventricular pacing, and intrinsic rhythm. Each patient was his or her own control, and all pacing comparisons were implemented in random sequence. Single-ventricle palliation was performed for 17 children ages 0–21 years. Pacing increased mean arterial pressure (MAP) versus intrinsic rhythm, with the following configurations: bipolar multisite pacing increased MAP by 2.2 % (67.7 ± 2.4 to 69.2 ± 2.4 mmHg; p = 0.013) and unipolar multisite pacing increased MAP by 2.8 % (67.7 ± 2.4 to 69.6 ± 2.7 mmHg; p = 0.002). Atrioventricular single-site pacing increased MAP by 2.1 % (67.7 ± 2.4 to 69.1 ± 2.5 mmHg: p = 0.02, insignificant difference under Bonferroni correction). The echocardiographic fractional area change in nine patients increased significantly only with unipolar pacing (32 ± 3.1 to 36 ± 4.2 %; p = 0.02). No study-related adverse events occurred. Multisite pacing optimization is safe and feasible in the early postoperative period after single-ventricle palliation, with improvements in mean arterial pressure and fractional area shortening. Further study to evaluate clinical benefits is required.

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“…A previous substudy from the BiPACS trial demonstrated reduced VIS in BiVP patients over 3 hours after CPB. 19 How hemodynamics would influence the administration of vasoactive agents is undefined, however, and administration of these drugs is not regulated by protocol at Columbia. 19 The present analysis demonstrates no significant difference in VIS between BiVP and SOC patients in phase III.…”

Section: Discussionmentioning

confidence: 99%

“…19 How hemodynamics would influence the administration of vasoactive agents is undefined, however, and administration of these drugs is not regulated by protocol at Columbia. 19 The present analysis demonstrates no significant difference in VIS between BiVP and SOC patients in phase III. Heart rate differences in phase III, therefore, probably do not reflect differences in vasoactive medication doses, although a small trend to decreased VIS in the BiVP group is present.…”

Section: Discussionmentioning

confidence: 99%

Short-term reduction in intrinsic heart rate during biventricular pacing after cardiac surgery: A substudy of a randomized clinical trial

Pensiero

Aponte-Patel

et al. 2013

The Journal of Thoracic and Cardiovascular Surgery

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Background The Biventricular Pacing After Cardiac Surgery trial investigates hemodynamics of temporary pacing in selected patients at risk of left ventricular dysfunction. This trial demonstrates improved hemodynamics during optimized biventricular pacing compared with atrial pacing at the same heart rate 1 and 2 hours after bypass and reduced vasoactive-inotropic score over the first 4 hours after bypass. However, this advantage of biventricular versus atrial pacing disappears 12 to 24 hours later. We hypothesized that changes in intrinsic heart rate can explain variable effects of atrial pacing in this setting. Methods Heart rate, mean arterial pressure, cardiac output, and medications depressing heart rate were analyzed in patients randomized to continuous biventricular pacing (n = 16) or standard of care (n = 18). Results During 30-second testing periods without pacing, intrinsic heart rate was lower in the paced group 12 to 24 hours after bypass (76.5 ± 17.5 vs 91.7 ± 13.0 beats per minute; P = .040) but not 1 or 2 hours after bypass. Cardiac output (4.4 ± 1.2 vs 3.6 ± 1.9 L/min; P = .054) and stroke volume (53 ± 2 vs 42 ± 2 mL; P = .051) increased overnight in the paced group. Vasoactive medication doses were not different between groups, whereas dexmedetomidine administration was prolonged over postoperative hours 12 to 24 in the paced group (793 ± 528 vs 478 ± 295 minutes; P = .013). Conclusions These observations suggest that hemodynamic benefits of biventricular pacing 12 to 24 hours after cardiopulmonary bypass lead to withdrawal of sympathetic drive and decreased intrinsic heart rate. Depression of intrinsic rate increases the apparent benefit of atrial pacing in the chronically paced group but not in the control group. Additional study is needed to define clinical benefits of these effects.

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Temporary biventricular pacing decreases the vasoactive-inotropic score after cardiac surgery: A substudy of a randomized clinical trial

Cited by 44 publications

References 22 publications

Primary Endpoints of the Biventricular Pacing After Cardiac Surgery Trial

Primary Endpoints of the Biventricular Pacing After Cardiac Surgery Trial

Optimized Multisite Ventricular Pacing in Postoperative Single-Ventricle Patients

Short-term reduction in intrinsic heart rate during biventricular pacing after cardiac surgery: A substudy of a randomized clinical trial

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