Temporary Biventricular Pacing Postcardiopulmonary Bypass in Patients with Reduced Ejection Fraction

Muehlschlegel, Jochen D.; Peng, Yong; Lobato, Emilio B.; Hess, Philip J.; Martin, Tomas D.; Klodell, Charles T.

doi:10.1111/j.1540-8191.2007.00547.x

Cited by 19 publications

(11 citation statements)

References 32 publications

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“…This may explain the beneficial effect of BiV pacing compared with AAI pacing in our study compared with previous trials [6, 8, 9]. There are only limited data on postoperative VV optimization after cardiac surgery.…”

Section: Discussionsupporting

confidence: 47%

Optimized temporary bi-ventricular pacing improves haemodynamic function after on-pump cardiac surgery in patients with severe left ventricular systolic dysfunction: a two-centre randomized control trial

Russell

Tan

O’Keefe

et al. 2012

European Journal of Cardio-Thoracic Surgery

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OBJECTIVESOptimized temporary bi-ventricular (BiV) pacing may benefit heart failure patients after on-pump cardiac surgery compared with conventional dual-chamber right ventricular (RV) pacing. An improvement in haemodynamic function with BiV pacing may reduce the duration of ‘Level 3’ intensive care.METHODSThirty-eight patients in sinus rhythm, ejection fraction ≤35%, undergoing on-pump surgical revascularization, valve surgery or both were enrolled in this study. Before closing the sternum, temporary epicardial pacing wires were attached to the right atrium, RV outflow tract and basal posterolateral wall of the left ventricle. Patients were randomly assigned to postoperative BiV pacing with the optimization of the atrio- (AV) and inter-ventricular (VV) pacing intervals (Group 1) or conventional dual-chamber right AV pacing (Group 2). The primary end-point was the duration of ‘Level 3’ intensive care. Secondary end-points included cardiac output which was measured by thermodiluation at admission to the intensive care unit and at 6 and 18 h later, in five different pacing modes.RESULTSThe duration of ‘Level 3’ care was similar between groups (40 ± 35 vs 54 ± 63 h; Group 1 vs 2; P = 0.43). Cardiac output was similar in all pacing modes at baseline. At 18 h, cardiac output with BiV pacing (5.8 l/min) was 7% higher than atrial inhibited (5.4 l/min) and 9% higher than dual-chamber RV pacing (5.3 l/min; P = 0.02 and 0.001, respectively). Optimization of the VV interval produced a further 4% increase in cardiac output compared with baseline settings (P = 0.005).CONCLUSIONSPostoperative haemodynamic function may be enhanced by temporary BiV pacing of high-risk patients after on-pump cardiac surgery.

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Section: Discussionsupporting

confidence: 47%

Optimized temporary bi-ventricular pacing improves haemodynamic function after on-pump cardiac surgery in patients with severe left ventricular systolic dysfunction: a two-centre randomized control trial

Russell

Tan

O’Keefe

et al. 2012

European Journal of Cardio-Thoracic Surgery

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“…However, aside from limited examination of lead location [18,24,28] and VVD [25], formal optimization of BiVP had not been attempted in temporary pacing. We initiated the Biventricular Pacing after Cardiac Surgery (BiPACS) trial hoping that optimization would improve the results of temporary postoperative BiVP and improve understanding of high nonresponse rates in permanent CRT [29–31].…”

Section: Introductionmentioning

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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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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“…Importantly, this is not associated with changes in myocardial energy demand (21), unlike most inotropic agents, which improve contractility at the expense of increased oxygen consumption and energy store depletion (29). Acute functional benefit without increased energy cost makes BiVP an excellent option for treatment of postoperative ventricular failure, and initial studies have shown its utility after cardiac surgery (14,20,23,24,33).…”

mentioning

confidence: 99%

Simultaneous variation of ventricular pacing site and timing with biventricular pacing in acute ventricular failure improves function by interventricular assist

Quinn

Cabreriza²,

Richmond

et al. 2009

American Journal of Physiology-Heart and Circulatory Physiology

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The goal of this work was to investigate the hemodynamic effects of simultaneous left ventricular (LV) pacing site (LVPS) and interventricular pacing delay (VVD) variation with biventricular pacing (BiVP) during acute LV failure. Simultaneously varying LVPS and VVD with BiVP has been shown to improve hemodynamics during acute right ventricular (RV) failure. However, effects during acute LV failure have not been reported. In six open-chest pigs, acute LV volume overload was induced by regurgitant flow via an aortic-LV conduit. Epicardial BiVP was implemented with right atrial and ventricular leads and a custom LV pacing array. Fifty-four LVPS-VVD combinations were tested in random order. Cardiac output was evaluated by aortic flow probe, ventricular systolic function by maximum rate of ventricular pressure change, and mechanical interventricular synchrony by normalized RV-LV pressure diagram area. Simultaneous LVPS-VVD variation improved all measures of cardiac function. The observed effect was different for each functional index, with evidence of LVPS-VVD interaction. Compared with effects of LVPS-VVD variation in a model of acute RV failure, hemodynamic changes were markedly different. However, in both models, maximum rate of ventricular pressure change of the failing ventricle was improved with synchronous interventricular contraction, suggesting that, in acute ventricular failure, BiVP can recruit the unstressed ventricle to support systolic function of the failing one. Thus simultaneously varying LVPS and VVD with BiVP during acute ventricular failure can improve cardiac function by "interventricular assist", with hemodynamic effects dependent on the type of failure. This supports the potential utility of temporary BiVP for the treatment of acute ventricular failure commonly seen after cardiac surgery.

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Temporary Biventricular Pacing Postcardiopulmonary Bypass in Patients with Reduced Ejection Fraction

Abstract: In patients with low EF, BiV pacing immediately after CPB significantly improves LV systolic function and cardiac output, and suggests significantly improved diastolic function.

Cited by 19 publications

References 32 publications

Optimized temporary bi-ventricular pacing improves haemodynamic function after on-pump cardiac surgery in patients with severe left ventricular systolic dysfunction: a two-centre randomized control trial

Optimized temporary bi-ventricular pacing improves haemodynamic function after on-pump cardiac surgery in patients with severe left ventricular systolic dysfunction: a two-centre randomized control trial

Primary Endpoints of the Biventricular Pacing After Cardiac Surgery Trial

Simultaneous variation of ventricular pacing site and timing with biventricular pacing in acute ventricular failure improves function by interventricular assist

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