Transvenous biventricular pacing for heart failure: can the obstacles be overcome?

Auricchio, Angelo; Klein, Helmut U.; Tockman, Bruce; Sack, Stefan; Stellbrink, Christoph; Neuzner, Jörg; Kramer, Andrew; Ding, Jiang; Pochet, Thierry; Maarse, A.; Spinelli, Julio

doi:10.1016/s0002-9149(98)01015-7

Cited by 181 publications

(103 citation statements)

References 18 publications

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“…9 Indeed, in CRT patients the increase in LV dP/dtmax during LV apex pacing is low when using an average AV delay, but almost maximal when using the optimal AV delay. 51 Most studies show that the amount of non-responders is highest in patients who suffer from ischemic cardiomyopathy (ICM). One possible mechanism is that there is insufficient viable tissue to allow an increase in contractility by CRT.…”

Section: Electrical Substrate Is Sufficient For Effective Crtmentioning

confidence: 99%

Cardiac Resynchronization Therapy - Refocus on the Electrical Substrate -

Strik

Ploux

Vernooy

et al. 2011

Circ J

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Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp s its name suggests, cardiac resynchronization therapy (CRT) aims to treat the electrical substrate in symptomatic heart failure (HF) patients with reduced LV ejection fraction (EF) and wide QRS complex. A recent metaanalysis pooled more than 3,000 CRT patients from 6 trials and reported a reduction in all-cause mortality of 29% and a reduction in the number of new hospitalizations for worsening HF of 37%. 1 Nevertheless, a QRS duration >120 ms has proven to be a moderate predictor of CRT efficacy, as 30-50% of implanted patients do not respond to the therapy. This has sparked major efforts into identifying patients who benefit from CRT by investigating mechanical dyssynchrony. However, the relatively slow improvement in CRT efficacy in recent years has renewed interest in the electrical substrate. It has become increasingly clear that left bundle branch block (LBBB) is the hallmark conduction disease that is treatable by CRT, as evidenced by efficacy of CRT in canine hearts with isolated LBBB and in CRT patients with LBBB compared to CRT patients with other conduction disorders. 2, 3 In this review we will explore current knowledge concerning the electrical substrate in CRT candidates and apply this to current CRT practice. We will then discuss why the electrical substrate is both essential and sufficient for successful CRT. We will show that this is true if the electrical substrate is defined more accurately than just by duration of the QRS complex. LBBBA century has passed since Eppinger and Tothberger first described LBBB by associating distinctive electrophysiological changes with the destruction of only a small region in the interventricular septum in the canine heart. 4 The typical QRSmorphology changes seen in the esophageal-to-rectal lead in the dogs were directly extrapolated to leads II and III in human patients. This misinterpretation caused LBBB to be erroneously diagnosed as right bundle branch block (RBBB) and vice versa in the first quarter of the past century.It was only until decades after the rectification that the anatomy of the left bundle branch (LBB) and the significance of its dysfunction were investigated in detail. In 1972, Demoulin et al reported their histopathological findings in human patients without known cardiac disease, showing that the LBB emerges from the His bundle between the non-coronary and right-coronary aortic cusps and runs as a 6-10-mm wide ribbon-like structure inferiorly and slightly anteriorly over the septal subendocardium. 5 With considerable variation, the fibers of the LBB quickly separate to form fasciculi in anterior, posterior and often septal main radiations (Figure 1). The LBB enables fast activation of the left ventricle (LV) because it ends in a rich peripheral Purkinje network that couples with individual (sub)endocardial myocardial cells. 6 Extensive electrical mapping in isolated human hearts with an intact LBB showed up to 3 LV endocardial breakthrough si...

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Section: Electrical Substrate Is Sufficient For Effective Crtmentioning

confidence: 99%

Cardiac Resynchronization Therapy - Refocus on the Electrical Substrate -

Strik

Ploux

Vernooy

et al. 2011

Circ J

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“…La innovación tecnológica en el campo de la TRC ha conducido a la generalización de la técnica mediante procedimientos mínimamente invasivos que permiten la selección de la región del VI a estimular 14 . Nuestra tasa de éxito en los implantes es similar a la de otras series recientes, que alcanzan un porcentaje de estimulación ventricular izquierda entre el 84 y el 92% 9,17 .…”

Section: Discussionunclassified

“…La etapa inicial de implantes del electrodo ventricular izquierdo mediante toracotomía ha dado paso al acceso transvenoso epicárdico a través de las venas tributarias del seno coronario, mediante electrodos y material específicamente diseñado a tal fin. La técnica actual, mínimamente invasiva pero todavía muy desafiante, conjuga aspectos de estimulación antibradicardia convencional, electrofisiología y hemodinámica, aceptándose comúnmente como mejor estrategia la realización de un enfoque multidisciplinario 14 .…”

Section: Introductionunclassified

Tratamiento de la insuficiencia cardíaca avanzada mediante estimulación biventricular. Experiencia inicial en una serie de 22 casos consecutivos

García‐Bolao

Macı́as

Alegría

et al. 2003

Revista Española de Cardiología

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“…16 After analysing the acute haemodynamic eVects of BiV pacing, others have concluded that the best configuration includes pacing of the left ventricular free wall. 17 However, achieving the optimum configuration is subject to certain limitations linked to the anatomical variability of the coronary sinus and its branches. Indeed, even though the mid-and great cardiac veins are constantly present, no lateral or posterior branches can be found in around 1% of patients.…”

Section: Discussionmentioning

confidence: 99%

Aortic recoarctation as the source of arterial embolism 32 years after synthetic patch angioplasty

Vollmann¹

2001

Heart

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Background-Biventricular pacing has been proposed as an adjuvant to optimal medical treatment in patients with drug refractory heart failure caused by chronic left ventricular systolic dysfunction and intraventricular conduction delay. Objective-To assess the technical feasibility and long term results (over six years) of transverse left ventricular pacing with the lead inserted into a tributary vein of the coronary sinus. Subjects-From August 1994 to February 2000, left ventricular lead implantation was attempted in 116 patients who were eligible for biventricular pacing (mean (SD) age 67 (9) years, New York Heart Association (NYHA) functional class III/IV, left ventricular ejection fraction 22 (6)%, QRS duration 185 (26) ms). Results-The overall implantation success rate was 88% (n = 102). A learning curve was indicated by a progressive increase in success from 61% early on to 98% in the last year. The mean pacing threshold was 1.1 (0.7) V/0.5 ms at the time of implantation and increased slightly up to 1.9 (0.9) V/0.5 ms at the end of the follow up period (15 (13) months). The rate of acute and delayed left ventricular lead dislodgement decreased from 30% in the early years to 11% after 1999. During follow up, 19 patients required reoperation for delayed lead dislodgement or increase in left ventricular pacing threshold (n = 15), phrenic nerve stimulation (n = 3), or infection (n = 3). Conclusions-Transverse left ventricular pacing through the coronary sinus is feasible and safe. The rate of implantation failure and of lead related problems has decreased greatly with increasing experience and with improvements in the equipment. (Heart 2001;86:405-410)

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Transvenous biventricular pacing for heart failure: can the obstacles be overcome?

Cited by 181 publications

References 18 publications

Cardiac Resynchronization Therapy - Refocus on the Electrical Substrate -

Cardiac Resynchronization Therapy - Refocus on the Electrical Substrate -

Tratamiento de la insuficiencia cardíaca avanzada mediante estimulación biventricular. Experiencia inicial en una serie de 22 casos consecutivos

Aortic recoarctation as the source of arterial embolism 32 years after synthetic patch angioplasty

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