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Biventricular Pacing in End-Stage Heart Failure Improves Functional Capacity and Left Ventricular Function

  • Patricia F. Bakker
  • Huub W. Meijburg
  • Jaap W. de Vries
  • Morton M. Mower
  • Andra C. Thomas
  • Michael L. Hull
  • Etienne O. Robles de Medina
  • Johan J. Bredée
Article

Abstract

Background Asynchronous patterns of contraction and relaxation may contribute to hemodynamic and functional impairment in heart failure. In 1993, we introduced biventricular pacing as a novel method to treat heart failure by synchronous stimulation of the right and left ventricles after an appropriate atrioventricular delay. The objectives of this study were to assess the early and long-term effects of this therapy on functional capacity and left ventricular function in patients with severe heart failure and left bundle branch block.

Methods and Results Twelve patients with end-stage congestive heart failure, sinus rhythm and complete left bundle branch block were treated with biventricular stimulation at optimized atrioventricular delay. The NYHA functional class and maximal bicycle exercise capacity were assessed. Systolic and diastolic left ventricular function were studied with echocardiography and radionuclide angiography. Data was collected at various intervals during 1-year follow-up. Cumulative survival [95% CI] was 66.7% [40.0,93.4] at 1 year and 50 % [21.8, 78.2] at 2 and 3 years. Median NYHA class improved from class IV to class II at 1 year (p=0.008). After 6weeks an increase in exercise capacity occurred, which was sustained. A less restrictive left ventricular filling pattern, an increase in dP/dt and left ventricular ejection fraction, and a decrease in mitral regurgitation were observed early and long-term.

Conclusions Biventricular pacing at optimized atrioventricular delay results in improvement in functional capacity, which is associated with improved systolic and diastolic left ventricular function, and a decrease in mitral regurgitation during short- and long-term follow-up.

biventricular pacing heart failure functional capacity hemodynamics 

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References

  1. 1.
    Heyndrickx GR, Paulus WJ. Effect of asynchrony on left ventricular relaxation. Circulation 1990;81 (Suppl III):III-41-III-47.Google Scholar
  2. 2.
    Brutsaert DL. Nonuniformity: a physiologic modulator of contraction and relaxation of the normal heart. J Am Coll Cardiol 1987;9:341-348.Google Scholar
  3. 3.
    Grines CL, Bashore TM, Boudoulas H, Olson S, Shafer P, Wooley CF. Functional abnormalities in isolated left bundle branch block. The effect of interventricular asynchrony. Circulation 1989;79:845-853.Google Scholar
  4. 4.
    Burkhoff D, Oikawa RY, Sagawa K. Influence of pacing site on canine left ventricular contraction. Am J Physiol 1986;H428-H435.Google Scholar
  5. 5.
    Bakker PFA. Cardiac stimulation as nonpharmalogical treatment for heart failure. In: Van Hemel NM, Wittkampf FHM and Ector H, eds. The pacemaker clinic of the 90's. Dordrecht, The Netherlands: Kluwer Academic Publishers, 1995; 185-197.Google Scholar
  6. 6.
    Bramlet DA, Morris KG, Coleman RE, Albert D, Cobb FR. Effect of rate dependent left bundle branch block on global and regional left ventricular function. Circulation 1983;7:1059-1065.Google Scholar
  7. 7.
    Xiao HB, Lee CH, Gibson DG. Effect of left bundle branch block on diastolic function in dilated cardiomyopathy. Br Heart J 1991;66:443-447.Google Scholar
  8. 8.
    Bakker P, de Jonge N, Klöpping C, Meijburg H, Barmen 't Loo C, Wittkampf F, van Mechelen R, Mower M, Thomas A. Biventricular pacing in congestive heart failure. Clinical Research 1994;42:327A.Google Scholar
  9. 9.
    Stevenson LW, Couper G, Natterson B, Fonarow G, Hamilton MA, Woo M, Creaser JW. Target heart failure populations for newer therapies. Circulation 1995;92 [suppl II]:II-174-II-181.Google Scholar
  10. 10.
    Hunt SA. Cardiac transplantation: the 24th Bethesda Conference. J Am Coll Cardiol 1993;22:1-64.Google Scholar
  11. 11.
    Reynolds DW. Hemodynamics of cardiac pacing. In: Ellenbogen KA, ed. Cardiac Pacing. Cambridge, Massachusetts: Blackwell Science; 1996:145-146.Google Scholar
  12. 12.
    Beaver WL, Wasserman K, Whipp BJ. A new method for detecting anaerobic threshold by gas exchange. J Appl Physiol 1986;60:2020-2027.Google Scholar
  13. 13.
    Sahn DJ, DeMaria A, Kisslo J, Weyman AE. Recommendations regarding quantitation in M-mode echocardiography: Results of a survey of echocardiographic measurements. Circulation 1978;58:1072-1084.Google Scholar
  14. 14.
    Rakowski H, Appleton C, Chan KL, Dumesnil JG, Honos G, Jue J, Koilpillai C, Lepage S, Martin RP, Mercier LA, O'Kelly B, Prieur T, Sanfilippo A, Sasson Z, Alvarez N, Pruitt R, Thompson C, Tomlinson C. Biventricular Pacing Improves Heart Failure 403 Canadian consensus recommendations for the measurement and reporting of diastolic dysfunction by echocardiography. J Am Soc Echocardiogr 1996;9:736-760.Google Scholar
  15. 15.
    Bargiggia GS, Bertucci C, Recusani F, Raisaro A, de Servi S, Valdes-Cruz LM, Sahn DJ, Tronconi L. A new method for estimating left ventricular dP/dt by continuous wave Doppler-echocardiography; Validation studies at cardiac catheterization. Circulation 1989;80:1287-1292.Google Scholar
  16. 16.
    Helmcke F, Nauda NC, Hsiang MC. Color Doppler assessment of mitral regurgitation with orthogonal planes. Circulation 1987;75:175-183.Google Scholar
  17. 17.
    Thrall JH, Freitas JE, Swanson D, Rogers WL, Clare JM, Brown ML, Pitt B. Clinical comparison of cardiac blood pool visualization with technetium-99m red blood cells labeled in vivo and with technetium-99m human serum albumin. J Nucl Med 1978;19:796-803.Google Scholar
  18. 18.
    Middlekauff HF, Stevenson WG, Stevenson LW, Saxon LA. Syncope in advanced heart failure: high risk of sudden death regardless of origin of syncope. J Am Coll Cardiol 1993;21:110-116.Google Scholar
  19. 19.
    Nishimura RA, Hayes DL, Holmes DR, Tajik AJ. Mechanisms of hemodynamic improvement by dualchamber pacing for severe left ventricular dysfunction: an acute Doppler and catheterization hemodynamic study. J Am Coll Cardiol. 1995;25:281-288.Google Scholar
  20. 20.
    Saxon LA, Kerwin WF, Cahalan MK, Kalman JM, Olgin JE, Foster E, Schiller NB, Shinbane JS, Lesh MD, Merrick SH. Acute effects of intraoperative multisite ventricular pacing on left ventricular function and activation/contraction sequences in patients with depressed ventricular function. J Cardiovasc Electrophysiol 1998;9:13-21.Google Scholar
  21. 21.
    Cazeau S, Ritter P, Bakdach S, Lazarus A, Limousin M, Henao L, Mundler O, Daubert JC, Mugica J. Four chamber pacing in dilated cardiomyopathy. PACE 1994;17(Pt. II):1974-1979.Google Scholar
  22. 22.
    Foster AH, Gold MR, McLaughlin JS. Acute hemodynamic effects of atrio-biventricular pacing in humans. Ann Thorac Surg 1995;59:294-300.Google Scholar
  23. 23.
    Auricchio A, Salo RW. Acute hemodynamic improvement by pacing in patients with severe congestive heart failure. PACE 1997;20 (Pt.1):313-324.Google Scholar
  24. 24.
    Kass DA, Chen C-H, Curry C, Talbot M, Berger R, Fetics B, Nevo E. Improved left ventricular mechanics from acute VDD pacing in patients with dilated cardiomyopathy and ventricular conduction delay. Circulation 1999;99:1567-1573.Google Scholar
  25. 25.
    Auricchio A, Stellbrink C, Block M, Sack S, Vogt J, Bakker P, Klein H, Kramer A, Ding J, Salo R, Tockman B, Pochet T, Spinelli J. Effect of pacing chamber and atrioventricular delay on acute systolic function of paced patients with congestive heart failure. Circulation 1999;99:2993-3001.Google Scholar
  26. 26.
    Blanc J-J, Etienne Y, Gilard M, Mansourati J, Munier S, Boschat J, Benditt D, Lurie KG. Evaluation of different ventricular pacing sites in patients with severe heart failure. Results of an acute hemodynamic study. Circulation 1997;96:3273-3277.Google Scholar
  27. 27.
    Cazeau S, Ritter P, Lazarus A, Gras D, Backdach H, Mundler O, Mugica J. Multisite pacing for end-stage heart failure: Early experience. PACE 1996;19 (Pt.II):1748-1757.Google Scholar
  28. 28.
    Gras D, Mabo P, Tang T, Oude Luttikuis, Chatoor R, Pedersen A-K, Tscheliessnigg H-H, Deharo J-C, Puglisi A, Silvestre J, Kimber S, Ross H, Ravazzi A, Paul V, Skehan D. Multisite pacing as a supplemental treatment of congestive heart failure: Preliminary results of the Medtronic Inc. InSync Study. PACE 1998;21 (Pt.II):2249-2255.Google Scholar
  29. 29.
    Lister JW, Klotz KH, Jomain SL, Stuckey JH, Hoffman BF. Effect of pacemaker site on cardiac output and ventricular activation in dogs with complete heart block. Am J Cardiol 1964;14:494-503.Google Scholar

Copyright information

© Kluwer Academic Publishers 2000

Authors and Affiliations

  • Patricia F. Bakker
    • 1
    • 2
  • Huub W. Meijburg
    • 1
    • 2
  • Jaap W. de Vries
    • 1
    • 2
  • Morton M. Mower
    • 1
    • 2
  • Andra C. Thomas
    • 1
    • 2
  • Michael L. Hull
    • 1
    • 2
  • Etienne O. Robles de Medina
    • 1
    • 2
  • Johan J. Bredée
    • 1
    • 2
  1. 1.Heart Lung Institute (P.F.B., H.W.M., E.O.R.d.M., J.J.B.) and Institute of Anesthesiology (J.W.d.V.)University HospitalUtrechtThe Netherlands
  2. 2.Guidant/CPI (M.M.M., A.C.T., M.L.H.)St. Paul

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