A Prospective Comparison of AV Delay Programming Methods for Hemodynamic Optimization during Cardiac Resynchronization Therapy

Gold, Michael R.; Niazi, Imran Khan; Giudici, Michael; Leman, Robert B.; Sturdivant, J. Lacy; Kim, Michael; Yu, Yinghong; Ding, Jiang; Waggoner, Alan D.

doi:10.1111/j.1540-8167.2007.00770.x

Cited by 97 publications

(97 citation statements)

References 30 publications

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“…In this study, we also found that echocardiography-guided optimization of AV/VV delays was accurate and achievable, and this method was generally the first choice for postsurgery interval optimization in the several previously reported studies [13-15]. Optimal delays are determined by mitral inflow velocity profile and LV outflow tract velocity profile (VTI; reflecting the volume of blood ejected by the left ventricle to the aorta), which are obtained via Doppler echocardiography.…”

Section: Discussionsupporting

confidence: 53%

Long-Term Effect of Different Optimizing Methods for Cardiac Resynchronization Therapy in Patients with Heart Failure: A Randomized and Controlled Pilot Study

et al. 2019

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Aim: During cardiac resynchronization therapy (CRT), optimized programming of the atrioventricular (AV) delay and ventricular-to-ventricular (VV) interval can lead to improved hemodynamics, symptomatic response, and left ventricular systolic function. Currently, however, there is no recommendation for the best optimization method. This study aimed to compare the long-term clinical outcomes of 4 different CRT optimization methods. Methods: One hundred and twenty-four consecutive CRT patients with severe heart failure and left bundle-branch block configuration were randomly assigned into four groups to undergo AV/VV delay optimization through echocardiogram (ECHO; n = 30), electrocardiogram (ECG; n = 32), QuickOpt algorithm (n = 28), and nominal AV/VV (n = 36) groups. Patients were followed up and underwent examinations, including New York Heart Association (NYHA) cardiac functional classification, 6-min walking distance (6MWD), and echocardiography, at 6, 12, 24, 36, and 48 months, respectively. The patients’ survival and clinical outcomes were compared among the four groups. Results: Kaplan-Meier survival analyses showed that the median survival was the same in the 4 groups: ECHO, 43 months; ECG, 44 months; QuickOpt, 44 months, and nominal, 41 months. At the 6-month follow-up, the reduction in left ventricular end diastolic diameter (LVEDD) was significantly less in the nominal group (–1.91 ± 2.58 mm) than that in the other three groups (ECHO: –3.70 ± 2.78 mm, p = 0.012; ECG: –3.53 ± 3.14 mm, p = 0.020; QuickOpt: –3.46 ± 2.65 mm, p = 0.032); 6MWD was significantly shorter in the nominal group (87.88 ± 34.76 m) than that in the other three groups (ECHO: 120.63 ± 56.93 m, p = 0.006; ECG: 114.97 ± 54.95 m, p = 0.020; QuickOpt: 114.57 ± 35.41 m, p = 0.027). Left ventricular ejection fraction (LVEF) significantly increased in ECHO (7.23 ± 2.76%, p = 0.010), ECG (8.50 ± 3.17%, p < 0.001), and QuickOpt (8.39 ± 2.90%, p < 0.001) compared with the nominal group (5.35 ± 2.59%). There were no significant differences among the groups in the aforementioned parameters at 24, 36, and 48 months, respectively. Conclusion: While LVEDD, LVEF, 6MWD, and NYHA were significantly improved in ECHO, ECG, and QuickOpt at 6 months, there were no significant improvements in any of the groups at 12, 24, and 48 months. These findings suggested that the long-term effect of the four CRT methods for heart failure was not significantly different.

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Section: Discussionsupporting

confidence: 53%

Long-Term Effect of Different Optimizing Methods for Cardiac Resynchronization Therapy in Patients with Heart Failure: A Randomized and Controlled Pilot Study

et al. 2019

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“…13,35,36 This method calculates sensed and paced AV delays that provide maximum hemodynamic response based on the measurement of electric conduction delays (ie, AV intervals and QRS duration). 19,20 The algorithm further accounts for LV lead location, which is generally considered an important variable in ensuring optimal patient response. 19,20 The results from the CRT-AVO study demonstrated that the SD algorithm recommended a customized AV delay that increased the acute hemodynamic responses in terms of percent change in LV dP/dtmax compared with fixed nominal AV delays of 100, 120, 140, or 160 milliseconds as well as the Ritter method and aortic velocity-time integral.…”

Section: Discussionmentioning

confidence: 99%

“…19,20 The algorithm further accounts for LV lead location, which is generally considered an important variable in ensuring optimal patient response. 19,20 The results from the CRT-AVO study demonstrated that the SD algorithm recommended a customized AV delay that increased the acute hemodynamic responses in terms of percent change in LV dP/dtmax compared with fixed nominal AV delays of 100, 120, 140, or 160 milliseconds as well as the Ritter method and aortic velocity-time integral. 19 Thus far, however, no large-scale clinical study has directly compared different methods of AV delay optimization to determine whether there are LV reverse remodeling benefits.…”

Section: Discussionmentioning

confidence: 99%

“…18 In further contrast, the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) investigators used an algorithm based on the intrinsic AV interval and baseline QRS width to determine a predicted optimal programmed sensed AV delay 1 ; a modified version of this algorithm known as SmartDelay ™ (SD) is available in the current Boston Scientific CRT devices. 1,19 The SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in Cardiac Resynchronization Therapy (SMART-AV) study was designed to compare 3 alternative techniques and to assess the hypotheses that systematic AV delay optimization with echocardiography and/or the SD algorithm is superior to a fixed nominal AV delay as demonstrated by improved left ventricular (LV) geometry after 6 months and that programming according to SD is noninferior to using echocardiography-determined AV delay optimization.…”

Section: Clinical Perspective On P 2668mentioning

confidence: 99%

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Primary Results From the SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in Cardiac Resynchronization Therapy (SMART-AV) Trial

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Meyer³

et al. 2010

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Background-One variable that may influence cardiac resynchronization therapy response is the programmed atrioventricular (AV) delay. The SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in Cardiac Resynchronization Therapy (SMART-AV) Trial prospectively randomized patients to a fixed empirical AV delay (120 milliseconds), echocardiographically optimized AV delay, or AV delay optimized with SmartDelay, an electrogram-based algorithm. Methods and Results-A total of 1014 patients (68% men; mean age, 66Ϯ11 years; mean left ventricular ejection fraction, 25Ϯ7%) who met enrollment criteria received a cardiac resynchronization therapy defibrillator, and 980 patients were randomized in a 1:1:1 ratio. All patients were programmed (DDD-60 or DDDR-60) and evaluated after implantation and 3 and 6 months later. The primary end point was left ventricular end-systolic volume. Secondary end points included New York Heart Association class, quality-of-life score, 6-minute walk distance, left ventricular end-diastolic volume, and left ventricular ejection fraction. The medians (quartiles 1 and 3) for change in left ventricular end-systolic volume at 6 months for the SmartDelay, echocardiography, and fixed arms were Ϫ21 mL (Ϫ45 and 6 mL), Ϫ19 mL (Ϫ45 and 6 mL), and Ϫ15 mL (Ϫ41 and 6 mL), respectively. No difference in improvement in left ventricular end-systolic volume at 6 months was observed between the SmartDelay and echocardiography arms (Pϭ0.52) or the SmartDelay and fixed arms (Pϭ0.66). Secondary end points, including structural (left ventricular end-diastolic volume and left ventricular ejection fraction) and functional (6-minute walk, quality of life, and New York Heart Association classification) measures, were not significantly different between arms. Conclusions-Neither SmartDelay nor echocardiography was superior to a fixed AV delay of 120 milliseconds. The routine use of AV optimization techniques assessed in this trial is not warranted. However, these data do not exclude possible utility in selected patients who do not respond to cardiac resynchronization therapy. Clinical Perspective on p 2668Achieving the optimal outcome from CRT may be dependent on proper programming of the optimal atrioventricular (AV) delay. 13,14 Suboptimal AV delay programming can result in as much as a 10% to 15% decline in cardiac output. 15,16 However, the large-scale randomized clinical trials establishing the overall efficacy of CRT have differed widely in their approach to AV optimization. In the CONTAK CD trial, there was no AV optimization. 6 In contrast, the Cardiac Resynchronization-Heart Failure (CARE-HF) and Multicenter InSync Randomized Clinical Evaluation (MIRACLE) investigators used Doppler echocardiography of transmitral flow to select the optimal AV delay, 2,3,13,14,17 an approach endorsed by the American Society of Echocardiography. 18 In further contrast, the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) investigators used an algorithm based on the i...

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“…Doppler echocardiography may also be used to assess mitral inflow velocities (utilizing the Iterative or Ritter method, described below) as well as aortic and left ventricular outflow tract (LVOT) outflow velocities across several AV intervals to find the one that maximizes cardiac output. Invasive techniques involve direct endovascular intracardiac hemodynamic measurements (LV dP/dt or pulse pressure) [21][22][23][24][25][26][27][28][29][30]. The majority of the landmark CRT trials that utilized AV optimization employed either the Ritter [31,32] or Iterative [33] techniques.…”

Section: Effects Of the Atrioventricular Interval On Hemodynamicsmentioning

confidence: 99%

Strategies for pacemaker programming in acute heart failure

2011

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In the past decade, cardiac pacing devices (either permanent pacemakers or Implanted Cardioverter Defibrillators) have become increasingly common in patients with heart failure. The manner in which the device is programmed to pace the heart can have significant implications on cardiac hemodynamics, both positive and negative. As such, in patients hospitalized with acute heart failure who have cardiac pacing devices, the clinician should note whether the programming of the device could be contributing to the patient's symptoms, and whether further programming changes could be made to improve the patient's clinical status. As of this date, there are no consensus guidelines available for the management of pacemaker programming in acute heart failure. This review article will discuss the physiologic implications of several parameters of pacemaker programming on heart failure, including the degree of RV pacing, the programmed atrioventricular (AV) interval, and the programmed interventricular pacing delay in patients with cardiac resynchronization therapy (CRT) devices. Based on the available data on the above parameters, this article will then propose a general algorithmic approach to the evaluation and management of patients with pacing devices who are hospitalized with acute heart failure.

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A Prospective Comparison of AV Delay Programming Methods for Hemodynamic Optimization during Cardiac Resynchronization Therapy

Abstract: An electrogram-based optimization method accurately predicts the optimal AVD among patients over a wide range of QRS intervals during CRT in both AS and AP modes. This simple technique may obviate the need for echocardiography for AVD programming.

Cited by 97 publications

References 30 publications

Long-Term Effect of Different Optimizing Methods for Cardiac Resynchronization Therapy in Patients with Heart Failure: A Randomized and Controlled Pilot Study

Long-Term Effect of Different Optimizing Methods for Cardiac Resynchronization Therapy in Patients with Heart Failure: A Randomized and Controlled Pilot Study

Primary Results From the SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in Cardiac Resynchronization Therapy (SMART-AV) Trial

Strategies for pacemaker programming in acute heart failure

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