Atrioventricular Delay Optimization by Doppler‐Derived Left Ventricular dP/dt Improves 6‐Month Outcome of Resynchronized Patients

Morales, Maria‐Aurora; Startari, Umberto; Panchetti, Luca; Rossi, Andrea; Piacenti, Marcello

doi:10.1111/j.1540-8159.2006.00402.x

Cited by 97 publications

(67 citation statements)

References 25 publications

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“…21 One possibility is that systematic optimization of the programmed AV delay might improve overall outcomes. However, even though many trials have shown acute benefits of AV optimization, 3,4,6,13,22 only limited data exist to suggest that systematic AV interval optimization results in long-term improvement in clinical outcomes. 20,[23][24][25][26][27] On the other hand, AV optimization by echocardiography is time-consuming and costly, and it would be desirable to avoid the procedure or, at the very least, to replace it with a simpler yet equally effective technique.…”

Section: Discussionmentioning

confidence: 99%

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

Ellenbogen

Gold

Meyer³

et al. 2010

Circulation

376

123

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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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Section: Discussionmentioning

confidence: 99%

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

Ellenbogen

Gold

Meyer³

et al. 2010

Circulation

376

123

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“…Modern DDD pacemakers allow a wide range of programming of AVD and AVD-related algorithms [6]. Proper setting of AVD allows to achieve electromechanical synchrony of atrial and ventricular contractions and the individual setting of AVD in patients with atrio-ventricular block can have the beneficial effects not only on the contractile function of the heart; but also on long-term prognosis [7]. Too short AVD results in initiation of ventricular contraction during atrial systole and hence abbreviates atrial systole and results in underfilling of the ventricle [8,9].…”

Section: Discussionmentioning

confidence: 99%

“…Several studies from single centers have shown improvement in cardiac output by echo Doppler-guided AVD optimization [11][12][13]. Doppler parameters used for echoguided optimization include aortic VTI [14,15]; diastolic mitral flow pattern by Ritter's method [16]; iterative method [17]; diastolic filling time [13]; VTI of mitral inflow [18]; Dopplerderived dP/dt [7]; tissue Doppler imaging [11,12]; LV and right ventricular (RV) pre-ejection delays; and myocardial performance index [19].…”

Section: Discussionmentioning

confidence: 99%

Optimizing the Atrioventricular Delay in Dual Chamber Pacemakers; Is It Worth?

2016

JCCR

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IntroductionThe hemnodynamically optimal delay programmed is dependent on the interval between LA and LV contraction; which in turn is subject to the interatrial conduction delay [1]. The Optimal AV synchrony will not only maximize cardiac output by increasing ventricular preload; thus lowering mean atrial pressure; but it will also minimize the diastolic mitral regurgitation [2].The usual nominally programmed A-V intervals in a DDDR pacemaker; 125 to 175 msec; May not provide the optimal AV synchrony at these patients; and AV delays as long as 250 to 350 msec may be required [1]. Currently; individualized optimization of the AVI is not performed in the clinical routine. This is mainly because of the time-consuming process of manual optimization and the lack of guideline recommendations [3,4].Here in; we aimed in this study to optimize the AVD in patients with an implanted DDD pacemaker and to compare the systolic and diastolic performance between the optimized AVD and the default AVD of the manufacturer; as well as to assess the optimal AbstractBackground: The number of patients treated with a dual chamber (DDD) pacemaker is continually increased each year. The Optimal AV synchrony will not only maximize cardiac output by increasing ventricular preload, thus lowering mean atrial pressure, but it will also minimize the diastolic mitral regurgitation. Until now, individualized optimization of the AVI is not performed in the clinical routine. This is mainly because of the time-consuming process of manual optimization and the lack of guideline recommendations.

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“…In various preliminary studies, optimization of the AV delay has been demonstrated to significantly increase hemodynamic response, New York Heart Association (NYHA) class, LVEF and B-type natriuretic peptide level in the short-time follow-up [10][11][12][13][14]. In contrast, the recently published SmartDelay determined AV Optimization: A comparison to Other AV Delay Methods Used in Cardiac Resynchronization Therapy (SMART-AV) trial implied otherwise.…”

Section: Av Delay Optimization and Qrs Fusionmentioning

confidence: 99%

Comprehensive cardiac resynchronization therapy optimization in the real world

et al. 2014

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Background: Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in patients suffering from chronic heart failure (CHF (17.5% and 28.4% for sAV and pAV, respectively). In contrast, interventricular delay (VV delay) was rarely changed (11.9%). Conclusions: In our "real world" cohort, a substantial proportion of patients presented to their first post-operative consultation with suboptimal device settings. Our data indicate that the opportunity to optimize device settings is frequently wasted in the "real world", underlining the necessity for expert device follow-up to deliver optimal care to this challenging group of heart failure patients. (Cardiol J 2014; 21, 3: 316-324)

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Atrioventricular Delay Optimization by Doppler‐Derived Left Ventricular dP/dt Improves 6‐Month Outcome of Resynchronized Patients

Abstract: Doppler-derived dP/dt for AV delay optimization determines better functional class and LVEF at 6 months follow-up relative to an empiric AV delay program.

Cited by 97 publications

References 25 publications

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

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

Optimizing the Atrioventricular Delay in Dual Chamber Pacemakers; Is It Worth?

Comprehensive cardiac resynchronization therapy optimization in the real world

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