Biventricular pacing reduces ventricular arrhythmic burden and defibrillator therapies in patients with heart failure

Voigt, Andrew; Barrington, William; Ngwu, Ogundu; Jain, Sandeep; Saba, Samir

doi:10.1002/clc.4960290208

Cited by 29 publications

(15 citation statements)

References 13 publications

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“…9 Interestingly, in patients having a stroke, which is well known to cause an increased sympathetic tone 33 and impaired parasympathetic function 34 both of which are predisposing factors for sudden cardiac death, 35 impaired longitudinal function of the inferior wall has been demonstrated to be the strongest echocardiographic predictor of outcome. 29 Several studies have indicated that CRT treatment reduces the risk of VT/VF [36][37][38][39] ; however, other studies have shown a proarrhythmic effect of CRT. [40][41][42] The mechanism by which CRT has been thought to reduce the risk of VT/VF has been attributed to the improved hemodynamic status and LV reverse remodeling.…”

Section: Myocardial Deformation and Prognosismentioning

confidence: 99%

Regional Longitudinal Deformation Improves Prediction of Ventricular Tachyarrhythmias in Patients With Heart Failure With Reduced Ejection Fraction

Knappe

Pouleur

Claggett

et al. 2017

Circ: Cardiovascular Imaging

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Background— Left ventricular dysfunction is a known predictor of ventricular arrhythmias. We hypothesized that measures of regional longitudinal deformation by speckle-tracking echocardiography predict ventricular tachyarrhythmias and provide incremental prognostic information over clinical and conventional echocardiographic characteristics. Methods and Results— We studied 1064 patients enrolled in the MADIT-CRT trial (Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy) with speckle-tracking data available. Peak longitudinal strain was obtained for the septal, lateral, anterior, and inferior myocardial walls at baseline. The end point was the first event of ventricular tachycardia (VT) or fibrillation (VF). During the median follow-up of 2.9 years, 254 (24%) patients developed VT/VF. Patients with VT/VF had significantly lower left ventricular ejection fraction (28.3% versus 29.5%; P <0.001) and longitudinal strain in all myocardial walls compared with patients without VT/VF (anterior-strain, −7.7% versus −8.8%; P <0.001; lateral-strain, −7.3% versus −7.9%; P =0.022; inferior-strain, −8.3% versus −9.9%; P <0.001; septal-strain, −9.1% versus −10.0%; P <0.001). After multivariate adjustment, only anterior and inferior longitudinal strain remained independent predictors of VT/VF (anterior: hazard ratio, 1.08 [1.03–1.13]; P =0.001; inferior: hazard ratio, 1.08 [1.04–1.12]; P <0.001; per 1% absolute decrease for both). When including B-type natriuretic peptide in the model, only a decreasing myocardial function in the inferior myocardial wall predicted VT/VF (hazard ratio, 1.05 [1.00–1.11]; P =0.039). Only strain obtained from the inferior myocardial wall provided incremental prognostic information for VT/VF over clinical and echocardiographic parameters (C statistic 0.71 versus 0.69; P =0.005). Conclusions— Assessment of regional longitudinal myocardial deformation in the inferior region provided incremental prognostic information over clinical and echocardiographic risk factors in predicting ventricular tachyarrhythmias. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00180271.

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Section: Myocardial Deformation and Prognosismentioning

confidence: 99%

Regional Longitudinal Deformation Improves Prediction of Ventricular Tachyarrhythmias in Patients With Heart Failure With Reduced Ejection Fraction

Knappe

Pouleur

Claggett

et al. 2017

Circ: Cardiovascular Imaging

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“…31 Cases have been reported of CRT inducing ventricular arrhythmias, but several trials report a reduction in these events. [32][33][34][35][36] A review of the 2 largest CRT trials did not show significant increases or decreases in ventricular arrhythmia. 37 …”

Section: Patient Selection and Therapeutic Resultsmentioning

confidence: 99%

Interventional Electrophysiology and Cardiac Resynchronization Therapy

Burkhardt

Wilkoff

2007

Circulation

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Abstract-Implantable devices have become a readily available option for patients with heart failure. Not only do these patients develop bradycardia and ventricular tachycardia, but their ventricular dysfunction can often improve with cardiac resynchronization therapy. However, this is a complex and rapidly developing clinical science for which the physician chooses techniques and selects patients on the basis of the results of clinical trials, clinical experience, and rapidly evolving tools. The results depend on the interplay of these complex variables. Placement of the left ventricular lead has forced the device physician to develop new skills and/or interdisciplinary relationships with physicians with vascular intervention, imaging, and surgical skills. Familiarity with the cardiac venous anatomy, occlusive venography, venoplasty, guide wire tools, guiding catheters, stenting, and new intracardiac visualization and magnetic intracardiac lead positioning tools are examples of just a few of the novel skills that are useful in the delivery of cardiac resynchronization therapy. Beyond implantation, these patients and devices require specialized follow-up with continued medical therapy and echo-guided adjustments of device programming. Finally, there are ongoing controversies and many as yet unanswered questions that are the subject of ongoing and planned clinical trials. (Circulation. 2007;115:2208-2220.)Key Words: electrical stimulation Ⅲ heart failure Ⅲ pacemakers Ⅲ defibrillators, implantable P atients with advanced congestive heart failure (CHF) on maximal medical therapy have had very limited options until recently. The advent of cardiac resynchronization therapy (CRT) has revolutionized the treatment of these patients. Many patients with advanced CHF demonstrate dyssynchrony by evidence of a widened QRS complex on the EKG. Most frequently this takes the form of a left bundle-branch block morphology, but right bundle-branch block morphology and intraventricular conduction delay are also less frequently present. 1,2 Electrical dyssynchrony usually implies that different portions of the ventricle contract at different times, unlike that of a normal heart in which contraction of all segments is nearly simultaneous. The presence of a widened QRS itself in the presence of CHF symptoms is associated with increased mortality. 3,4 Dyssynchrony on EKG, particularly of the left bundle-branch type, is associated with delayed activation of the left lateral wall, mitral regurgitation, impaired left ventricular filling, and reduced measures of cardiac contractility. 5-8 CRT operates on the premise that attempts to normalize the timing of activation of the left and right ventricle or lateral wall and septum may improve the consequences of this impaired activation. 9 Multiple trials have shown that CRT improves heart failure symptoms in the majority of recipients. 10 -14 These trials include the Multicenter InSync Randomized Clinical Evaluation (MIRACLE) trial, which studied 453 patients. All patients had a CRT device impla...

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“…Some studies have suggested an anti-arrhythmic effect of BIV pacing16, 17 while others have reported a pro-arrhythmic effect from BIV pacing18, presumably due to pacing very close to the reentrant circuit in the LV, thus facilitating the induction of reentrant ventricular arrhythmias. Whether the shorter repolarization time documented in our rabbit model, albeit in a normal heart, constitutes one of the mechanisms of reduced ventricular arrhythmia burden with BIV pacing in heart failure patients remains unclear but deserves further investigation.…”

Section: Discussionmentioning

confidence: 99%

Effect of Right Ventricular Versus Biventricular Pacing on Electrical Remodeling in the Normal Heart

Saba

Mehdi

Mathier

et al. 2010

Circ: Arrhythmia and Electrophysiology

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Background-Biventricular (BIV) pacing can improve cardiac function in heart failure by altering the mechanical and electric substrates. We investigated the effect of BIV versus right ventricular (RV) pacing on the normal heart. Methods and Results-Male New Zealand White rabbits (nϭ33) were divided into 3 groups: sham-operated (control), RV pacing, and BIV pacing groups. Four weeks after surgery, the native QT (Pϭ0.004) interval was significantly shorter in the BIV group compared with the RV or sham-operated groups. Also, compared with rabbits in the RV group, rabbits in the BIV group had shorter RV effective refractory period at all cycle lengths and shorter LV paced QT interval during the drive train of stimuli and close to refractoriness (PϽ0.001 for all comparisons). Protein expression of the KVLQT1 was significantly increased in the BIV group compared with the RV and control groups, whereas protein expression of SCN5A and connexin43 was significantly decreased in the RV compared with the other study groups. Erg protein expression was significantly increased in both pacing groups compared with the controls. Conclusions-In this rabbit model, we demonstrate a direct effect of BIV but not RV pacing on shortening the native QT interval as well as the paced QT interval during burst pacing and close to the ventricular effective refractory period. These findings underscore the fact that the effect of BIV pacing is partially mediated through direct electric remodeling and may have implications as to the effect of BIV pacing on arrhythmia incidence and burden. (Circ Arrhythm Electrophysiol. 2010;3:79-87.)

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Biventricular pacing reduces ventricular arrhythmic burden and defibrillator therapies in patients with heart failure

Cited by 29 publications

References 13 publications

Regional Longitudinal Deformation Improves Prediction of Ventricular Tachyarrhythmias in Patients With Heart Failure With Reduced Ejection Fraction

Regional Longitudinal Deformation Improves Prediction of Ventricular Tachyarrhythmias in Patients With Heart Failure With Reduced Ejection Fraction

Interventional Electrophysiology and Cardiac Resynchronization Therapy

Effect of Right Ventricular Versus Biventricular Pacing on Electrical Remodeling in the Normal Heart

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