Critical PQ Interval for the Appearance of Diastolic Mitral Regurgitation and Optimal PQ Interval in Patients Implanted with DDD Pacemakers

Ishikawa, Toshiyuki; Sumita, Shinnichi; Kimura, Kazuo; Kuji, Naomitsu; Nakayama, Riichiro; Nagura, Toshiro; Miyazaki, Nobuyuki; Tochikubo, Osamu; Usui, Takashi; Kashiwagi, Masanobu; Ishii, Masao

doi:10.1111/j.1540-8159.1994.tb03786.x

Cited by 46 publications

(27 citation statements)

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“…However, reducing ventricular pacing by extending AV delay may lead to AV desynchronization. Prolonged PQ interval or stimulus-R interval in atrial pacing may result in diastolic mitral regurgitation, and in consequence in heart failure [10,11,16]. Thus, the LV performance depends on both intra-ventricular and AV synchrony.…”

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confidence: 99%

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Minimizing right ventricular pacing in patients with sinus node disease and prolonged PQ interval: The impact on exercise capacity

et al. 2015

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confidence: 99%

“…Two thirds of these patients have first degree AV block [8,9]. Prolonged AV conduction may lead to diastolic mitral regurgitation and in some patients may decrease exercise capacity [10,11].…”

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confidence: 99%

Minimizing right ventricular pacing in patients with sinus node disease and prolonged PQ interval: The impact on exercise capacity

et al. 2015

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“…11 In our previous studies, diastolic MR was detected during the interval between the end of the A wave and complete closure of the mitral valve, and the critical PQ interval that induces diastolic MR may represent the upper limit of the optimal PQ interval. [4][5][6][7][8][9][10][11][12] We devised a simple method for predicting the optimal AV delay: slightly prolonged AV delay -interval between the end of the atrial kick and complete closure of the mitral valve (duration of diastolic MR) at the AV delay setting. 12 DDD pacing and AV delay optimization are not always effective for congestive heart failure and the indication for this therapy remains unclear.…”

Section: Discussionmentioning

confidence: 99%

“…[5][6][7][8][9][10][11][12] Cardiac function may be improved by AV sequential pacing and by setting the AV delay at less than the critical PQ interval for the appearance of diastolic MR when the latter is observed in patients with intrinsic AV conduction. 11 We have determined a new formula for predicting the optimal AV delay using Doppler echocardiography: optimal AV delay = slightly prolonged AV delay -interval between the end of the atrial kick and complete closure of the mitral valve (duration of diastolic MR) at the AV delay setting (Fig 1).…”

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Optimization of Atrioventricular Delay and Follow-up in a Patient With Congestive Heart Failure With an Implanted DDD Pacemaker

et al. 2001

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he efficacy of a short atrioventricular (AV) delay in patients with severely impaired cardiac function has been reported, 1-3 but the delay required to achieve optimal AV synchrony varies from patient to patient and may change with changes in cardiac function.Diastolic mitral regurgitation (MR) is observed in patients with elevated left ventricular end-diastolic pressure 4 and can be induced by prolonging the AV delay in patients with DDD pacemakers. [5][6][7][8][9][10][11][12] Cardiac function may be improved by AV sequential pacing and by setting the AV delay at less than the critical PQ interval for the appearance of diastolic MR when the latter is observed in patients with intrinsic AV conduction. 11 We have determined a new formula for predicting the optimal AV delay using Doppler echocardiography: optimal AV delay = slightly prolonged AV delay -interval between the end of the atrial kick and complete closure of the mitral valve (duration of diastolic MR) at the AV delay setting (Fig 1). 12 We report a patient with severe congestive heart failure who remained in good condition for more than 4 years with pacemaker implantation and AV delay optimization. Case ReportThe patient, an 84-year-old man with an old myocardial infarction, had had percutaneous transluminal angioplasty for total occlusion of the proximal portion of the left ascending artery successfully performed in August 1994. Although there had not been restenosis or progression of the coronary artery lesion, he had repeated admissions to hospital for congestive heart failure (Fig 2A). Medications were unchanged during follow-up (oral administration of furosemide 40 mg, spironoractone 25 mg, digoxine 0.125 mg, captopril 18.75 mg, isosorbide dinitrate 60 mg, nicorandil 15 mg, aspirin 100 mg daily). He complained of dizziness, but the dose of captopril could not be increased andblocker could not be used because of the risk of hypotension or bradycardia.ECG showed prolongation of the PQ interval (0.28 s) and complete left bundle branch block (Fig 2B). The Hisventricular interval was prolonged (90 ms on intracardiac electrocardiogram) and the ejection fraction was 31%, estimated by left ventriculography. Marked diastolic MR was detected ( Fig 3A) and during 80 beats/min AV sequential pacing, it was observed when the AV delay was set at 240 ms. The interval between the end of the atrial kick and complete closure of the mitral valve (duration of diastolic MR) was 120 ms (Fig 3B). Therefore, by our method, the predicted optimal AV delay was 240 -120 = 120 ms, and the diastolic MR disappeared when the AV delay was set at 120 ms (Fig 3C). Cardiac output was 4.7 L/min during 80 /min Tomohiko Shigemasa, MD; Tsutomu Endo, MD; Kazuo Kimura, MD; Takashi Usui, MD; Satoshi Umemura, MD It has been reported that cardiac function can be improved by implanting a DDD pacemaker (PM) and setting a short atrioventricular (AV) delay in patients with impaired cardiac function. A previous report found that the critical AV delay that induces diastolic mitral regurgitation (MR)...

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“…To determine the optimal AV delay, pulsed Doppler echocardiography is commonly used, 4 and our method was reported previously. 5,[7][8][9][10][11][12][13] However, echocardiography has several problems. The examination is time-consuming, and the optimal AV delay varies from patient to patient and with the patient's heart rate during exercise, sleep and other activities.…”

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Novel Method of Predicting the Optimal Atrioventricular Delay in Patients With Complete AV Block, Normal Left Ventricular Function and an Implanted DDD Pacemaker

Miki

Ishikawa

Matsushita

et al. 2009

Circ J

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Circ J 2009; 73: 654 -657 t is important to set the optimal atrioventricular (AV) delay to achieve optimal AV synchrony in patients with an implanted DDD pacemaker. [1][2][3][4][5][6] The optimal AV delay allows completion of end-diastolic filling flow prior to ventricular contraction, providing the longest diastolic filling time, consequently increasing cardiac output and reducing the pulmonary wedge pressure. To determine the optimal AV delay, pulsed Doppler echocardiography is commonly used, 4 and our method was reported previously. 5,[7][8][9][10][11][12][13] However, echocardiography has several problems. The examination is time-consuming, and the optimal AV delay varies from patient to patient and with the patient's heart rate during exercise, sleep and other activities. Therefore, although the optimal AV delay is set using echocardiography only once, that value may not be adequate in the patient's daily life. If a more simple method of assessing the optimal AV delay was available, the delay could be set more frequently. Therefore, the aim of this study was to predict the optimal AV delay by a novel method using phonocardiography. Methods Study PopulationWe included 6 patients (mean age 72.7±5.7 [SD] years, 3 males) with complete AV block, normal left ventricular (LV) function and an implanted DDD pacemaker (Table). Informed consent was given by each participant before enrollment in this study. Study ProtocolThe amplitude of the first heart sound (S1) was recorded on a phonocardiogram (PCG) during AV sequential pacing. Transmitral flow and the time velocity integral (TVI) of the LV outflow tract (LVOT) were measured by pulsed Doppler echocardiography at the same time. The AV delay was set from 50 to 250 ms in a stepwise fashion at 20-or 25-ms increments. The pacing rate was fixed at 70-80 beats/min to maintain atrial and ventricular pacing. All patients were examined at rest in the left lateral decubitus position, at the end of each 5-min period of AV sequential pacing. Measurement of S1An acceleration-type PCG microphone (MA-250, Fukuda Denshi, Tokyo, Japan) was positioned at the cardiac apex and connected to an echocardiograph. Phonocardiograms were filtered from 20 to 600 Hz and recorded on the echocardiograph. The S1 amplitude from peak to peak was measured. The acceleration-type PCG microphone converts the vibration of chest by the heartbeat to electrical signals according to acceleration. There was little PCG noises and (Received April 16, 2008; revised manuscript received November 14, 2008; accepted December 7, 2008; released online February 26, 2009 Background: The optimal atrioventricular (AV) delay setting is important for achieving optimal AV synchrony in patients with an implanted DDD pacemaker. Using pulsed Doppler echocardiography is the most common method of predicting the optimal AV delay, but it is a complicated and time-consuming method. Therefore, an automatic optimizing function of the AV delay at different atrial rates is desirable for achieving a favorable hemodynamic state. This...

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Critical PQ Interval for the Appearance of Diastolic Mitral Regurgitation and Optimal PQ Interval in Patients Implanted with DDD Pacemakers

Cited by 46 publications

References 13 publications

Minimizing right ventricular pacing in patients with sinus node disease and prolonged PQ interval: The impact on exercise capacity

Minimizing right ventricular pacing in patients with sinus node disease and prolonged PQ interval: The impact on exercise capacity

Optimization of Atrioventricular Delay and Follow-up in a Patient With Congestive Heart Failure With an Implanted DDD Pacemaker

Novel Method of Predicting the Optimal Atrioventricular Delay in Patients With Complete AV Block, Normal Left Ventricular Function and an Implanted DDD Pacemaker

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