Prospective comparison of echocardiographic atrioventricular delay optimization methods for cardiac resynchronization therapy

Kerlan, J.; Sawhney, Navinder; Waggoner, Alan D.; Chawla, Mohit; Garhwal, Sanjeev; Osborn, Judy L.; Faddis, Mitchell N.

doi:10.1016/j.hrthm.2005.11.006

Cited by 107 publications

(96 citation statements)

References 18 publications

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“…1-3,8,13,14,19,29 -33 A few studies have compared whether acute benefits attributed to CRT are different, depending on which method of AV delay optimization is used. 20,24,[32][33][34] For example, the CRT-AVO Study by Gold et al 19 studied the acute effects of an electrogram-based algorithm, now known as SD, against other commonly used AV delay optimization methods such as aortic velocity-time integral and the Ritter method, as well as various fixed AV delays. The development of SD was based on studies in which hemodynamic changes (as measured by LV dP/dtmax and pulse pressure) were recorded during CRT at different stimulation sites and AV delays.…”

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

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376

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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

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376

123

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“…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%

“…Moreover; Kerlan [14] claimed AV delay optimization by Doppler echocardiography for patients with severe heart failure treated with a CRT device yields a greater systolic improvement when guided by the aortic VTI method compared with the mitral inflow method [14].…”

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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“…32, 8, 439-441 (2009) and to determine the optimal interval. 9,10 In this study, we measured and recorded the spectra of blood flow through the left ventricle using pulsed Doppler ultrasound recordings, which allow accurate positioning and simple measuring, and analysis can be performed in sequence for every heart stroke. This therefore provides a practical method for determining the optimal atrioventricular interval.…”

Section: Discussionmentioning

confidence: 99%

Echocardiography for Determining the Optimal Atrioventricular Interval in Patients with Dual Chamber Pacemakers

Sun¹,

Zhao²,

Wang³

et al. 2009

Clinical Cardiology

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Background:We investigated the clinical value of Doppler echocardiography for determining the optimal setting of atrioventricular interval in patients with dual chamber pacemakers (DDD). In 38 patients with complete atrioventricular block and DDD pacemakers, the atrioventricular interval was prolonged in a stepwise fashion by 20 ms, from 90 to 250 ms, and cardiac stroke volume and transmitral flow were measured by pulsed Doppler echocardiography. Methods: The optimal atrioventricular interval at which the cardiac stroke volume was maximal was 168.9 ± 15.6 ms. The atrioventricular interval was 178.4 ± 23.4 ms when the end of the A wave coincided with complete closure of the mitral valve.Results: There was a significant linear relationship between the optimal atrioventricular interval and the predicted optimal atrioventricular interval (Y = 86.2 ± 0.5X, r = 0.70, standard error of the estimate [SEE] = 11.5, P < 0.01). Conclusion:The optimal atrioventricular interval setting for DDD pacing can be successfully determined using Doppler echocardiography, which is a noninvasive, repeatable, and simple approach. IntroductionThe atrioventricular interval of dual chamber pacemakers (DDD) and the hemodynamic efficiency of pacing are closely correlated. 1 The engorgement of the ventricle caused by atrial contraction is disturbed or absent when the atrioventricular interval is too short, but cardiac output is decreased by a reduced engorgement period if the atrioventricular interval is too long. Individual differences in optimal atrioventricular interval exist when pacing by DDD. It is therefore important to establish a method for setting the optimal atrioventricular interval for each patient with a fixed DDD pacemaker. We assessed the clinical value of Doppler echocardiography for determining the optimal atrioventricular interval and for evaluating the hemodynamics at different atrioventricular intervals in patients with DDD pacemakers.

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Prospective comparison of echocardiographic atrioventricular delay optimization methods for cardiac resynchronization therapy

Cited by 107 publications

References 18 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?

Echocardiography for Determining the Optimal Atrioventricular Interval in Patients with Dual Chamber Pacemakers

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