Ventricular optimization of biventricular pacing: a systematic review

Abstract

Biventricular pacing has been shown to improve the overall clinical outcomes in patients with systolic heart failure and ventricular conduction delay on electrocardiogram. As correction of ventricular dyssynchrony is the putative mechanism of benefit, biventricular pacing is also termed as cardiac resynchronization therapy. The development of separate programmability of right and left ventricular output has led to a growing number of reports on the potential benefit of optimization of cardiac resynchronization by sequential biventricular pacing with different techniques and endpoints. This systematic review summarizes the current data for the optimization of sequential (V-V delay) compared with (default) simultaneous biventricular pacing in heart failure.

Validation of Automated Monitoring of Cardiac Output for Biventricular Pacing Optimization

“…21 BiVP optimization is critical to improving clinical results and cost effectiveness and has recently been reviewed. 22 We are examining these issues in our clinical trial.…”

Cardiac Electronic Implantable Devices in the Treatment of Heart Failure

“…These studies examined parameters including tissue Doppler imaging, 3D volumetric assessment, LVEF, interand intra-ventricular measures of dyssynchrony, aortic velocity time integral and myocardial performance index, all of which support the fact that ventricular optimisation by echocardiography reduced many functional abnormalities intrinsic to the delayed and abnormal pattern of ventricular activation. However, recent post hoc analysis of the MIRACLE trial (InSync III) did not report any significant difference in the NYHA class or quality of life improvement despite modest improvements on 6 min walk test, following optimisation using Doppler derived stroke volume [95,96]. Other optimisation approaches include invasive techniques utilising micromanometer catheters in the LV to measure dP/dt, use of radionuclide ventriculography, impedance cardiography and digital photoplesthysmography which have limitations of their own but also demonstrated improvements in overall LV filling and cardiac output.…”

“…All the evidence so far has been from single centre, non-randomised short-term studies. The emergence of newer echocardiographic parameters such as speckle tracking, strain analysis allows direct assessment of the degree of myocardial deformation during systole and thus provides important information on the timing of onset and peak of myocardial contraction permitting measurement of dyssynchrony [94,96]. The use of strain rate is proposed to have the advantage of better differentiation between active systolic contraction and passive displacement [94,97].…”

“…The use of strain rate is proposed to have the advantage of better differentiation between active systolic contraction and passive displacement [94,97]. Another approach to CRT optimisation has been to optimise the AV delay to shorted the pre-aortic ejection and LV filling intervals [98] which also revealed improvements in dysynchrony, LVEF, cardiac output and blood pressure [96]. More recently, the intra-cardiac electrogram has been used to optimise V-V delay but it is still unclear if the acute haemodynamic will translate into clinically significant functional improvement [96,99]…”

Multiple Vector Impedance Measurements During Biventricular Pacing: Feasibility and Possible Implications for Hemodynamic Monitoring

“…In patients with chronic heart failure and severe left ventricular (LV) dysfunction, biventricular pacing provides beneficial effects, by reducing mortality and hospitalizations 2,3 . During biventricular pacing, individual optimization of pacemaker settings may provide further beneficial effects by tailoring the sequence of ventricular activation 4,5 . In spite of these positive effects, patients treated with biventricular pacing still experience clinical deterioration and need hospitalization from time to time.…”