Mechanism of hemodynamic improvement by dual-chamber pacing for severe left ventricular dysfunction: an acute Doppler and catheterization hemodynamic study

Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905.

OBJECTIVES. This study was undertaken to determine the mechanism by which improvement in hemodynamic variables may occur with dual-chamber pacing in patients with severe left ventricular dysfunction. BACKGROUND. Dual-chamber pacing has recently been proposed as a therapeutic alternative for the relief of symptoms in patients with dilated cardiomyopathy. METHODS. Fifteen patients with severe left ventricular systolic dysfunction were studied acutely during atrioventricular (AV) sequential pacing at various AV intervals (60, 100, 120, 140, 180 and 240 ms) with use of combined Doppler velocity curves and pressures obtained by high fidelity manometer-tipped catheters and thermodilution cardiac output. RESULTS. Neither cardiac output nor mean left atrial pressure was significantly different when hemodynamic variables in the baseline state were compared with those during AV sequential pacing at the various AV intervals in all patients. The patients were classified into two groups. In group I (eight patients with PR intervals > 200 ms on the rest 12-lead electrocardiogram), cardiac output was significantly increased when AV sequential pacing at the optimal AV interval to output was compared with that at the baseline state (3.0 +/- 1.0 vs. 3.9 +/- 0.43 liters/min, p = 0.005) because timing of mechanical atrial and ventricular synchrony was optimized. In addition, left ventricular end-diastolic pressure and duration of diastolic filling were increased, and diastolic mitral regurgitation was abolished. In group II (seven patients who had normal AV conduction at rest), cardiac output during AV pacing decreased from the baseline value without change in the diastolic filling period. CONCLUSIONS. Dual-chamber pacing may improve acute hemodynamic variables in selected patients with dilated cardiomyopathy, mainly by optimization of the timing of mechanical atrial and ventricular synchrony. Reestablishment of the optimal diastolic filling period and abolition of diastolic mitral regurgitation may also contribute to hemodynamic improvement.

This article has been cited by other articles:

				S. H. Lim, G. Y.H. Lip, and J. E. Sanderson Ventricular optimization of biventricular pacing: a systematic review Europace, August 1, 2008; 10(8): 901 - 906. [Abstract] [Full Text] [PDF]

				M. Brignole, D. Oddone, R. Maggi, G. Lupi, R. Bollini, S. Corallo, S. Robotti, A. Solano, P. Donateo, and F. Croci Resynchronization of the left ventricular contraction by tailored programming of right and left ventricular pacing Europace, April 1, 2008; 10(4): 489 - 495. [Abstract] [Full Text] [PDF]

				O. Hajiseyedjavadi, M. Pasque, M. Moon, R. Damiano, T. Mucha, K. Hebert, and N. Moazami Coronary artery bypass grafting and biventricular pacing efficacy: Do past trials dictate a change in future practice? J. Thorac. Cardiovasc. Surg., October 1, 2006; 132(4): 974 - 975. [Full Text] [PDF]

				E Agricola, M Oppizzi, M Galderisi, M Pisani, A Meris, C Pappone, and A Margonato Role of regional mechanical dyssynchrony as a determinant of functional mitral regurgitation in patients with left ventricular systolic dysfunction Heart, October 1, 2006; 92(10): 1390 - 1395. [Abstract] [Full Text] [PDF]

				C-M Yu, Q Zhang, Y-S Chan, C-K Chan, G W K Yip, L C C Kum, E B Wu, P-W Lee, Y-Y Lam, S Chan, et al. Tissue Doppler velocity is superior to displacement and strain mapping in predicting left ventricular reverse remodelling response after cardiac resynchronisation therapy Heart, October 1, 2006; 92(10): 1452 - 1456. [Abstract] [Full Text] [PDF]

				M. Kindermann, B. Hennen, J. Jung, J. Geisel, M. Bohm, and G. Frohlig Biventricular Versus Conventional Right Ventricular Stimulation for Patients With Standard Pacing Indication and Left Ventricular Dysfunction: The Homburg Biventricular Pacing Evaluation (HOBIPACE) J. Am. Coll. Cardiol., May 16, 2006; 47(10): 1927 - 1937. [Abstract] [Full Text] [PDF]

				K. A. Sheehan, A. V. Zima, and L. A. Blatter Regional differences in spontaneous Ca2+ spark activity and regulation in cat atrial myocytes J. Physiol., May 1, 2006; 572(3): 799 - 809. [Abstract] [Full Text] [PDF]

				Z. I. Whinnett, J. E.R. Davies, K. Willson, A. W. Chow, R. A. Foale, D. W. Davies, A. D. Hughes, D. P. Francis, and J. Mayet Determination of optimal atrioventricular delay for cardiac resynchronization therapy using acute non-invasive blood pressure. Europace, January 1, 2006; 8(5): 358 - 366. [Abstract] [Full Text] [PDF]

				J. J. Bax, T. Abraham, S. S. Barold, O. A. Breithardt, J. W.H. Fung, S. Garrigue, J. Gorcsan III, D. L. Hayes, D. A. Kass, J. Knuuti, et al. Cardiac Resynchronization Therapy: Part 2--Issues During and After Device Implantation and Unresolved Questions J. Am. Coll. Cardiol., December 20, 2005; 46(12): 2168 - 2182. [Abstract] [Full Text] [PDF]

				A. Bernheim, P. Ammann, C. Sticherling, P. Burger, B. Schaer, H. P. Brunner-La Rocca, J. Eckstein, S. Kiencke, C. Kaiser, A. Linka, et al. Right Atrial Pacing Impairs Cardiac Function During Resynchronization Therapy: Acute Effects of DDD Pacing Compared to VDD Pacing J. Am. Coll. Cardiol., May 3, 2005; 45(9): 1482 - 1487. [Abstract] [Full Text] [PDF]

				I. H. Styliadis, N. I. Gouzoumas, H. I. Karvounis, C. E. Papadopoulos, G. K. Efthimiadis, M. Karamouzis, G. E. Parharidis, and G. E. Louridas Effects of variation of atrioventricular interval on left ventricular diastolic filling dynamics and atrial natriuretic peptide levels in patients with DDD pacing for complete heart block Europace, January 1, 2005; 7(6): 576 - 583. [Abstract] [Full Text] [PDF]

				H. Kanzaki, R. Bazaz, D. Schwartzman, K. Dohi, L. E. Sade, and J. Gorcsan III A mechanism for immediate reduction in mitral regurgitation after cardiac resynchronization therapy: Insights from mechanical activation strain mapping J. Am. Coll. Cardiol., October 19, 2004; 44(8): 1619 - 1625. [Abstract] [Full Text] [PDF]

				P. Palka, A. Lange, J. Atherton, W. J. Stafford, and D. J. Burstow Biventricular diastolic behaviour in patients with hypertrophic and hereditary hemochromatosis cardiomyopathies Eur J Echocardiogr, October 1, 2004; 5(5): 356 - 366. [Abstract] [Full Text] [PDF]

				R. R Brandt, J. Sperzel, H. F Pitschner, and C. W Hamm Echocardiographic assessment of mitral regurgitation in patients with heart failure Eur. Heart J. Suppl., August 1, 2004; 6(suppl_D): D25 - D28. [Abstract] [Full Text] [PDF]

				W. T. Abraham and D. L. Hayes Cardiac Resynchronization Therapy for Heart Failure Circulation, November 25, 2003; 108(21): 2596 - 2603. [Full Text] [PDF]

				S. D.R. Thackray, K. K.A. Witte, N. P. Nikitin, A. L. Clark, G. C. Kaye, and J. G.F. Cleland The prevalence of heart failure and asymptomatic left ventricular systolic dysfunction in a typical regional pacemaker population Eur. Heart J., June 2, 2003; 24(12): 1143 - 1152. [Abstract] [Full Text] [PDF]

				T. V. Salukhe, M. Y. Henein, and R. Sutton Pacing in heart failure: patient and pacing mode selection Eur. Heart J., June 1, 2003; 24(11): 977 - 986. [Full Text] [PDF]

				S. Cazeau, C. Alonso, G. Jauvert, A. Lazarus, and P. Ritter Cardiac resynchronization therapy Europace, January 1, 2003; 5(s1): S42 - S48. [Abstract] [Full Text] [PDF]

				M. V. Pitzalis, M. Iacoviello, R. Romito, F. Massari, B. Rizzon, G. Luzzi, P. Guida, A. Andriani, F. Mastropasqua, and P. Rizzon Cardiac resynchronization therapy tailored by echocardiographic evaluation of ventricular asynchrony J. Am. Coll. Cardiol., November 6, 2002; 40(9): 1615 - 1622. [Abstract] [Full Text] [PDF]

				P. Sogaard, H. Egeblad, A. K. Pedersen, W. Y. Kim, B. O. Kristensen, P. S. Hansen, and P. T. Mortensen Sequential Versus Simultaneous Biventricular Resynchronization for Severe Heart Failure: Evaluation by Tissue Doppler Imaging Circulation, October 15, 2002; 106(16): 2078 - 2084. [Abstract] [Full Text] [PDF]

				A. R. Leon, J. M. Greenberg, N. Kanuru, C. M. Baker, F. V. Mera, A. L. Smith, J. J. Langberg, and D. B. DeLurgio Cardiac resynchronization in patients with congestive heart failure and chronic atrial fibrillation: Effect of upgrading to biventricular pacing after chronic right ventricular pacing J. Am. Coll. Cardiol., April 17, 2002; 39(8): 1258 - 1263. [Full Text] [PDF]

				C Varma, P O'Callaghan, N G Mahon, K Hnatkova, W McKenna, A J Camm, E Rowland, and S J D Brecker Effect of multisite pacing on ventricular coordination Heart, April 1, 2002; 87(4): 322 - 328. [Abstract] [Full Text] [PDF]

				M Gasparini, M Mantica, P Galimberti, U La Marchesina, M Manglavacchi, F Faletra, and E Gronda Optimization of cardiac resynchronization therapy: technical aspects Eur. Heart J. Suppl., April 1, 2002; 4(suppl_D): D82 - D87. [Abstract] [PDF]

				A Auricchio and H.U Klein Beyond expectations: a decade of positive results with cardiac resynchronization therapy for heart failure Eur. Heart J. Suppl., April 1, 2002; 4(suppl_D): D95 - D101. [Abstract] [PDF]

				R.G Charles Cardiac resynchronization therapy: when and for whom? Eur. Heart J. Suppl., April 1, 2002; 4(suppl_D): D117 - D121. [Abstract] [PDF]

				C. Leclercq and D. A. Kass Retiming the failing heart: principles and current clinical status of cardiac resynchronization J. Am. Coll. Cardiol., January 16, 2002; 39(2): 194 - 201. [Abstract] [Full Text] [PDF]

				M. C. Porciani, A. Sabini, A. Colella, A. Michelucci, N. Musilli, P. Pieragnoli, and L. Padeletti Interatrial septum pacing avoids the adverse effect of interatrial delay in biventricular pacing: an echo-Doppler evaluation Europace, January 1, 2002; 4(3): 317 - 324. [Abstract] [PDF]

				W Y Kim, P Søgaard, P T Mortensen, H K. Jensen, A K. Pedersen, B O Kristensen, and H Egeblad Three dimensional echocardiography documents haemodynamic improvement by biventricular pacing in patients with severe heart failure Heart, May 1, 2001; 85(5): 514 - 520. [Abstract] [Full Text]

				S. Cazeau, C. Leclercq, T. Lavergne, S. Walker, C. Varma, C. Linde, S. Garrigue, L. Kappenberger, G. A. Haywood, M. Santini, et al. Effects of Multisite Biventricular Pacing in Patients with Heart Failure and Intraventricular Conduction Delay N. Engl. J. Med., March 22, 2001; 344(12): 873 - 880. [Abstract] [Full Text] [PDF]

				H. Sakai, H. Kunichika, K. Murata, K. Seki, K. Katayama, T. Hiro, T. Miura, and M. Matsuzaki Improvement of afterload mismatch of left atrial booster pump function with positive inotropic agent J. Am. Coll. Cardiol., January 1, 2001; 37(1): 270 - 277. [Abstract] [Full Text] [PDF]

				T. Ishikawa, T. Sugano, S. Sumita, T. Nakagawa, K. Hanada, M. Kosuge, I. Kobayashi, K. Kimura, O. Tochikubo, T. Usui, et al. Optimal atrioventricular delay setting determined by evoked QT interval in patients with implanted stimulus-T-driven DDDR pacemakers Europace, January 1, 2001; 3(1): 46 - 51. [Abstract] [PDF]

				S. Sack, F. Heinzel, N. Dagres, S. Enger, A. Auricchio, C. Stellbrink, J. Neuzner, P. Potty, A. Maarse, B. Tockman, et al. Stimulation of the left ventricle through the coronary sinus with a newly developed 'over the wire' lead system -- early experiences with lead handling and positioning Europace, January 1, 2001; 3(4): 317 - 323. [Abstract] [PDF]

				S CAZEAU, D GRAS, A LAZARUS, P RITTER, and J MUGICA Multisite stimulation for correction of cardiac asynchrony Heart, December 1, 2000; 84(6): 579 - 581. [Full Text]

				M. H. Hamdan, J. D. Zagrodzky, J. A. Joglar, C. J. Sheehan, K. Ramaswamy, J. F. Erdner, R. L. Page, and M. L. Smith Biventricular Pacing Decreases Sympathetic Activity Compared With Right Ventricular Pacing in Patients With Depressed Ejection Fraction Circulation, August 29, 2000; 102(9): 1027 - 1032. [Abstract] [Full Text] [PDF]

				C LECLERCQ and J-C DAUBERT Why biventricular pacing might be of value in refractory heart failure? Heart, August 1, 2000; 84(2): 125 - 126. [Full Text] [PDF]

				M. Debrunner, B. Naegeli, and O. Bertel The Acute Effects of Transvenous Biventricular Pacing in a Patient With Congestive Heart Failure Chest, June 1, 2000; 117(6): 1798 - 1800. [Abstract] [Full Text] [PDF]

				P. RITTER Cardiac stimulation in heart failure: are we going too fast, are we going too far? Europace, January 1, 2000; 2(1): 1 - 3. [PDF]

				R. A. O'Rourke Cardiac Pacing : An Alternative Treatment for Selected Patients With Hypertrophic Cardiomyopathy and Adjunctive Therapy for Certain Patients With Dilated Cardiomyopathy Circulation, August 24, 1999; 100(8): 786 - 788. [Full Text] [PDF]

				A. Auricchio, C. Stellbrink, M. Block, S. Sack, J. Vogt, P. Bakker, H. Klein, A. Kramer, J. Ding, R. Salo, et al. Effect of Pacing Chamber and Atrioventricular Delay on Acute Systolic Function of Paced Patients With Congestive Heart Failure Circulation, June 15, 1999; 99(23): 2993 - 3001. [Abstract] [Full Text] [PDF]

				D. A. Kass, C.-H. Chen, C. Curry, M. Talbot, R. Berger, B. Fetics, and E. Nevo Improved Left Ventricular Mechanics From Acute VDD Pacing in Patients With Dilated Cardiomyopathy and Ventricular Conduction Delay Circulation, March 30, 1999; 99(12): 1567 - 1573. [Abstract] [Full Text] [PDF]

				F. Victor, C. Leclercq, P. Mabo, D. Pavin, A. Deviller, C. de Place, P. Pezard, J. Victor, and C. Daubert Optimal right ventricular pacing site in chronically implanted patients: A prospective randomized crossover comparison of apical and outflow tract pacing J. Am. Coll. Cardiol., February 1, 1999; 33(2): 311 - 316. [Abstract] [Full Text] [PDF]

				E. Crystal and I. Eli Ovsyshcher Cardiac output-based versus empirically programmed AV interval -- how different are they? Europace, January 1, 1999; 1(2): 121 - 125. [Abstract] [PDF]

				T. Ishikawa, T. Sugano, S. Sumita, K. Kimura, M. Kikuchi, M. Kosuge, I. Kobayashi, T. Shigemasa, T. Endo, T. Usui, et al. Relationship between atrioventricular delay, QT interval and cardiac function in patients with implanted DDD pacemakers Europace, January 1, 1999; 1(3): 192 - 196. [Abstract] [PDF]

				C. Leclercq, S. Cazeau, H. Le Breton, P. Ritter, P. Mabo, D. Gras, D. Pavin, A. Lazarus, and J.-C. Daubert Acute hemodynamic effects of biventricular DDD pacing in patients with end-stage heart failure J. Am. Coll. Cardiol., December 1, 1998; 32(7): 1825 - 1831. [Abstract] [Full Text] [PDF]

				J.-J. Blanc, Y. Etienne, M. Gilard, J. Mansourati, S. Munier, J. Boschat, D. G. Benditt, and K. G. Lurie Evaluation of Different Ventricular Pacing Sites in Patients With Severe Heart Failure : Results of an Acute Hemodynamic Study Circulation, November 18, 1997; 96(10): 3273 - 3277. [Abstract] [Full Text]

				F. M. Kusumoto and N. Goldschlager Cardiac Pacing N. Engl. J. Med., January 11, 1996; 334(2): 89 - 99. [Full Text] [PDF]

				S. Broka, P. M. Eucher, A. Ducart, E. Collard, V. Delire, A. Mayne, P. Randour, and K. Joucken Hemodynamic Effects of Atrio-Biventricular Pacing Ann. Thorac. Surg., October 1, 1995; 60(4): 1156 - 1156. [Full Text]