Dual-chamber pacing with a short atrioventricular delay in congestive heart failure: a randomized study

Department of Medicine, University of Maryland, Baltimore, USA.

OBJECTIVES. This prospective study assessed the initial hemodynamic effects and long-term clinical benefits of dual-chamber pacing with a short atrioventricular (AV) delay in patients with chronic heart failure who had no traditional indication for pacemaker implantation. BACKGROUND. Dual-chamber pacing with a short AV delay has been proposed as a nonpharmacologic treatment for drug-refractory heart failure. Both initial and long-term hemodynamic as well as functional benefits have been reported. All previous studies have used an AV delay of 100 ms. Despite encouraging results, these previous studies have been anecdotal and uncontrolled. METHODS. This double-blind, randomized, crossover trial included 12 subjects with chronic congestive heart failure despite optimal medical therapy. Patients were required to be in sinus rhythm with no evidence of significant bradyarrhythmias. On the day after implantation of a dual-chamber pacemaker, invasive hemodynamic measurements were made at varying AV delays between 100 and 200 ms. Patients were then randomized to either dual-chamber pacing with a 100-ms AV delay or backup mode (VVI at 40 beats/min). After 4 to 6 weeks, crossover to the other pacing mode was programmed. RESULTS. Hemodynamic measurements on the day after pacemaker implantation demonstrated no benefit of pacing with any AV delay compared with intrinsic conduction. At the optimal AV interval for each patient, neither cardiac output (4.5 +/- 1.5 vs 4.7 +/- 1.6 liters/min [mean +/- SD]) nor wedge pressure (16 +/- 10 vs 17 +/- 8 mm Hg) improved significantly from baseline measurements during intrinsic conduction. The long-term pacing protocol was completed in nine patients. Ejection fraction was 16 +/- 6% with dual-chamber (VDD mode) pacing and 18 +/- 4% in backup mode (p = NS). No patient had an increase in ejection fraction by > or = 5% with VDD pacing, nor did any patient improve in New York Heart Association functional class with short AV delay dual-chamber pacing. Also, there were no significant reductions in body weight or diuretic requirements during this pacing period. CONCLUSIONS. Dual-chamber pacing with a short AV delay does not improve hemodynamic and clinical status or ejection fraction measured on the day after pacemaker implantation in patients with chronic congestive heart failure. Routine use of pacemaker therapy with a short AV delay aas a primary treatment of heart failure in patients without standard arrhythmic indications is unwarranted.

This article has been cited by other articles:

				H. Nagele, W. Rodiger, and M. A. Castel Rate-responsive pacing in patients with heart failure: long-term results of a randomized study Europace, October 1, 2008; 10(10): 1182 - 1188. [Abstract] [Full Text] [PDF]

				L. J. Anderson, C. Miyazaki, G. R. Sutherland, and J. K. Oh Patient Selection and Echocardiographic Assessment of Dyssynchrony in Cardiac Resynchronization Therapy Circulation, April 15, 2008; 117(15): 2009 - 2023. [Full Text] [PDF]

				R E Lane, J Mayet, N S Peters, D W Davies, and A W C Chow Comparison of temporary bifocal right ventricular pacing and biventricular pacing for heart failure: evaluation by tissue Doppler imaging Heart, January 1, 2008; 94(1): 53 - 58. [Abstract] [Full Text] [PDF]

				P. Ritter, S. Cazeau, D. Gras, and J.-C. Daubert Cardiac resynchronization therapy implantation: a blend of skill and technology Eur. Heart J. Suppl., December 1, 2007; 9(suppl_I): I107 - I112. [Abstract] [Full Text] [PDF]

				D. A. Kass Highlighting the R in CRT Circulation, September 25, 2007; 116(13): 1434 - 1436. [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]

				S Ellery, L Williams, and M Frenneaux Role of resynchronisation therapy and implantable cardioverter defibrillators in heart failure Postgrad. Med. J., January 1, 2006; 82(963): 16 - 23. [Abstract] [Full Text] [PDF]

				M. Wonisch, P. Lercher, D. Scherr, R. Maier, R. Pokan, P. Hofmann, and S. P. von Duvillard Influence of Permanent Right Ventricular Pacing on Cardiorespiratory Exercise Parameters in Chronic Heart Failure Patients With Implanted Cardioverter Defibrillators Chest, March 1, 2005; 127(3): 787 - 793. [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]

				R A Bleasdale and M P Frenneaux Cardiac resynchronisation therapy: when the drugs don't work. Heart, December 1, 2004; 90(suppl_6): vi2 - vi4. [Full Text] [PDF]

				J. Vogt, J. Heintze, B. Lamp, B. Hansky, and D. Horstkotte Standard haemodynamic measurements Eur. Heart J. Suppl., August 1, 2004; 6(suppl_D): D29 - D34. [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]

				J. G.F. Cleland, J. Ghosh, N. K. Khan, S. Ghio, L. Tavazzi, and G. Kaye Multi-chamber pacing: a perfect solution for cardiac mechanical dyssynchrony? Eur. Heart J., March 1, 2003; 24(5): 384 - 390. [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]

				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]

				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. R Gold ELECTROPHYSIOLOGY: Permanent pacing: new indications Heart, September 1, 2001; 86(3): 355 - 360. [Full Text] [PDF]

				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]

				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]

				D Farwell, N.R Patel, A Hall, S Ralph, and A.N Sulke How many people with heart failure are appropriate for biventricular resynchronization? Eur. Heart J., August 1, 2000; 21(15): 1246 - 1250. [Abstract] [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]

				Z.I. Harris and M.D. Gammage Alternative right ventricular pacing sites -- where are we going? Europace, January 1, 2000; 2(2): 93 - 98. [PDF]

				J. A. Morris-Thurgood, M. S. Turner, A. K. Nightingale, N. Masani, C. Mumford, and M. P. Frenneaux Pacing in heart failure: improved ventricular interaction in diastole rather than systolic re-synchronization Europace, January 1, 2000; 2(4): 271 - 275. [Abstract] [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]

				B. T. Wyman, W. C. Hunter, F. W. Prinzen, and E. R. McVeigh Mapping propagation of mechanical activation in the paced heart with MRI tagging Am J Physiol Heart Circ Physiol, March 1, 1999; 276(3): H881 - H891. [Abstract] [Full Text] [PDF]

				A. Capucci, S. Romano, A. Puglisi, M. Santini, M. Pagani, R. Cazzin, D. Zanuttini, S. Mangiameli, P.V. Moracchini, R. Neri, et al. Dual chamber pacing with optimal AV delay in congestive heart failure: A randomized study Europace, January 1, 1999; 1(3): 174 - 178. [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]