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J Am Coll Cardiol, 2002; 39:1163-1169
© 2002 by the American College of Cardiology Foundation
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CLINICAL STUDY: HEART FAILURE

Cardiac resynchronization therapy restores optimal atrioventricular mechanical timing in heart failure patients with ventricular conduction delay

Angelo Auricchio, MD, PhD*,*, Jiang Ding, PhD{dagger}, Julio C. Spinelli, PhD{dagger}, Andrew P. Kramer, PhD{dagger}, Rodney W. Salo, MSc{dagger}, Walter Hoersch, BE{dagger}, Bruce H. KenKnight, PhD{dagger}, Helmut U. Klein, MD* for the PATH-CHF Study Group1

* Division of Cardiology, University Hospital, Magdeburg, Germany
{dagger} Guidant Corporation, St. Paul, MinnesotaUSA

Manuscript received February 15, 2001; revised manuscript received December 21, 2001, accepted January 10, 2002.

* Reprint requests and correspondence: Dr. Angelo Auricchio, Division of Cardiology, University Hospital, Leipzigerstr. 44, 39120 Magdeburg, Germany.
angelo.auricchio{at}medizin.uni-magdeburg.de

OBJECTIVES: We characterized the relationship between systolic ventricular function and left ventricular (LV) end-diastolic pressure (LVEDP) in patients with heart failure (HF) and baseline asynchrony during ventricular stimulation.

BACKGROUND: The role of preload in the systolic performance improvement that can be obtained in HF patients with LV stimulation is uncertain.

METHODS: We measured the maximum rate of increase of LV pressure, LVEDP, aortic pulse pressure (PP) and the atrioventricular mechanical latency (AVL) between left atrial systole and LV pressure onset in 39 patients with HF. Two subgroups were identified: "responder" if PP improved, or "nonresponder."

RESULTS: Maximum hemodynamic improvement occurred at an atrioventricular (AV) delay that did not decrease LVEDP. Left ventricular and biventricular (BV) stimulation increased systolic hemodynamics significantly, despite no significant increase in LVEDP. All parameters decreased when the LVEDP was decreased by shorter AV delay. Left ventricular and BV stimulation provided better hemodynamics than right ventricular (RV) stimulation. For the nonresponder subgroup, systolic hemodynamics only worsened during AV delay shortening. For the responder subgroup, optimum PP was achieved when AVL was near zero.

CONCLUSIONS: Restoration of optimal left atrial-ventricular mechanical timing partly contributes to the hemodynamic improvements observed in this patient subgroup. However, preload alone cannot explain the differences seen between RV and BV stimulation and the contradictory PP decreases even at maximal preload in the nonresponder subgroup. These results may be explained by a site-dependent mechanism such as the degree of ventricular synchrony. Caution should be taken in these patients when optimizing AV delays using echocardiography techniques that focus on LV inflow.

Abbreviations and Acronyms
  AV
  atrioventricular
  AVL
  atrioventricular mechanical latency (RA-LS – RA-AP)
  BV
  biventricular
  CRT
  cardiac resynchronization therapy
  dP/dtmax
  maximum rate of increase of left ventricular pressure
  HF
  heart failure
  LV
  left ventricle/ventricular
  LVEDP
  left ventricular end-diastolic pressure
  PATH-CHF
  Pacing Therapies for Congestive Heart Failure study
  PP
  aortic pulse pressure
  RA
  right atrium
  RA-AP
  time from sensed activation in the right atrium to the peak of the atrial contraction as seen in the left ventricular pressure (AP)
  RA-LS
  time from right atrial sense to the start of left ventricular contraction (LS)
  RV
  right ventricle/ventricular




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