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CLINICAL RESEARCH: HEART RHYTHM DISORDERS

Right Atrial Pacing Impairs Cardiac Function During Resynchronization Therapy

Acute Effects of DDD Pacing Compared to VDD Pacing

Division of Cardiology, University Hospital, Basel, Switzerland.

Manuscript received August 16, 2004; revised manuscript received October 12, 2004, accepted January 11, 2005.

^_* Reprint requests and correspondence: Dr. Stefan Osswald, Cardiac Unit, University Hospital, CH 4031-Basel, Switzerland. (Email: sosswald{at}uhbs.ch).

OBJECTIVES: We aimed to compare the hemodynamic effects of right-atrial-paced (DDD) and right-atrial-sensed (VDD) biventricular paced rhythm on cardiac resynchronization therapy (CRT).

BACKGROUND: Cardiac resynchronization therapy improves hemodynamics in patients with severe heart failure and left ventricular (LV) dyssynchrony. However, the impact of active right atrial pacing on resynchronization therapy is unknown.

METHODS: Seventeen CRT patients were studied 10 months (range: 1 to 46 months) after implantation. At baseline, the programmed atrioventricular delay was optimized by timing LV contraction properly at the end of atrial contraction. In both modes the acute hemodynamic effects were assessed by multiple Doppler echocardiographic parameters.

RESULTS: Compared to DDD pacing, VDD pacing resulted in much better improvement of intraventricular dyssynchrony assessed by the septal-to-posterior wall motion delay (VDD 106 ± 83 ms vs. DDD 145 ± 95 ms; p = 0.001), whereas the interventricular mechanical delay (difference between onset of pulmonary and aortic outflow) did not differ (VDD 20 ± 21 ms vs. DDD 18 ± 17 ms; p = NS). Furthermore, VDD pacing significantly prolonged the rate-corrected LV filling period (VDD 458 ± 123 ms vs. DDD 371 ± 94 ms; p = 0.0001) and improved the myocardial performance index (VDD 0.60 ± 0.18 vs. DDD 0.71 ± 0.23; p < 0.01).

CONCLUSIONS: Our findings suggest that avoidance of right atrial pacing results in a higher degree of LV resynchronization, in a substantial prolongation of the LV filling period, and in an improved myocardial performance. Thus, the VDD mode seems to be superior to the DDD mode in CRT patients.

Abbreviations and Acronyms   AV = atrioventricular   AVD = atrioventricular delay   CRT = cardiac resynchronization therapy   ET = ejection time   ICT = isovolumic contraction time   IVRT = isovolumic relaxation time   LV = left ventricle/ventricular   LVOT-TVI = time velocity integral in the left ventricular outflow tract   SPWMD = septal-to-posterior wall motion delay   TDI = tissue Doppler imaging

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