CLINICAL RESEARCH: PACING SCHEMES AND RESYNCHRONIZATION
Cardiac Resynchronization With Sequential Biventricular Pacing for the Treatment of Moderate-to-Severe Heart Failure
Angel R. León, MD*,*,
William T. Abraham, MD , ,
Susan Brozena, MD¶,
James P. Daubert, MD ,
Westby G. Fisher, MD,||,
John C. Gurley, MD,
Chang Seng Liang, MD,
George Wong, MD# for the InSync III Clinical Study Investigators
* Carlyle Fraser Heart Center/Division of Cardiology, Emory University, Atlanta, Georgia
University of Kentucky, Lexington, Kentucky
The Ohio State University Heart Center, Columbus, Ohio
University of Rochester Medical Center, Rochester, New York
|| Northwestern University, Evanston, Illinois
¶ University of Pennsylvania, Philadelphia, Pennsylvania
# Cardiac Solutions, Peoria, Arizona
Manuscript received August 26, 2004;
revised manuscript received December 10, 2004,
accepted December 14, 2004.
* Reprint requests and correspondence: Dr. Angel R. León, Cardiology, MOT 6th Floor, Emory Crawford Long Hospital, 550 Peachtree Street, Atlanta, Georgia 30308 (Email: angel_leon{at}emoryhealthcare.org).
OBJECTIVES: The InSync III study evaluated sequential cardiac resynchronization therapy (CRT) in patients with moderate-to-severe heart failure and prolonged QRS.
BACKGROUND: Simultaneous CRT improves hemodynamic and clinical performance in patients with moderate-to-severe heart failure (HF) and a wide QRS. Recent evidence suggests that sequentially stimulating the ventricles might provide additional benefit.
METHODS: This multicenter, prospective, nonrandomized, six-month trial enrolled a total of 422 patients to determine the effectiveness of sequential CRT in patients with New York Heart Association (NYHA) functional class III or IV HF and a prolonged QRS. The study evaluated: whether patients receiving sequential CRT for six months experienced improvement in 6-min hall walk (6MHW) distance, NYHA functional class, and quality of life (QoL) over control group patients from the reported Multicenter InSync Randomized Clinical Evaluation (MIRACLE) trial; whether sequential CRT increased stroke volume compared to simultaneous CRT; and whether an increase in stroke volume translated into greater clinical improvements compared to patients receiving simultaneous CRT.
RESULTS: InSync III patients experienced greater improvement in 6MHW, NYHA functional class, and QoL at six months compared to control (all p < 0.0001). Optimization of the sequential pacing increased (median 7.3%) stroke volume in 77% of patients. No additional improvement in NYHA functional class or QoL was seen compared to the simultaneous CRT group; however, InSync III patients demonstrated greater exercise capacity.
CONCLUSIONS: Sequential CRT provided most patients with a modest increase in stroke volume above that achieved during simultaneous CRT. Patients receiving sequential CRT had improved exercise capacity, but no change in functional status or QoL.
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Abbreviations and Acronyms
| | Bi-V = biventricular | | CRT = cardiac resynchronization therapy | | HF = heart failure | | LV = left ventricle/ventricular | | MIRACLE = Multicenter InSync Randomized Clinical Evaluation trial | | NYHA = New York Heart Association | | PHD = prehospital discharge | | QoL = quality of life | | RV = right ventricle/ventricular | | V-V = interventricular | | 6MHW = 6-min hall walk |
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