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Biventricular Versus Conventional Right Ventricular Stimulation for Patients With Standard Pacing Indication and Left Ventricular Dysfunction

The Homburg Biventricular Pacing Evaluation (HOBIPACE)

Michael Kindermann, MD^_*,_*, Benno Hennen, MD^_*, Jens Jung, MD, Jürgen Geisel, MD, Michael Böhm, MD^_* and Gerd Fröhlig, MD^_*

^_* Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
Innere Klinik I, Stadtkrankenhaus, Worms, Germany
Klinisch-Chemisches Zentrallabor, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany

View larger version (19K): [in a new window]   Figure 1 Device types, number of first-time implantations, and upgrade procedures. ICD = implantable cardioverter defibrillator.

View larger version (20K): [in a new window]   Figure 2 Flow chart of the study protocol. *At three months, the patients underwent a trial procedure of QoL testing and CPET, which were not used for further data analysis. AVDO = optimization of the programmed atrioventricular delay; BV = biventricular; CPET = cardiopulmonary exercise testing; Echo = echocardiography; NT-proBNP = N-terminal pro-B-type natriuretic peptide; NYHA = New York Heart Association; PM-FU = pacemaker follow-up; QoL = quality of life as assessed by the Minnesota Living with Heart Failure questionnaire; RV = right ventricular.

View larger version (24K): [in a new window]   Figure 3 Blood flow and tissue Doppler echocardiographic measurements of heart cycle intervals and systolic left ventricular synchrony (LVS). a = interval between onset of the QRS complex and cessation of left ventricular/right ventricular outflow; b = interval between onset of the QRS complex and start of AV inflow; c = interval between stop and start of AV inflow; d = part of the ejection phase with tissue velocities >0.5 cm/s. CL, PET, ET, a, b, c, and d were directly measured. The other parameters were calculated using the following formulae: IVRT = b – a; IVCT = c – IVRT – ET; DFT = CL – c; Tei index = (c – ET)/ET; Z-ratio = 100 x (DFT + ET)/CL; LVS = 100 x (d/ET). AV = atrioventricular; CL = cycle length; DFT = diastolic filling time; ET = ejection time; IVCT = isovolumic contraction time; IVRT = isovolumic relaxation time; PET = pre-ejection time interval between onset of the QRS complex and onset of left or right ventricular outflow.

View larger version (33K): [in a new window]   Figure 4 (A and B) Summarized (box plots) and individual values (black circles) for left ventricular end-systolic volume (A) and left ventricular ejection fraction (B) before implantation of the study device (preop) and after three months of right (RVP) and biventricular (BVP) pacing. In the box plot graph, the boundaries of the box indicate the 25th and 75th percentiles, the whiskers indicate the 10th and 90th percentiles, and the solid and dashed horizontal lines mark the median and mean value, respectively.

View larger version (24K): [in a new window]   Figure 5 Summarized (box plots) and individual values (black circles) for peak oxygen consumption after three months of right (RVP) and biventricular (BVP) pacing. For description of the box plot design, see legend to Figure 4.

View larger version (33K): [in a new window]   Figures 6 (A and B) Tissue-Doppler–derived parameters of left intraventricular synchrony. LVS = duration of systolic ejection velocities >0.5 cm/s averaged for 12 myocardial segments and given in percent of ejection time; LVS-SD = standard deviation of 12 segmental measurements of LVS; other abbreviations as in Figure 4. For description of the box plot design, see legend to Figure 4.

View larger version (65K): [in a new window]   Figure 7 Left and right heart cycle intervals before device implantation (white rectangles), during right (stippled rectangles), and biventricular pacing (grey rectangles). DFT = diastolic filling time; ET = ejection time; IVCT = isovolumic contraction time; IVRT = isovolumic relaxation time. Values are given in percent of cardiac cycle length. The p values are given in the following order: pre-operative versus right ventricular pacing (top), pre-operative versus biventricular pacing (middle), right ventricular pacing versus biventricular pacing (bottom). Data represent only patients in sinus rhythm.