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Echo-driven V-V optimization determines clinical improvement in non responders to cardiac resynchronization treatment.

Naqvi TZ, Rafique AM, Peter CT - Cardiovasc Ultrasound (2006)

Bottom Line: In patients who derive sup-optimal benefit from biventricular pacing, optimization of atrioventricular delay post cardiac resynchronization treatment has been shown to improve cardiac output.In this report we describe the beneficial effect of sequential V-V pacing on inter and intraventricular synchrony, cardiac output and mitral regurgitation severity as the mechanisms whereby sequential biventricular pacing improves cardiac output and functional class in 8 patients who had derived no benefit or had deteriorated after CRT.Online tissue Doppler imaging including tissue velocity imaging, tissue synchronization imaging and strain and strain rate imaging were used in addition to conventional pulsed wave and color Doppler during sequential biventricular pacemaker programming.

View Article: PubMed Central - HTML - PubMed

Affiliation: Cardiac Non-Invasive Laboratory, Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA. tasneem.naqvi@cshs.org

ABSTRACT
Echocardiography plays an integral role in the detection of mechanical dyssynchrony in patients with congestive heart failure and in predicting beneficial response to cardiac resynchronization treatment. In patients who derive sup-optimal benefit from biventricular pacing, optimization of atrioventricular delay post cardiac resynchronization treatment has been shown to improve cardiac output. Some recent reports suggest that sequential ventricular pacing may further improve cardiac output. The mechanism whereby sequential ventricular pacing improves cardiac output is likely improved inter and possibly intraventricular synchrony, however these speculations have not been confirmed. In this report we describe the beneficial effect of sequential V-V pacing on inter and intraventricular synchrony, cardiac output and mitral regurgitation severity as the mechanisms whereby sequential biventricular pacing improves cardiac output and functional class in 8 patients who had derived no benefit or had deteriorated after CRT. Online tissue Doppler imaging including tissue velocity imaging, tissue synchronization imaging and strain and strain rate imaging were used in addition to conventional pulsed wave and color Doppler during sequential biventricular pacemaker programming.

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TSI in the apical 4 chamber views showing the effect of right ventricular pre-excitation on interventricular septal and right ventricular free wall delay. At baseline with LV pre-excitation of 20 ms there is marked delay in interventricular septum and RV free wall shown in orange color in A. VV of 0 ms reduces this interventricular septal and RV free wall delay (B). RV pre-excitation of 10 ms improves this further (C) and RV pre-excitation of 15 ms abolishes remaining mild delay in the interventricular septum (D). There is appearance of a small area of delay in the left ventricular apex (shown in red in C and D) with RV pre-excitation. There was progressive improvement in LV strain with RV pre-excitation as shown in Figure 11.
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Figure 10: TSI in the apical 4 chamber views showing the effect of right ventricular pre-excitation on interventricular septal and right ventricular free wall delay. At baseline with LV pre-excitation of 20 ms there is marked delay in interventricular septum and RV free wall shown in orange color in A. VV of 0 ms reduces this interventricular septal and RV free wall delay (B). RV pre-excitation of 10 ms improves this further (C) and RV pre-excitation of 15 ms abolishes remaining mild delay in the interventricular septum (D). There is appearance of a small area of delay in the left ventricular apex (shown in red in C and D) with RV pre-excitation. There was progressive improvement in LV strain with RV pre-excitation as shown in Figure 11.

Mentions: 61 year old female with non ischemic dilated cardiomyopathy possibly related to Anthracycline cardiotoxicity presented with persisting NYHA class III symptoms 8 months post CRT. LV lead was in the high lateral branch. LVEF was 35% (compared to 20% prior to CRT). Pacemaker was programmed at sensed AVD of 100 ms and LV pre-excitation of 20 ms. No E and A separation was seen at an AVD of 100 ms. Marked delay in the right ventricular free wall and interventricular septum decreased progressively as the VV settings were changed to VV 0, right ventricular pre-excitation of 10 and then 15 ms (Figure 10). This was associated with an improvement in LV and right ventricular strain (Figure 11). Further right ventricular pre-excitation lowered this strain (Figure 11). Mitral inflow E and A separation only occurred as the AVD was lowered to 30 ms.


Echo-driven V-V optimization determines clinical improvement in non responders to cardiac resynchronization treatment.

Naqvi TZ, Rafique AM, Peter CT - Cardiovasc Ultrasound (2006)

TSI in the apical 4 chamber views showing the effect of right ventricular pre-excitation on interventricular septal and right ventricular free wall delay. At baseline with LV pre-excitation of 20 ms there is marked delay in interventricular septum and RV free wall shown in orange color in A. VV of 0 ms reduces this interventricular septal and RV free wall delay (B). RV pre-excitation of 10 ms improves this further (C) and RV pre-excitation of 15 ms abolishes remaining mild delay in the interventricular septum (D). There is appearance of a small area of delay in the left ventricular apex (shown in red in C and D) with RV pre-excitation. There was progressive improvement in LV strain with RV pre-excitation as shown in Figure 11.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC1636667&req=5

Figure 10: TSI in the apical 4 chamber views showing the effect of right ventricular pre-excitation on interventricular septal and right ventricular free wall delay. At baseline with LV pre-excitation of 20 ms there is marked delay in interventricular septum and RV free wall shown in orange color in A. VV of 0 ms reduces this interventricular septal and RV free wall delay (B). RV pre-excitation of 10 ms improves this further (C) and RV pre-excitation of 15 ms abolishes remaining mild delay in the interventricular septum (D). There is appearance of a small area of delay in the left ventricular apex (shown in red in C and D) with RV pre-excitation. There was progressive improvement in LV strain with RV pre-excitation as shown in Figure 11.
Mentions: 61 year old female with non ischemic dilated cardiomyopathy possibly related to Anthracycline cardiotoxicity presented with persisting NYHA class III symptoms 8 months post CRT. LV lead was in the high lateral branch. LVEF was 35% (compared to 20% prior to CRT). Pacemaker was programmed at sensed AVD of 100 ms and LV pre-excitation of 20 ms. No E and A separation was seen at an AVD of 100 ms. Marked delay in the right ventricular free wall and interventricular septum decreased progressively as the VV settings were changed to VV 0, right ventricular pre-excitation of 10 and then 15 ms (Figure 10). This was associated with an improvement in LV and right ventricular strain (Figure 11). Further right ventricular pre-excitation lowered this strain (Figure 11). Mitral inflow E and A separation only occurred as the AVD was lowered to 30 ms.

Bottom Line: In patients who derive sup-optimal benefit from biventricular pacing, optimization of atrioventricular delay post cardiac resynchronization treatment has been shown to improve cardiac output.In this report we describe the beneficial effect of sequential V-V pacing on inter and intraventricular synchrony, cardiac output and mitral regurgitation severity as the mechanisms whereby sequential biventricular pacing improves cardiac output and functional class in 8 patients who had derived no benefit or had deteriorated after CRT.Online tissue Doppler imaging including tissue velocity imaging, tissue synchronization imaging and strain and strain rate imaging were used in addition to conventional pulsed wave and color Doppler during sequential biventricular pacemaker programming.

View Article: PubMed Central - HTML - PubMed

Affiliation: Cardiac Non-Invasive Laboratory, Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA. tasneem.naqvi@cshs.org

ABSTRACT
Echocardiography plays an integral role in the detection of mechanical dyssynchrony in patients with congestive heart failure and in predicting beneficial response to cardiac resynchronization treatment. In patients who derive sup-optimal benefit from biventricular pacing, optimization of atrioventricular delay post cardiac resynchronization treatment has been shown to improve cardiac output. Some recent reports suggest that sequential ventricular pacing may further improve cardiac output. The mechanism whereby sequential ventricular pacing improves cardiac output is likely improved inter and possibly intraventricular synchrony, however these speculations have not been confirmed. In this report we describe the beneficial effect of sequential V-V pacing on inter and intraventricular synchrony, cardiac output and mitral regurgitation severity as the mechanisms whereby sequential biventricular pacing improves cardiac output and functional class in 8 patients who had derived no benefit or had deteriorated after CRT. Online tissue Doppler imaging including tissue velocity imaging, tissue synchronization imaging and strain and strain rate imaging were used in addition to conventional pulsed wave and color Doppler during sequential biventricular pacemaker programming.

Show MeSH
Related in: MedlinePlus