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Right ventricular bifocal DDD pacing as primary choice for cardiac resynchronization in heart failure patients with severe mitral regurgitation
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P4-111 RIGHT VENTRICULAR BIFOCAL DDD PACING AS PRIMARY CHOICE FOR CARDIAC RESYNCHRONIZATION IN HEART FAILURE PATIENTS WITH SEVERE MITRAL REGURGITATION Luigi Zamparelli, MD and Alfonso R. Martiniello, MD. Monaldi Hospital, Napoli, Italy. Right ventricular bifocal DDD pacing (RVBP), performed at apex and at the root of interventricular septum (RIVS), reduces duration of paced QRS (QRSD) and mitral regurgitation (MR). Our study is addressed to assess if chronic RVBP may assure substantial and durable benefits in pts with CHF and severe mitral regurgitation (MR). In 25 pts (17M, mean age 64⫾10 yrs), all with: DCM, LBBB (with or without AV conduction disturbances), MR and CHF (NYHA class 3.2), were implanted with a three chamber DDD pacing system delivering ventricular pacing in two sites: RV apex and RIVS. Before implant and 3, 6, 12 and 18 months after device implantation QRSD, LVEF, MR index (MRI), LVDD and pulmonary arterial pressure (PAP) were measured. Cardiac dynamics during conventional DDD in apex only and DDD-RVBP were evaluated with Tissue echo-Doppler Imaging (TDI). Results achieved with DDD-RVBP pacing are reported in the Table, most of variations between data are statistically significative. TDI showed that DDD-RVBP induces a ventricular resynchronization effect by a shortening both inter- and intraventricular delays. These data collected in a limited group of pts show that DDD-RVBS induces several benefits: avoids the LBBB induced by pacing; increases LVEF; reduces MR and LVDD; and improves patient’s NYHA functional class. In conclusion, DDD-RVBP improves hemodynamics and quality of life in DCM patient with LBBB and CHF. More pts and a longer follow-up are required to verify if such benefits, demonstrated by other investigators too, will remain stable over a long period of time.
P4-112 CARDIAC VEINS FOR RESYNCHRONIZATION THERAPY: HOW MANY PATIENTS DEMONSTRATE OPTIMAL ANATOMICAL CONDITIONS FOR AN OPTIMAL HEMODYNAMIC RESULT? Ludger Obergassel, MD, Dorothee Meyer Zu Vilsendorf, MD, Thorsten Lawrenz, MD, Jens Reinhardt, MD and Horst Kuhn, MD. Department of Cardiology and Intensive Care, Bielefeld, Germany. Objectives: The transvenous implantation (TVI) of the left ventricular (LV) lead is the standard approach for cardiac resynchronization therapy (CRT). Therefore we analyzed the proportion of patients (pts) who dispose of at least one coronary sinus (CS) vein that reaches the hemodynamically optimal site defined at the posterolateral LV free wall (figure). Further we determined the proportion of pts with several alternative veins reaching this stimulation site.
Heart Rhythm, Vol 2, No 5, May Supplement 2005 Patients and Methods: The number, the position and the diameters of potential LV target veins (TV), origin between “Vena cordis media” and “Vena cordis anterior”, was determined by preoperative CS - angiography in 43 consecutive pts with indication for CRT (mean age 66 ⫾ 11 years, LV-EF: 24 ⫾ 8 %, QRS - duration: 175 ⫾ 17 ms). The implantation results were correlated with the vein anatomy. The reasons for an unavailing transvenous attempt were analyzed. LV - leads: Guidant Easytrak 1, 2 and 3, Medtronic Attain 4191, 2187 and OTW 4193. Results: In 42 (98 %) pts at least one potential target vein was present. The following distribution was found regarding to the number of potential target veins for LV stimulation: 1 / 2 / 3 TV ⫽ 33 (77 %) / 8 (19 %) / 1 (2 %). Thirty - five (81 %) pts demonstrated at least one target vein that reaches the hemodynamically optimal site at the posterolateral LV free wall. Of the 8 pts with two potential TVs however only 4 (9 %) veins reached the hemodynamically optimal site. Lately an exclusive TVI was conducted in 40 pts (93 %) whereby utilisation of inferolateral coronary sinus veins was necessary in 5 (12 %) pts. Conclusion: Eighty - one per cent of our consecutive pts demonstrated at least one cardiac vein reaching the hemodynamically optimal LV stimulation site. Only 9 % showed two optimal veins. One patient (2 %) didn’t have a transvenous implantation facility.
P4-113 EXPERIENCE OF AUTOCAPTURE PACEMAKERS IN CHILDREN: DOES IT REALLY PROLONG THE BATTERY? *Elisabeth Villain, MD. Hospital Necker-Enfants-Malades, Paris, France. Background: The AutoCapture (AC) system provides beat to beat monitoring of ventricular capture and adapts the output amplitude just above the patient’s threshold. We reviewed our pediatric series of pacemaker (PM) with AC to check whether it really prolonged device longevity. Methods: From 1997 to 2003, 62 children (mean age 6.5⫾3.7 years) were implanted with an AC device. Main indication for pacing was congenital or post-operative atrio-ventricular block and all systems were trans-venously implanted. All devices were Saint-Jude Medical® PM, Microny-SR in 34 pts, Integrity- in 16 pts, Regency-SR in 5 pts, Affinity-SR in 5 pts and Identity in 2 pts. Leads were bipolar, screw-in leads, mainly Tendril (St Jude Medical®). Acute ventricular threshold was 0.5⫾0.2V and patients were 100% paced. Single-chamber PM were programmed with a heart rate 70-150 bpm and double chamber system from 60 to 180 bpm. Results: Patient’s follow-up is 33 ⫾ 19 months (median 28 months). In 5 cases, AC could not be activated. For the other 57 pts, the table below summarizes device current drain obtained with or without AC.
Even when the manual amplitude is programmed to a lower value than the battery output voltage, there is a difference in the battery current drain (p ⬍ 0.001). Thus, in a device with a small battery such as the Microny-SR (ie. 0.35 Ah), the additional longevity obtained with AC is especially important: mean increase 16.4 months (range 4.2 to 43 months). Conclusion: When compared to operator’s programming with a sufficient
P4-111 RIGHT VENTRICULAR BIFOCAL DDD PACING AS PRIMARY CHOICE FOR CARDIAC RESYNCHRONIZATION IN HEART FAILURE PATIENTS WITH SEVERE MITRAL REGURGITATION Luigi Zamparelli, MD and Alfonso R. Martiniello, MD. Monaldi Hospital, Napoli, Italy. Right ventricular bifocal DDD pacing (RVBP), performed at apex and at the root of interventricular septum (RIVS), reduces duration of paced QRS (QRSD) and mitral regurgitation (MR). Our study is addressed to assess if chronic RVBP may assure substantial and durable benefits in pts with CHF and severe mitral regurgitation (MR). In 25 pts (17M, mean age 64⫾10 yrs), all with: DCM, LBBB (with or without AV conduction disturbances), MR and CHF (NYHA class 3.2), were implanted with a three chamber DDD pacing system delivering ventricular pacing in two sites: RV apex and RIVS. Before implant and 3, 6, 12 and 18 months after device implantation QRSD, LVEF, MR index (MRI), LVDD and pulmonary arterial pressure (PAP) were measured. Cardiac dynamics during conventional DDD in apex only and DDD-RVBP were evaluated with Tissue echo-Doppler Imaging (TDI). Results achieved with DDD-RVBP pacing are reported in the Table, most of variations between data are statistically significative. TDI showed that DDD-RVBP induces a ventricular resynchronization effect by a shortening both inter- and intraventricular delays. These data collected in a limited group of pts show that DDD-RVBS induces several benefits: avoids the LBBB induced by pacing; increases LVEF; reduces MR and LVDD; and improves patient’s NYHA functional class. In conclusion, DDD-RVBP improves hemodynamics and quality of life in DCM patient with LBBB and CHF. More pts and a longer follow-up are required to verify if such benefits, demonstrated by other investigators too, will remain stable over a long period of time.
P4-112 CARDIAC VEINS FOR RESYNCHRONIZATION THERAPY: HOW MANY PATIENTS DEMONSTRATE OPTIMAL ANATOMICAL CONDITIONS FOR AN OPTIMAL HEMODYNAMIC RESULT? Ludger Obergassel, MD, Dorothee Meyer Zu Vilsendorf, MD, Thorsten Lawrenz, MD, Jens Reinhardt, MD and Horst Kuhn, MD. Department of Cardiology and Intensive Care, Bielefeld, Germany. Objectives: The transvenous implantation (TVI) of the left ventricular (LV) lead is the standard approach for cardiac resynchronization therapy (CRT). Therefore we analyzed the proportion of patients (pts) who dispose of at least one coronary sinus (CS) vein that reaches the hemodynamically optimal site defined at the posterolateral LV free wall (figure). Further we determined the proportion of pts with several alternative veins reaching this stimulation site.
Heart Rhythm, Vol 2, No 5, May Supplement 2005 Patients and Methods: The number, the position and the diameters of potential LV target veins (TV), origin between “Vena cordis media” and “Vena cordis anterior”, was determined by preoperative CS - angiography in 43 consecutive pts with indication for CRT (mean age 66 ⫾ 11 years, LV-EF: 24 ⫾ 8 %, QRS - duration: 175 ⫾ 17 ms). The implantation results were correlated with the vein anatomy. The reasons for an unavailing transvenous attempt were analyzed. LV - leads: Guidant Easytrak 1, 2 and 3, Medtronic Attain 4191, 2187 and OTW 4193. Results: In 42 (98 %) pts at least one potential target vein was present. The following distribution was found regarding to the number of potential target veins for LV stimulation: 1 / 2 / 3 TV ⫽ 33 (77 %) / 8 (19 %) / 1 (2 %). Thirty - five (81 %) pts demonstrated at least one target vein that reaches the hemodynamically optimal site at the posterolateral LV free wall. Of the 8 pts with two potential TVs however only 4 (9 %) veins reached the hemodynamically optimal site. Lately an exclusive TVI was conducted in 40 pts (93 %) whereby utilisation of inferolateral coronary sinus veins was necessary in 5 (12 %) pts. Conclusion: Eighty - one per cent of our consecutive pts demonstrated at least one cardiac vein reaching the hemodynamically optimal LV stimulation site. Only 9 % showed two optimal veins. One patient (2 %) didn’t have a transvenous implantation facility.
P4-113 EXPERIENCE OF AUTOCAPTURE PACEMAKERS IN CHILDREN: DOES IT REALLY PROLONG THE BATTERY? *Elisabeth Villain, MD. Hospital Necker-Enfants-Malades, Paris, France. Background: The AutoCapture (AC) system provides beat to beat monitoring of ventricular capture and adapts the output amplitude just above the patient’s threshold. We reviewed our pediatric series of pacemaker (PM) with AC to check whether it really prolonged device longevity. Methods: From 1997 to 2003, 62 children (mean age 6.5⫾3.7 years) were implanted with an AC device. Main indication for pacing was congenital or post-operative atrio-ventricular block and all systems were trans-venously implanted. All devices were Saint-Jude Medical® PM, Microny-SR in 34 pts, Integrity- in 16 pts, Regency-SR in 5 pts, Affinity-SR in 5 pts and Identity in 2 pts. Leads were bipolar, screw-in leads, mainly Tendril (St Jude Medical®). Acute ventricular threshold was 0.5⫾0.2V and patients were 100% paced. Single-chamber PM were programmed with a heart rate 70-150 bpm and double chamber system from 60 to 180 bpm. Results: Patient’s follow-up is 33 ⫾ 19 months (median 28 months). In 5 cases, AC could not be activated. For the other 57 pts, the table below summarizes device current drain obtained with or without AC.
Even when the manual amplitude is programmed to a lower value than the battery output voltage, there is a difference in the battery current drain (p ⬍ 0.001). Thus, in a device with a small battery such as the Microny-SR (ie. 0.35 Ah), the additional longevity obtained with AC is especially important: mean increase 16.4 months (range 4.2 to 43 months). Conclusion: When compared to operator’s programming with a sufficient