Pressure-volume loop analysis during implantation of biventricular pacemaker/cardiac resynchronization therapy device to optimize right and left ventricular pacing sites

Q: What are the key findings of this study?

Optimal biventricular pacing guided by pressure-volume loops acutely increased stroke work by 39±41%, LVEF by 22±13%, and cardiac output by 16±16% vs baseline.

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Heart failure and chronic RV apical pacing (n=29). Intervention: Pressure-volume loop analysis to guide biventricular and single-site LV pacing vs. Baseline chronic RV apical pacing and RV outflow tract pacing. Primary outcome: Acute hemodynamic response including stroke work (SW), LV ejection fraction (LVEF), cardiac output (CO), and LV dP/dt(max) (p=<0.05).

Q: What does this research mean for the field?

Optimal biventricular pacing guided by pressure-volume loop analysis acutely improves left ventricular function, increasing stroke work, ejection fraction, and cardiac output in heart failure patients with chronic right ventricular pacing. Novelty: ClaimNovelty.METHODOLOGICAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To evaluate the clinical utility of real-time pressure-volume loop analysis during pacemaker or defibrillator implantation to determine optimal right and left ventricular pacing locations.

Peter Paul H.M. Delnoy; Jan Paul Ottervanger; Henk Oude Luttikhuis; DICK H. S. VOS; Arif Elvan; Anand R. Ramdat Misier; Willem P. Beukema; Paul Steendijk A; Norbert M. van Hemel

doi:10.1093/eurheartj/ehp011

December 9, 2008European Heart Journal

Pressure-volume loop analysis during implantation of biventricular pacemaker/cardiac resynchronization therapy device to optimize right and left ventricular pacing sites

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Key result

PV loop–guided biventricular pacing is linked to ~39% higher stroke work over baseline.

P<0.05
n=29

Why the study?

The clinical utility of pressure-volume loop analyses during pacemaker or ICD implantation for assessing optimal RV and LV lead positions required evaluation.

Does intraprocedural pressure-volume loop analysis optimize LV pacing site selection and acutely improve LV hemodynamic function in patients with heart failure and chronic RV apical pacing?

Key Points

To evaluate the clinical utility of real-time pressure-volume loop analysis during pacemaker or defibrillator implantation to determine optimal right and left ventricular pacing locations.
Assessed 29 patients with heart failure and chronic right ventricular apical pacing who had a baseline left ventricular ejection fraction of 34.3 ± 9.8%.
Placed an intraventricular conductance catheter to continuously measure stroke work, ejection fraction, cardiac output, and LV dP/dt(max) across right ventricular apical, right ventricular outflow tract, single-site left ventricular, and biventricular pacing sites.
Optimal biventricular pacing significantly enhanced left ventricular function compared with baseline, increasing stroke work by 39 ± 41%, ejection fraction by 22 ± 13%, cardiac output by 16 ± 16%, and LV dP/dt(max) by 10 ± 11% (all P < 0.05).
In 45% of patients, the optimal left ventricular lead position was located outside the standard first-choice posterolateral or lateral target vein.

Study Design

Type

Observational (n=29)

Structured PICO

Does intraprocedural pressure-volume loop analysis optimize LV pacing site selection and acutely improve LV hemodynamic function in patients with heart failure and chronic RV apical pacing?

P

Population

29 patients with heart failure (LVEF 34.3 ± 9.8%) and chronic right ventricular apical pacing evaluated acutely during pacemaker/ICD implantation.

I

Intervention

Intraprocedural pressure-volume loop analysis using a left ventricular conductance catheter during RV apical, RV outflow tract, single-site LV, and biventricular pacing at different left-sided pacing locations

C

Comparator

Baseline RV apical pacing and RV outflow tract pacing (within-patient comparison)

O

Outcome

Acute hemodynamic parameters: stroke work (SW), left ventricular ejection fraction (LVEF), cardiac output (CO), and LV dP/dt(max)surrogate

Main Result

p-value: p=<0.05

Intraprocedural pressure-volume loop analysis identifies an optimal LV pacing site that differs from standard anatomical target veins in 45% of heart failure patients with chronic RV pacing, yielding significant acute hemodynamic improvements.

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Implication

Acute hemodynamic gains with PV-loop guided BiV pacing in RV-paced HF; hypothesis-generating pending randomized outcome trials.

Abstract

AIMS: To evaluate the clinical utility of pressure-volume loop analyses during pacemaker/implantable cardioverter defibrillator (ICD) implantations to assess the optimal right ventricular (RV) and/or left ventricular (LV) lead position. METHODS AND RESULTS: 29 patients with heart failure and chronic RV apical pacing were studied. Stroke work (SW), LV ejection fraction (LVEF), cardiac output (CO), and LV dP/dt(max) were assessed using a conductance catheter in the LV during RV apical, RV outflow tract, single-site LV, and biventricular pacing at different left-sided pacing locations. Left ventricular ejection fraction was 34.3 +/- 9.8%. Compared with baseline, RV outflow tract pacing showed a small increase of 4.0 +/- 6.4% in LV dP/dt(max) and no improvement in SW, LVEF, or CO. In the optimal biventricular configuration, SW increased 39 +/- 41%, LVEF increased 22 +/- 13%, CO increased 16 +/- 16%, and LV dP/dt(max) increased 10 +/- 11% (all P < 0.05). In 45% of the patients, the optimal LV lead position was found at a different location as the 'first choice' postero-lateral or lateral target vein. CONCLUSION: Pressure-volume loop analysis during pacemaker/ICD implantations facilitates to determine the optimal LV pacing site. Patients with chronic RV pacing showed a significant acute improvement in LV function when LV pacing or biventricular pacing is applied.

Discussion

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Cite This Study

Delnoy et al. (2008) conducted an observational in Heart failure and chronic RV apical pacing (n=29). Pressure-volume loop analysis to guide biventricular and single-site LV pacing vs. Baseline chronic RV apical pacing and RV outflow tract pacing was evaluated on Acute hemodynamic response including stroke work (SW), LV ejection fraction (LVEF), cardiac output (CO), and LV dP/dt(max) (p=<0.05). Optimal biventricular pacing guided by pressure-volume loops acutely increased stroke work by 39±41%, LVEF by 22±13%, and cardiac output by 16±16% vs baseline.

synapsesocial.com/papers/6af77dff6205a0bfd26fa659 https://doi.org/10.1093/eurheartj/ehp011

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Pressure-volume loop analysis during implantation of biventricular pacemaker/cardiac resynchronization therapy device to optimize right and left ventricular pacing sites

Key Points

Study Design

Structured PICO

Main Result

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Pressure-volume loop analysis during implantation of biventricular pacemaker/cardiac resynchronization therapy device to optimize right and left ventricular pacing sites

Key Points

Study Design

Structured PICO

Main Result

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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