August 24, 1999Open Access
View Full PaperVentricular Pacing With Premature Excitation for Treatment of Hypertensive-Cardiac Hypertrophy With Cavity-Obliteration
Structured PICO
Does dual-chamber pacing with ventricular preactivation improve exercise tolerance in patients with hypertensive left ventricular hypertrophy with cavity-obliteration?
P
Population
9 patients with exertional dyspnea caused by hypertensive left ventricular hypertrophy with supranormal systolic ejection and distal cavity obliteration (HHCO)
I
Intervention
Dual-chamber pacing with ventricular preactivation achieved by shortening the atrial-ventricular delay (pacing-on for 3 months, followed by 6 additional months)
C
Comparator
Pacing-off for 3 months (crossover design)
O
Outcome
Exercise duration and maximal oxygen consumption at 3 monthssurrogate
Dual-chamber pacing with ventricular preactivation significantly improves exercise capacity, cardiac reserve, and symptoms in patients with hypertensive left ventricular hypertrophy and cavity obliteration.
Abstract
BACKGROUND: Hypertensive left ventricular hypertrophy with supranormal systolic ejection and distal cavity obliteration (HHCO) can result in debilitating exertional fatigue and dyspnea. Dual-chamber pacing with ventricular preactivation generates discoordinate contraction, which can limit cavity obliteration and thereby increase potential ejection reserve. Accordingly, we hypothesized that pacing may improve exercise tolerance long-term in this syndrome. METHODS AND RESULTS: Dual-chamber pacemakers were implanted in 9 patients with exertional dyspnea caused by HHCO. Intrinsic atrial rate was sensed, and ventricular preactivation was achieved by shortening the atrial-ventricular delay. Pacing was on or off for successive 3-month periods (randomized, double-blind, crossover design), followed by 6 additional pacing-on months. Metabolic exercise testing, quality-of-life assessment, and rest and dobutamine-stress echocardiographic/Doppler data were obtained. After 3 months of pacing-on, exercise duration rose from 324+/-133 to 588+/-238 s (mean+/-SD; P=0.001, with 7 of 9 patients improving >/=30%), and maximal oxygen consumption increased from 13.6+/-2.9 to 16.7+/-3.3 mL of O(2). min(-1). kg(-1) (P<0.02). Both parameters were little changed from baseline during the pacing-off period. Improved exercise capacity persisted at 1-year follow-up. Clinical symptoms and activities of daily living improved during the pacing-on period and stayed improved at 1 year, but they were little changed during the pacing-off period. Despite similar basal values, stroke volume (P<0.001) and cardiac output (P<0.02) increased with dobutamine stimulation 2 to 3 times more after 1 year of follow-up as compared with baseline. CONCLUSIONS: Long-term dual-chamber pacing can improve exercise capacity, cardiac reserve, clinical symptoms, and activities of daily living in patients with HHCO. This therapy may provide a novel alternative for patients in whom traditional pharmacological treatment proves inadequate.