Author + information
- Received December 31, 2018
- Revision received May 21, 2019
- Accepted May 28, 2019
- Published online September 16, 2019.
- Alwin Zweerink, MDa,
- Odette A.E. Salden, MDb,
- Wouter M. van Everdingen, MD, PhDb,
- Gerben J. de Roest, MD, PhDa,
- Peter M. van de Ven, PhDc,
- Maarten J. Cramer, MD, PhDb,
- Pieter A. Doevendans, MD, PhDb,
- Albert C. van Rossum, MD, PhDa,
- Kevin Vernooy, MD, PhDd,e,
- Frits W. Prinzen, PhDf,
- Mathias Meine, MD, PhDb and
- Cornelis P. Allaart, MD, PhDa,∗ ()
- aDepartment of Cardiology, and Amsterdam Cardiovascular Sciences (ACS), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
- bDepartment of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
- cDepartment of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, the Netherlands
- dDepartment of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
- eDepartment of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
- fDepartment of Physiology, CARIM, Maastricht University, Maastricht, the Netherlands
- ↵∗Address for correspondence:
Dr. Cornelis P. Allaart, Department of Cardiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, the Netherlands.
Objectives This study evaluated the acute effect of dP/dtmax- versus stroke work (SW)-guided cardiac resynchronization therapy (CRT) optimization and the related acute hemodynamic changes to long-term CRT response.
Background Hemodynamic optimization may increase benefit from CRT. Typically, maximal left ventricular (LV) pressure rise dP/dtmax is used as an index of ventricular performance. Alternatively, SW can be derived from pressure−volume (PV) loops.
Methods Forty-one patients underwent CRT implantation followed by invasive PV loop measurements. The stimulation protocol included 16 LV pacing configurations using each individual electrode of the quadripolar lead with 4 atrioventricular (AV) delays. Conventional CRT was defined as pacing from the distal electrode with an AV delay of approximately 120 ms.
Results Compared with conventional CRT, dP/dtmax-guided optimization resulted in a one-third additional dP/dtmax increase (17 ± 11% vs. 12 ± 9%; p < 0.001). Similarly, SW-guided optimization resulted in a one-third additional SW increase (80 ± 55% vs. 53 ± 48%; p < 0.001). Comparing both optimization strategies, dP/dtmax favored contractility (8 ± 12% vs. 5 ± 10%; p = 0.015), whereas SW optimization improved ventricular−arterial (VA) coupling (45% vs. 32%; p < 0.001). After 6 months, mean LV ejection fraction (LVEF) change was 10 ± 9% with 23 (56%) patients becoming super-responders to CRT (≥10% LVEF improvement). Although acute changes in SW were predictive for long-term CRT response (area under the curve: 0.78; p = 0.002), changes in dP/dtmax were not (area under the curve: 0.65; p = 0.112).
Conclusions PV-guided hemodynamic optimization in CRT results in approximately one-third SW improvement on top of conventional CRT, caused by a mechanism of enhanced VA coupling. In contrast, dP/dtmax optimization favored LV contractility. Ultimately, acute changes in SW showed larger predictive value for long-term CRT response compared with dP/dtmax.
- cardiac resynchronization therapy (CRT)
- hemodynamic optimization
- pressure−volume loops
- quadripolar LV leads
- stroke work
Dr. Vernooy has been a consultant for Medtronic and Abbott; and has received a research grant from Medtronic. Dr. Prinzen has received research grants from Medtronic, Biotronik, Microport, Abbott, Biosense Webster, and EBR Systems; and has been an advisor to Medtronic. Dr. Meine has received research grants from Boston Scientific and Abbott. Dr. Allaart has received speaker fees from Biotronik, Abbott, and Boston Scientific; and has received research grants from Biotronik and Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received December 31, 2018.
- Revision received May 21, 2019.
- Accepted May 28, 2019.
- 2019 American College of Cardiology Foundation
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