Hemodynamic Optimization in Cardiac Resynchronization Therapy: Should We Aim for dP/dtmax or Stroke Work?
Zweerink, Alwin; Salden, Odette A E; van Everdingen, Wouter M; de Roest, Gerben J; van de Ven, Peter M; Cramer, Maarten J; Doevendans, Pieter A; van Rossum, Albert C; Vernooy, Kevin; Prinzen, Frits W; Meine, Mathias; Allaart, Cornelis P
(2019) JACC: Clinical Electrophysiology, volume 5, issue 9, pp. 1013 - 1025
(Article)
Abstract
Objectives: This study evaluated the acute effect of dP/dt max- 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/dt max is used as an
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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/dt max-guided optimization resulted in a one-third additional dP/dt max 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/dt max 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/dt max 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/dt max optimization favored LV contractility. Ultimately, acute changes in SW showed larger predictive value for long-term CRT response compared with dP/dt max.
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Keywords: cardiac resynchronization therapy (CRT), dP/dt, hemodynamic optimization, pressure−volume loops, quadripolar LV leads, stroke work, Cardiology and Cardiovascular Medicine, Physiology (medical), Journal Article
ISSN: 2405-500X
Publisher: Elsevier USA
Note: Funding Information: 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. Publisher Copyright: © 2019 American College of Cardiology Foundation
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