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Current Directions in Biomedical Engineering

Joint Journal of the German Society for Biomedical Engineering in VDE and the Austrian and Swiss Societies for Biomedical Engineering

Editor-in-Chief: Dössel, Olaf

Editorial Board: Augat, Peter / Buzug, Thorsten M. / Haueisen, Jens / Jockenhoevel, Stefan / Knaup-Gregori, Petra / Kraft, Marc / Lenarz, Thomas / Leonhardt, Steffen / Malberg, Hagen / Penzel, Thomas / Plank, Gernot / Radermacher, Klaus M. / Schkommodau, Erik / Stieglitz, Thomas / Urban, Gerald A.

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Left cardiac atrioventricular delay and inter-ventricular delay in cardiac resynchronization therapy responder and non-responder

Matthias Heinke
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  • Biomedical Engineering Department of University of Applied Sciences Offenburg, Badstrasse 24, D-77652 Offenburg, Germany
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/ Helmut Kühnert
  • Department of Internal Medicine I, Cardiology Division, University of Jena, Erlanger Allee 101, D-07743 Jena, Germany
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/ Tobias Heinke / Jonas Tumampos
  • Biomedical Engineering Department of University of Applied Sciences Offenburg, Badstrasse 24, D-77652 Offenburg, Germany
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/ Gudrun Dannberg
  • Department of Internal Medicine I, Cardiology Division, University of Jena, Erlanger Allee 101, D-07743 Jena, Germany
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Published Online: 2016-09-30 | DOI: https://doi.org/10.1515/cdbme-2016-0055

Abstract

Cardiac resynchronization therapy is an established therapy for heart failure patients. The aim of the study was to evaluate electrical left cardiac atrioventricular delay and interventricular desynchronization in sinus rhythm cardiac resynchronization therapy responder and non-responder. Cardiac electrical desynchronization were measured by surface ECG and focused transesophageal bipolar left atrial and left ventricular ECG before implantation of cardiac resynchronization therapy defibrillators. Preoperative electrical cardiac desynchronization was 195.7 ± 46.7 ms left cardiac atrioventricular delay and 74.8 ± 24.5 ms interventricular delay in cardiac resynchronization therapy responder. Cardiac resynchronization therapy responder New York Heart Association class improved during long term biventricular pacing. Transesophageal left cardiac atrioventricular delay and interventricular delay may be additional useful parameters to improve patient selection for cardiac resynchronization therapy.

Keywords: atrioventricular delay; biventricular pacing; cardiac resynchronization therapy; heart failure; interventricular delay; left atrial ECG; left ventricular ECG; transesophageal ECG

1 Introduction

Cardiac resynchronization therapy is an established therapy for heart failure patients with sinus rhythm, reduced left ventricular ejection fraction, ventricular desynchronization with QRS duration >150 ms and left bundle branch block [1], [2]. Transesophageal focused left heart electrocardiography is a non-invasive method for evaluation of cardiac desynchronization with electrical interatrial delay, left atrial delay, interventricular delay and left ventricular delay in heart failure patients [3], [4].

The aim of the study was to evaluate electrical left cardiac atrioventricular delay and interventricular desynchronization in sinus rhythm cardiac resynchronization therapy responder and non-responder.

2 Methods

Twenty-one heart failure patients with sinus rhythm, New York Heart Association class 3.1 ± 0.3, 26.6 ± 6.1% left ventricular ejection fraction and 170.6 ± 41.4 ms QRS duration were measured by surface ECG and focused transesophageal bipolar left atrial and left ventricular ECG (TO4, TO8 Osypka AG, Rheinfelden, Germany) before implantation of cardiac resynchronization therapy defibrillator (see Figure 1). The mean age of one female and 20 males was 67.7 ± 8.7 years. Left cardiac atrioventricular delay was measured between onset of left atrial signal and onset of left ventricular signal in the transesophageal ECG. Interventricular delay was measured between onset of QRS in the surface ECG and onset of left ventricular signal in the transesophageal ECG. Cardiac resynchronization therapy atrioventricular delay between right atrial and left ventricular electrodes and biventricular pacing delay between right ventricular and left ventricular electrodes were optimized by transthoracic impedance cardiography [5], [6] (see Figure 2).

Cardiac resynchronization therapy responder surface ECG I, II, III, aVR, aVL, aVF, V1, V2, V3, V4, V5, V6, two transesophageal focused bipolar left atrial ECG ESO56, ESO78 and two transesophageal focused bipolar ventricular ECG ESO12, ESO34 before implantation of cardiac resynchronization therapy defibrillator with sinus rhythm, left bundle branch block, long left cardiac atrioventricular delay, long interventricular delay and long. QRS duration. LA, Left atrial signal; LV, left ventricular signal; LAVD, left cardiac atrioventricular delay; IVD, interventricular delay; QRS, QRS duration.
Figure 1

Cardiac resynchronization therapy responder surface ECG I, II, III, aVR, aVL, aVF, V1, V2, V3, V4, V5, V6, two transesophageal focused bipolar left atrial ECG ESO56, ESO78 and two transesophageal focused bipolar ventricular ECG ESO12, ESO34 before implantation of cardiac resynchronization therapy defibrillator with sinus rhythm, left bundle branch block, long left cardiac atrioventricular delay, long interventricular delay and long. QRS duration. LA, Left atrial signal; LV, left ventricular signal; LAVD, left cardiac atrioventricular delay; IVD, interventricular delay; QRS, QRS duration.

Statistical analysis was performed by Origin® 2016 software (OriginLab Corporation, Northampon, MA, USA) using paired and unpaired t-tests, as appropriate, with a statistical significance of p < 0.05 and with Pearson correlation coefficients.

Simulation of cardiac resynchronization therapy with right atrial, right ventricular and left ventricular bipolar pacing and higher left ventricular pacing voltage. RA, Bipolar right atrial electrode; RV, bipolar right ventricular electrode; LV, bipolar left ventricular electrode; V, pacing voltage.
Figure 2

Simulation of cardiac resynchronization therapy with right atrial, right ventricular and left ventricular bipolar pacing and higher left ventricular pacing voltage. RA, Bipolar right atrial electrode; RV, bipolar right ventricular electrode; LV, bipolar left ventricular electrode; V, pacing voltage.

3 Results

Twenty-one heart failure cardiac resynchronization therapy patient left cardiac atrioventricular delay and interventricular delay desynchronization were 200.4 ± 45.4 ms left cardiac atrioventricular delay, 75.3 ± 23.5 ms interventricular delay and 2.35 ± 0.59 QRS duration to interventricular delay ratio.

3.1 Cardiac resynchronization therapy responder

There were 18 cardiac resynchronization therapy responders with 195.7 ± 46.7 ms left cardiac atrioventricular delay, 74.8 ± 24.5 ms interventricular delay and 2.44 ± 0.58 QRS duration to interventricular delay ratio with negative correlation between interventricular delay and QRS duration to interventricular delay ratio (r = −0.54, p = 0.022) (see Figure 3).

Sinus rhythm cardiac resynchronization therapy responder with transesophageal electrical interventricular delay, left cardiac atrioventricular delay and QRS duration to interventricular delay ratio. IVD, Interventricular delay; LAVD, left cardiac atrioventricular delay; QRSD-IVD-ratio, QRS duration to interventricular delay ratio, r; P, Pearson correlation coefficients.
Figure 3

Sinus rhythm cardiac resynchronization therapy responder with transesophageal electrical interventricular delay, left cardiac atrioventricular delay and QRS duration to interventricular delay ratio. IVD, Interventricular delay; LAVD, left cardiac atrioventricular delay; QRSD-IVD-ratio, QRS duration to interventricular delay ratio, r; P, Pearson correlation coefficients.

3.2 Cardiac resynchronization therapy non-responder

There were three cardiac resynchronization therapy non-responders with 228.7 ± 25.8 ms left cardiac atrioventricular delay, 78.0 ± 19.3 ms interventricular delay and 1.81 ± 0.35 QRS duration to interventricular delay ratio (see Figure 4). The left cardiac atrioventricular delay was shorter in cardiac resynchronization therapy responder than in cardiac resynchronization therapy non-responder with negative correlation (r = −0.998, p = 0.037).

Cardiac resynchronization therapy non-responder surface ECG I, V2 and transesophageal focused bipolar left cardiac ECG Oe34 with left atrial signal and left ventricular signal before implantation of cardiac resynchronization therapy defibrillator with sinus rhythm, right bundle branch block, long left cardiac atrioventricular delay, short interventricular delay and long QRS duration. LA, Left atrial signal; LV, left ventricular signal; LAVD, left cardiac atrioventricular delay; IVD, interventricular delay; QRS, QRS duration.
Figure 4

Cardiac resynchronization therapy non-responder surface ECG I, V2 and transesophageal focused bipolar left cardiac ECG Oe34 with left atrial signal and left ventricular signal before implantation of cardiac resynchronization therapy defibrillator with sinus rhythm, right bundle branch block, long left cardiac atrioventricular delay, short interventricular delay and long QRS duration. LA, Left atrial signal; LV, left ventricular signal; LAVD, left cardiac atrioventricular delay; IVD, interventricular delay; QRS, QRS duration.

3.3 Cardiac resynchronization therapy follow-up

During 9.4 ± 11.0 month cardiac resynchronization therapy follow-up, the cardiac resynchronization therapy responder New York Heart Association class improved from 3.1 ± 0.3 to 2.1 ± 0.2 (p = 0.038) (see Figure 5). During 5.7 ± 3.7 month cardiac resynchronization therapy follow-up, the cardiac resynchronization therapy non-responder New York Heart Association class not improved from 2.8 ± 0.3 to 2.7 ± 0.6.

Cardiac resynchronization therapy responder surface ECG I, II, III, aVR, aVL, aVF, V1, V2, V3, V4, V5, V6 and bipolar focused left cardiac ECG ESObip34 with two hemispherical transesophageal electrodes before implantation of cardiac resynchronization therapy defibrillator during sinus rhythm (left side). Simulation of focused transesophageal left atrial electrical pacing field between two 6 mm hemispherical electrodes (right side). LA, Left atrial signal; LV, left ventricular signal; LAVD, left cardiac atrioventricular delay; IVD, interventricular delay; QRS, QRS duration.
Figure 5

Cardiac resynchronization therapy responder surface ECG I, II, III, aVR, aVL, aVF, V1, V2, V3, V4, V5, V6 and bipolar focused left cardiac ECG ESObip34 with two hemispherical transesophageal electrodes before implantation of cardiac resynchronization therapy defibrillator during sinus rhythm (left side). Simulation of focused transesophageal left atrial electrical pacing field between two 6 mm hemispherical electrodes (right side). LA, Left atrial signal; LV, left ventricular signal; LAVD, left cardiac atrioventricular delay; IVD, interventricular delay; QRS, QRS duration.

4 Discussion

Gold and co-workers evaluated the correlation between invasive electrical interventricular delay -measured between QRS onset and peak of left ventricular electrocardiogram- and left ventricular remodelling in 426 patients from the SMART-AV trail [7] with atrioventricular delay optimized cardiac resynchronization therapy [8]. More than 95 ms interventricular delay predicted 6 month cardiac resynchronization therapy response with increasing of left ventricular ejection fraction and decreasing of quality of live, left ventricular end-systolic volume, left ventricular end-diastolic volume. Less than 95 ms interventricular delay predicted 6 month cardiac resynchronization therapy non-response without left ventricular remodelling [8].

Transesophageal electrocardiography can be utilized to analyse interventricular delay and left cardiac atrioventricular delay before implantation of cardiac resynchronization therapy devices. QRS duration to interventricular delay ratio was smaller in cardiac resynchronization therapy non-responder than in cardiac resynchronization therapy responder. Left cardiac atrioventricular delay was shorter in cardiac resynchronization therapy responder than in cardiac resynchronization therapy non-responder. Transesophageal interventricular and atrioventricular delay may be additional useful parameters to improve patient selection for cardiac resynchronization therapy.

Author’s Statement

Research funding: The author state no funding involved. Conflict of interest: Authors state no conflict of interest. Material and methods: Informed consent: Informed consent has been obtained from all individuals included in this study. Ethical approval: The research related to human use complies with all the relevant national regulations, institutional policies and was performed in accordance with the tenets of the Helsinki Declaration, and has been approved by the authors’ institutional review board or equivalent committee.

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About the article

Published Online: 2016-09-30

Published in Print: 2016-09-01


Citation Information: Current Directions in Biomedical Engineering, Volume 2, Issue 1, Pages 247–250, ISSN (Online) 2364-5504, DOI: https://doi.org/10.1515/cdbme-2016-0055.

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©2016 Matthias Heinke et al., licensee De Gruyter.. This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License. BY-NC-ND 4.0

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