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Georg Fröhlich, Jan Steffel, David Hürlimann, Frank Enseleit, Thomas F. Lüscher, Frank Ruschitzka, William T. Abraham, Johannes Holzmeister, Upgrading to resynchronization therapy after chronic right ventricular pacing improves left ventricular remodelling, European Heart Journal, Volume 31, Issue 12, June 2010, Pages 1477–1485, https://doi.org/10.1093/eurheartj/ehq065
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Abstract
Chronic right ventricular (RV) pacing may impose ventricular dyssynchrony leading to LV remodelling and is associated with increased morbidity and mortality. Upgrading patients with chronic RV pacing to cardiac resynchronization therapy (CRT) may be considered to restore synchronicity and prevent these deleterious effects.
A total of 172 patients from two tertiary centres were analysed over a mean follow-up of 21.7 and 23.5 months after primary CRT implantation (n = 102) and CRT upgrade (n = 70), respectively. In the latter group, mean duration of RV pacing before CRT upgrade was 80.3 months, and ventricular stimulation was >95%. A significant improvement in left ventricular (LV) ejection fraction (10 and 11% absolute increase in primary CRT vs. upgrades, respectively), LV end-diastolic diameter index (−0.15 cm/m2 vs. −0.2 cm/m2), and LV end-systolic diameter (−6.0 vs. −7.0 mm) was observed in both groups, which did not differ between primary CRT recipients and CRT upgrades. Response to CRT upgrade was independent of the underlying rhythm, QRS duration, duration of prior RV pacing, or LV function and size at baseline. Of note, even seven of nine patients with RV pacing >12 years responded favourably to CRT.
The current study demonstrates that CRT reverses LV remodelling in heart failure patients with chronic RV pacing in a similar way as in primary CRT recipients, even after very long periods of RV pacing. Our data, therefore, may have important implications for the treatment of pacemaker-dependent patients with heart failure, and support the use of CRT in this setting.
- artificial cardiac pacemaker
- ventricular function, left
- echocardiography
- left ventricular remodeling
- heart failure
- left ventricle
- diastole
- follow-up
- heart ventricle
- systole
- morbidity
- mortality
- cardiac resynchronization therapy
- ejection fraction
- ventricular pacing
- qrs complex duration
- ventricular dyssynchrony
- diameter
- rhythm
Comments
We read with interest the paper by Frohlich et al. (1) which showed similar response to RV pacing upgrade to that acheived by CRT for heart failure. It seems that mid-term follow up of these patients is very consistent in this study and others (2-4). In fact, we ourselves have found similar results in a group of patients 15 months after 5.2 years of RV pacing (5). In addition to what has been reported by Frohlich et al. we found significant improvement in electromechanical delay of the left ventricle (LV) lateral, septal walls and right ventricle free wall. Upgrading to biventricular pacing decreased intra- and interventricular dyssynchrony (44 to 18 ms and 78 to 49 ms; p < 0,001 respectively). This decrease in intraventricular dyssynchrony correlated with the increase in LVEF and decrease in LV end-diastolic, systolic dimension and volumes. We also found significant improvement of the LV myocardial performance index (0.84 to 0.68 ; p < 0.001).
The current evidence on upgrading to CRT for patients with heart failure persuades us to believe of its beneficial effect on reverse remodelling. Despite that, we have to accept the fact that CRT does not have any rule in stopping or delaying the progressive myocardial disease known in these patients. Therefore, longer follow up that might show deterioration of ventricular function, does not necessarily mean failure of CRT to maintain long term function, but perpetual myocardial dysfunction.
Mehmet Akif Vatankulu, MD Etlik Ihtisas Education and Research Hospital, Cardiology Department Ankara, Turkey Tel: 0090 312 5672547 , Fax: 0090 312 3234270 Email: [email protected]
Omer Goktekin MD Bezm-i Alem University Vakif Gureba Medical Faculty, Cardiology Department Istanbul, Turkey
Selim Ayhan, MD Kutahya State Hospital Kutahya, Turkey
Michael Henein MD PhD FESC FACC FRCP Professor of Cardiology, Umea University Consultant Cardiologist, Umea Heart Centre, Sweden Phone: 46 90 785 00 00 (Sweden) Fax: 46 90 13 76 33 (Sweden) Phone: 44 20 72288546 (UK) Fax: 44 20 70348269 (UK) e-mail [email protected]
References
1. Frohlich G, Steffel J, Hurlimann D, Enseleit F, Luscher TF, Ruschitzka F, Abraham WT, Holzmeister J. Upgrading to resynchronization therapy after chronic right ventricular pacing improves left ventricular remodelling. Eur Heart J. 2010 ;31:1477-85
2. Witte KK, Pipes RR, Nanthakumar K, Parker JD. Biventricular pacemaker upgrade in previously paced heart failure patients-improvements in ventricular dyssynchrony. J Card Fail 2006;12:199-204.
3. Nagele H, Dodeck J, Behrens S, Azizi M, Hashagen S, Eisermann C, Castel MA. Hemodynamics and prognosis after primary cardiac resynchronization system implantation compared to upgrade procedures. Pacing Clin Electrophysiol 2008;31:1265-71.
4. Wokhlu A, Rea RF, Asirvatham SJ, Webster T, Brooke K, Hodge DO, Wiste HJ, Dong Y, Hayes DL, Cha YM. Upgrade and de novo cardiac resynchronization therapy: impact of paced or intrinsic QRS morphology on outcomes and survival. Heart Rhythm. 2009; 6: 1439-47
5. Vatankulu MA, Goktekin O, Kaya MG, Ayhan S, Kucukdurmaz Z, Sutton R, Henein M.Effect of long-term resynchronization therapy on left ventricular remodeling in pacemaker patients upgraded to biventricular devices. Am J Cardiol. 2009; 103: 1280-4
Conflict of Interest:
None declared