Biventricular Pacing in Patients with ICD: How Many Patients are Possible Candidates?

Abstract

Background: About 80 % of patients receiving an implantable cardioverter-defibrillator (ICD) due to life-threatening episodes of ventricular tachycardia (VT) or ventricular fibrillation (VF) have structural heart disease. ICD implantation reduces the risk of sudden cardiac death to less than 2 %. However, the major obstacle in these patients is chronic heart failure (CHF). Biventricular stimulation (BIV) has shown its efficiency as an alternative therapy in drug refractory CHF. Methods: According to the InSync registry, we predefined possible indications for BIV as follows: complete branch bundle block (> 120 ms), left-ventricular ejection fraction (EF) < 35 % and NYHA class > II. We evaluated the number of patients presenting this indication at time of implant and during follow-up (FU) at our ICD clinic. Results: Between 1992 and 1998, 360 patients were provided with an ICD (mean age 64.6 ± 5.4 yrs, mean EF 37 ± 14 % at implant, 82 % of patients with organic heart disease). Mean FU was 34 ± 21 months. During FU 46 patients (13 %) died, 15 of these (33 %) presenting criteria for BIV. 33 patients died of heart failure, there was 1 sudden death and 12 patients died for non-cardiac reasons. 35 % of the patients who died of heart failure had an indication for BIV. Conclusions: About 10 % of ICD patients had an indication for BIV at time of implant. Over a mean FU period of 34 months, 16% of all patients presented an indication for BIV. Patients with an indication for BIV had a higher mortality rate and more frequent atrial fibrillation compared to patients without. With this data and the good clinical results after BIV-ICD implantation, we consider the implantation of a BIV-ICD system in every patient with appropriate indications.

Biventricular pacing - ICP - Indication

References

• 1 Gras D, Mabo P, Tang T, Luttikuis O, Chatoor R, Pedersen A-K, Tscheliessnigg K-H, Deharo J-C, Puglisi A, Silvestre J, Kimber S, Ross H, Ravazzi A, Paul V, Shehan D. Multisite Pacing as a supplemental Treatment of congestive heart failure: Preliminary results of Medtronic Inc.  Insync study PACE. 1998;  21 (II) 2249-2255
• 2 Kerwin W F, Botvinick E H, O'Conell J W, Merrick S H, DeMarco T, Chatterjee K, Saxon L A. Biventricular Pacing: acute improvements in ejection fraction correspond with measures of improved RV/LV synchrony.  Archives des maladies du coeur et de vaisseaux. 1998;  91 (III) 152
• 3 The S OLVD . Effect of enalapril on survival in patients with reduced left ventricular ejection fraction and congestive heart failure.  N Engl J Med. 1991;  325 293-302
• 4 Gradman A, Deedwania P, Cody R, Massie B, Pitt B, Goldstein S. Predictors of total mortality and sudden death in mild to moderate heart failure.  J Am Coll Cardiol. 1989;  14 564-570
• 5 Wilson J R, Schwartz J S, Sutton M, Ferraro N, Horowitz L N, Reichek N, Josephson M E. Prognosis in heart failure: relation to hemodynamic measurements and ventricular ectopic activity.  J Am Coll Cardiol. 1983;  2 403-410
• 6 Kjekshus J. Arrhythmias and mortality in congestive heart failure.  Am J Cardiol. 1990;  65 421-481
• 7 Brecker S JD, Xiao H B, Sparrow J, Gibson D G. Effects of dual chamber pacing with short atrioventricular delay in dilated cardiomyopathy.  Lancet. 1992;  340 1308-1312
• 8 Innes D, Leitch J W, Fletscher P J. VDD pacing at short atrio ventricular intervals does not improve cardiac output in patients with dilated heart failure.  PACE. 1994;  17 (I) 959-965
• 9 Nishimura R A, Hayes D L, Holmes D R, Tajik A J. Mechanism of hemodynamic improvement by dual-chamber pacing for severe left ventricular dysfunction: an acute Doppler and catheterisation hemodynamic study.  J Am Coll Cardiol. 1995;  25 281-288
• 10 Leclercq C, Pavin D, Carre F, Victor F, Le Breton H, Gras D, Mabo P, Daubert C. Permanent biventricular pacing improves exercise tolerance in patients with end-stage congestive heart failure.  Archives des maladies du Coeur et des vaisseaux. 1998;  91 64
• 11 Gras D, Leclercq C, Cazeau S, Ritter P, Mabo P, Lazarus A, Mugica J, Daubert C. Biventricular synchronization for heart failure: the VAL d'Or and Rennes experience.  Archives des maladies du Coeur et des vaisseaux. 1998;  91 (III) 154
• 12 Bakker P. Biventricular pacing improves functional capacity in patients with end-stage congestive heart failure.  PACE. 1995;  18 825
• 13 Leclercq C. Permanent biventricular pacing: a new alternative to treat end-stage congestive heart failure.  Circulation. 1997;  96 1-95
• 14 Mahaux V, Demoulin J C, Pierard L, Soyeur D, Fourny J, Kulbertus H. Biventricular stimulation in congestive heart failure: initial clinical experience. Oto A Euro Pace Monduzzi Editore 1995 95: 533-536
• 15 Leclercq C, Le Breton H, Pavin D, Victor F, Mabo P, Daubert J C. Acute hemodynamic response to biventricular DDD pacing in patients with severe congestive heart failure and without conventional indication to permanent pacemaker.  Circulation. 1997;  96 (8) 1-95
• 16 Lamp B, Hammel D, Kerbe S. Multisite pacing in severe heart failure - how many patients are eligible?.  PACE. 1998;  21 (II) 973
• 17 Appleton C P, Hatle L K, Popp R L. Relation of transmitral flow velocity to left ventricular diastolic function: new insights from a combined hemodynamic and Doppler echocardiographic study.  J Am Coll Cardio. 1988;  12 426-440
• 18 Brecker S JD, Gibson D G. What is the role of pacing in dilated cardiomyopathy?.  Eur Heart J. 1996;  17 819-824
• 19 Nishimura R A, Symanski J D, Hurrell D G, Trusty J M, Hayes D L, Tajik A L. Dual-chamber pacing for cardiomyopathies: a 1996 clinical perspective. Mayo Clin Proc 1996: 1077-1087
• 20 Kataoka H. Hemodynamic effect of physiologic dual chamber pacing in a patient with end stage dilated cardiomyopathy: a case report.  PACE. 1991;  14 1330-1335
• 21 Skinner N S, Mitchell J H, Wallace A G, Sarnoff S J. Hemodynamic effects of altering the timing of atrial systole.  Am J Physiol. 1963;  205 499-503
• 22 Auricchio A, Sommariva L, Salo R W, Scafuri A, Chiariello L. Improvement of cardiac function in patients with severe congestive heart failure and coronary artery disease by dual-chamber pacing with shortened AV delay.  PACE Pacing Clin Electrophysiol. 1993;  16 2034-2043
• 23 Brecker S JD, Xiao H B, Sparrow J, Gibson D G. Effects of dual-chamber pacing with short atrioventricular delay in dilated cardiomyopathy.  Lancet. 1992;  340 1308-1312
• 24 Linde C, Gadler F, Edner M, Nordlander R, Rosenqvist M, Ryden L. Results of atrioventricular synchronous pacing with optimised delay in patients with severe congestive heart failure.  Am J Cardiol. 1995;  75 919-923
• 25 Gold M R, Feliciano Z, Gottlieb S S, Fisher M L. Dual-chamber pacing with short atrioventricular delay in congestive heart failure: a randomised study.  J Am Coll Cardiol. 1995;  26 967-973

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