European Journal of Echocardiography Advance Access published online on November 7, 2008
European Journal of Echocardiography, doi:10.1093/ejechocard/jen300
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
Improving cardiac function after cardiac surgery by biventricular pacing in patient selected by three-dimensional echocardiography
Stéphane Combes1,*,
Nicolas Combes2,
Etienne Geoffroy1,
Romain Eschalier1,
Kasra Azarnoush1,
Lionel Camilleri1 and
Charles De Riberolles1
1 Department of Cardiac Surgery, CHU Gabriel Montpied, 58 Rue Montalembert, BP 69, 63003 Clermont Ferrand, France
2 Electrophysiology and Pacing/Defibrillation Department, Clinique Pasteur, Toulouse, France
Received 3 August 2008; accepted after revision 10 October 2008.
* Corresponding author. Tel: +33 4 73 75 15 77; fax: +33 4 73 75 15 79. E-mail address: combesstephane{at}voila.fr
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Abstract
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We present the case of a 57-year-old woman with severe aortic
regurgitation and ventricular dysfunction (ejection fraction
34%) requiring surgical intervention. In pre-operative period,
no left ventricular (LV) asynchrony was detected by QRS duration
and current echocardiographic techniques, including tissue Doppler
imaging. A new echocardiographic technology, the timing of regional
volumetric changes by three-dimensional echocardiography (3DEcho),
demonstrated an intraventricular mechanical asynchrony. Indeed,
during surgery, epicardial leads were attached to the right
atrium and the right ventricle as part of the standard management.
Two additional epicardial leads were attached to the left ventricle
on the most delayed wall localized precisely by 3DEcho on the
inferolateral wall. In post-operative period, biventricular
(BiV) pacing showed improvement in the LV mechanical synchronization,
resulting in improvement in the LV systolic function compared
with right ventricular pacing or no pacing. This case shows
the potential utility of 3DEcho in prediction of favourable
response of the BiV pacing in patients with depressed LV systolic
function ongoing cardiac surgery.
Keywords: Biventricular pacing; Cardiac surgery; Three-dimensional echocardiography
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Case report
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A 57-year-old woman was referred to our institution for aortic
valve replacement. She had a history of severe and symptomatic
aortic valve regurgitation with depressed left ventricular (LV)
function [ejection fraction (EF) = 34%]. The preoperative transthoracic
echocardiography did not showed atrio-ventricular or intra-LV
asynchrony with current echocardiographic techniques, including
tissue Doppler imaging (TDI,
Figure 1B). An opposing wall
delay between the antero-septal to posterior wall or septal
to lateral wall was <65 ms (
Figure 1B). On the electrocardiogram
(EKG), QRS duration was <120 ms (QRS duration = 90 ms,
Figure 1A).
Three-dimensional echocardiography (3DEcho) was applied to assess
intraventricular mechanical synchrony. We calculated the degree
of dispersion by measuring the standard deviation of the time
to achieve minimum systolic volume (Tmsv) for each of the 17
segments described by the American Society of Echocardiography
and then corrected that for the R–R interval (systolic
dyssynchrony index, SDI). Time to minimum systolic volume is
significantly delayed in the septal segment and on the parametric
image (indicated in red colour) (SDI = 11.24%) (
Figure 1C and
D). For a visual summary of LV regional contraction timings,
segments with a Tmsv about global Tmsv are coded in green and
early segments are coded in blue, whereas late segments are
coded in red (‘bulls eye’
Figure 1D). During
surgery, epicardial leads were positioned on the right atrium
and the right ventricle as part of the standard management.
Because of depressed EF, two additional epicardial leads were
positioned in this patient on the left ventricle. According
to 3DEcho, these lead were attached on infero-lateral wall,
in the opposite of late segments. At post-operative period,
the haemodynamically stable patient was stimulated with an external
constant-current dual-chamber demand pacemaker (Medtronic 5388,
Medtronic Inc, Minneapolis, MN, USA). Biventricular (BiV) pacing
was achieved by connecting ventricular leads to ventricular
port of the pacemaker (BiV simultaneous pacing). The atrio ventricular
(AV) delay was fixed at 150 ms. During the echocardiographic
study, intravenous drug infusions were not changed and no additional
medications were started. Following cardiac resynchronization
therapy (CRT) with BiV, most segments achieved a minimum volume
at the same time in the cardiac cycle and the parametric image
displays a more homogeneous green colour (
Figure 2B) in
contrast with right ventricular (RV) pacing alone (
Figure 2D)
and no pacing (
Figure 1D). RV pacing was associated with
a delayed lateral wall motion and worsening of cardiac synchronization.
Moreover, BiV was associated with a significant increase of
LVEF and RV pacing with a decrease of LVEF (51% for BiV, 32%
for RV pacing, and 36% for no pacing, respectively) measured
by 3DEcho compared with sinus rhythm. Same evolution was found
with cardiac output determined by echocardiography Doppler and
by the automated thermodilution method (8l per minute for BiV,
5.2l per minute for RV pacing, and 5.9l per minute for no pacing).
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Figure 1 Pre-operative period. (A) Electrocardiogram showing narrow QRS. (B) Tissue Doppler imaging evaluation of intraventricular dyssynchrony. Colour tissue Doppler sample placed at the middle of basal and mid of four ventricular segment in an apical four-chamber view. Maximal electromechanical delay was 35 ms and maximal electrosystolic delay was 30 ms. (C) The cast of the left ventricular that is obtained using semi-automated endocardial border tracking from the three-dimensional data set. It is automatically segmented into the standard 16 or 17 segments. It is possible to assess for each volumetric segment, the time taken to reach the minimum systolic volume expressed in percentage of cardiac cycle (Tmsv 16 SD). (D) Time to minimum volume is significantly delayed in the septal segment and on the parametric image (indicated in red colour).
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Figure 2 Post-operative period. Electrocardiogram during right ventricular stimulation (A) and biventricular stimulation (B) with the same atrio ventricular delay (150 ms), resulting in a fusion with spontaneous rhythm. Parametric LV cast and ‘bulls eye’ display during right ventricular stimulation (C) and biventricular stimulation (D). (C) Time to minimum volume is significantly delayed in the lateral segments and on the parametric image (red colour). (D) Following biventricular pacing, most segments achieve minimum volume at the same time in the cardiac cycle and the parametric image displays a more homogeneous green colour and Left ejection fraction improved.
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Discussion
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In this case, new modality of echocardiography with three-dimensional
analysis identifies BiV pacing responder alone after cardiac
surgery. Epicardial pacing is commonly indicated in cardiac
surgical patients using right ventricular (RV) and/or right
atrial (RA) pacing leads. In patients in sinus rhythm (SR),
two RA and two RV epicardial wires are attached, resulting in
dual-chamber or sequential atrio-ventricular pacing (DDD). Some
studies are consistent with a deleterious effect of RV stimulation
in the chronic phase with patient with depressed EF.
1,2 Minimal
data exist regarding BiV pacing in surgical patients.
3 In these
studies, patients were selected on the basis of an LVEF and
wide QRS on the surface EKG. The peculiarity of this case is
ventricular asynchrony undetected by normal QRS duration and
usual echocardiographic techniques such as TDI currently considered
the ‘gold standard’. Some studies in patients with
heart failure have demonstrated that QRS duration is a poor
indicator of mechanical dyssynchrony.
4 Additionally, the use
of TDI-based measurements of LV asynchrony do not appear to
be a robust predictor of clinical response to CRT.
5 An initial
study by Kapetenakis
et al.6 demonstrated promising results
when real-time 3DEcho was applied in a small group of patients
undergoing CRT. In this study, the value of 3DEcho for prediction
of response to CRT and the assessment of LV volumes was evaluated
in a group of patients with an arbitrary cut-off value defined
as an SDI > 3 SD above the mean for a group of normal subjects
(8.3%). Recently,
Marsan et al.7 found an SDI of
5.6% as the
optimal cut-off value with a sensibility of 88% and a specificity
of 86% to predict an acute response to BiV pacing.
7 In our case,
3DEcho was the only mean to detect intraventricular asynchrony,
with a direct access to spatio-temporal synchrony with an SDI
of >11%. The interest of this evaluation was supported by
the heamodynamic improvement associated with correction of this
asynchrony. A heamodynamic improvement can be interesting in
this high-risk patient with low EF. But, prospective studies
are necessary to determine whether all cardiac surgery patients
with cardiac dysfunction must have BiV pacing in the post-operative
period.
In conclusion, a new method for the measurement of LV synchronicity by 3DEcho using regional volumetric changes can identify responders of BiV pacing, guided the site of LV leads. It can be used to quantify CRT effect on global LV function in patients with ventricular dysfunction in the post-operative cardiac surgery period.
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References
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- Wilkoff BL, Cook JR, Epstein AE, Greene HL, Hallstrom AP, Hsia H, et al. Dual chamber or ventricular backup pacing in patients with an implantable defibrillator: the Dual chamber and VVI Implantable Defibrillator (DAVID) trial. J Am Med Assoc (2002) 288:3115–3123.[Abstract/Free Full Text]
- Leclercq C, Cazeau S, Lellouche D, Fossati F, Anselme F, Davy JM, et al. Upgrading from single chamber right ventricular to biventricular pacing in permanently paced patients with worsening heart failure: the RD-CHF study. Pacing Clin Electrophysiol (2007) 30((Suppl. 1)):S23–S30.[Medline]
- Flynn MJ, McComb JM, Dark JH. Temporary left ventricular pacing improves haemodynamic performance in patients requiring epicardial pacing post cardiac surgery. Eur J Cardio-thoracic Surg (2005) 28:250–253.[Abstract/Free Full Text]
- Yu CM, Yang H, Lau CP, Wang Q, Lam L, Sanderson JE. Regional left mechanical asynchrony in patients with heart disease and normal QRS duration: implication for biventricular pacing therapy. PACE (2003) 26:562–570.[Medline]
- Cleland JG, Abdellah AT, Khaleva O. Clinical trials update of the European Society of cardiology congress 2007: PROSPECT. Eur J Heart Fail (2007) 84:579–581.
- Kapetanakis S, Kearney MT, Siva A, Gall N, Cooklin M, Monaghan MJ. Real-time three-dimensional echocardiography. A novel technique to quantify global left ventricular mechanical dyssynchrony. Circulation (2005) 112:992–1000.[Abstract/Free Full Text]
- Marsan NA, Bleeker GB, Ypenburg C, Ghio S, Van De Veire NR, Holman ER, et al. Real-time three-dimensional echocardiography permits quantification of left ventricular mechanical dyssynchrony and predicts acute response to cardiac resynchronization therapy. J Cardiovasc Electrophysiol (2008) 19:392–399.[CrossRef][Web of Science][Medline]
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Abstract
Case report