S M Afzal Sohaib1, Ian Wright2, Elaine Lim2, Philip Moore2, P Boon Lim2, Michael Koawing2, David C Lefroy2, Daniel Lusgarten3, Nick W F Linton1, D Wyn Davies2, Nicholas S Peters1, Prapa Kanagaratnam2, Darrel P Francis4, Zachary I Whinnett5. 1. National Heart & Lung Institute, Imperial College London, London, United Kingdom. 2. Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom. 3. Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont. 4. National Heart & Lung Institute, Imperial College London, London, United Kingdom. Electronic address: d.francis@imperial.ac.uk. 5. National Heart & Lung Institute, Imperial College London, London, United Kingdom; Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom.
Abstract
OBJECTIVES: The purpose of this study was to investigate whether heart failure patients with narrow QRS duration (or right bundle branch block) but with long PR interval gain acute hemodynamic benefit from atrioventricular (AV) optimization. We tested this with biventricular pacing and (to deliver pure AV shortening) direct His bundle pacing. BACKGROUND: Benefits of pacing for heart failure have previously been indicated by acute hemodynamic studies and verified in outcome studies. A new target for pacing in heart failure may be PR interval prolongation, which is associated with 58% higher mortality regardless of QRS duration. METHODS: We enrolled 16 consecutive patients with systolic heart failure, PR interval prolongation (mean, 254 ± 62 ms) and narrow QRS duration (n = 13; mean QRS duration: 119 ± 17 ms) or right bundle branch block (n = 3; mean, QRS duration: 156 ± 18 ms). We successfully delivered temporary direct His bundle pacing in 14 patients and temporary biventricular pacing in 14 participants. We performed AV optimization using invasive systolic blood pressure obtaining parabolic responses (mean R2: 0.90 for His, and 0.85 for biventricular pacing). RESULTS: The mean increment in systolic BP compared with intrinsic ventricular conduction was 4.1 mm Hg (95% confidence interval [CI]: +1.9 to +6.2 mm Hg for His and 4.3 mm Hg [95% CI: +2.0 to +6.5 mm Hg] for biventricular pacing. QRS duration lengthened with biventricular pacing (change = +22 ms [95% CI: +18 to +25 ms]) but not with His pacing (change = +0.5 ms [95% CI: -2.6 to +3.6 ms). CONCLUSIONS: AV-optimized pacing improves acute hemodynamic function in patients with heart failure and long PR interval without left bundle branch block. That it can be achieved by single-site His pacing shows that its mechanism is AV shortening. The improvement is ∼60% of the effect size previously reported for biventricular pacing in left bundle branch block. Randomized, blinded trials are warranted to test for long-term beneficial effects.
OBJECTIVES: The purpose of this study was to investigate whether heart failurepatients with narrow QRS duration (or right bundle branch block) but with long PR interval gain acute hemodynamic benefit from atrioventricular (AV) optimization. We tested this with biventricular pacing and (to deliver pure AV shortening) direct His bundle pacing. BACKGROUND: Benefits of pacing for heart failure have previously been indicated by acute hemodynamic studies and verified in outcome studies. A new target for pacing in heart failure may be PR interval prolongation, which is associated with 58% higher mortality regardless of QRS duration. METHODS: We enrolled 16 consecutive patients with systolic heart failure, PR interval prolongation (mean, 254 ± 62 ms) and narrow QRS duration (n = 13; mean QRS duration: 119 ± 17 ms) or right bundle branch block (n = 3; mean, QRS duration: 156 ± 18 ms). We successfully delivered temporary direct His bundle pacing in 14 patients and temporary biventricular pacing in 14 participants. We performed AV optimization using invasive systolic blood pressure obtaining parabolic responses (mean R2: 0.90 for His, and 0.85 for biventricular pacing). RESULTS: The mean increment in systolic BP compared with intrinsic ventricular conduction was 4.1 mm Hg (95% confidence interval [CI]: +1.9 to +6.2 mm Hg for His and 4.3 mm Hg [95% CI: +2.0 to +6.5 mm Hg] for biventricular pacing. QRS duration lengthened with biventricular pacing (change = +22 ms [95% CI: +18 to +25 ms]) but not with His pacing (change = +0.5 ms [95% CI: -2.6 to +3.6 ms). CONCLUSIONS: AV-optimized pacing improves acute hemodynamic function in patients with heart failure and long PR interval without left bundle branch block. That it can be achieved by single-site His pacing shows that its mechanism is AV shortening. The improvement is ∼60% of the effect size previously reported for biventricular pacing in left bundle branch block. Randomized, blinded trials are warranted to test for long-term beneficial effects.
Authors: Nadine Ali; Daniel Keene; Ahran Arnold; Matthew Shun-Shin; Zachary I Whinnett; S M Afzal Sohaib Journal: Arrhythm Electrophysiol Rev Date: 2018-06
Authors: Daniel Keene; Ahran Arnold; Matthew J Shun-Shin; James P Howard; Sm Afzal Sohaib; Philip Moore; Mark Tanner; Norman Quereshi; Amal Muthumala; Badrinathan Chandresekeran; Paul Foley; Francisco Leyva; Shaumik Adhya; Emanuela Falaschetti; Hilda Tsang; Pugal Vijayaraman; John G F Cleland; Berthold Stegemann; Darrel P Francis; Zachary I Whinnett Journal: ESC Heart Fail Date: 2018-07-09
Authors: Andrew J M Lewis; Paul Foley; Zachary Whinnett; Daniel Keene; Badrinathan Chandrasekaran Journal: J Am Heart Assoc Date: 2019-03-19 Impact factor: 5.501