Hemodynamic Optimization in Cardiac Resynchronization Therapy: Should We Aim for dP/dtmax or Stroke Work?

Alwin Zweerink; Odette A E Salden; Wouter M van Everdingen; Gerben J de Roest; Peter M van de Ven; Maarten J Cramer; Pieter A Doevendans; Albert C van Rossum; Kevin Vernooy; Frits W Prinzen; Mathias Meine; Cornelis P Allaart

doi:10.1016/j.jacep.2019.05.020

Hemodynamic Optimization in Cardiac Resynchronization Therapy: Should We Aim for dP/dtmax or Stroke Work?

Alwin Zweerink, Odette A E Salden, Wouter M van Everdingen, Gerben J de Roest, Peter M van de Ven, Maarten J Cramer, Pieter A Doevendans, Albert C van Rossum, Kevin Vernooy, Frits W Prinzen, Mathias Meine, Cornelis P Allaart^*

^*Corresponding author for this work

Research output: Contribution to journal › Article › Academic › peer-review

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Abstract

OBJECTIVES: This study evaluated the acute effect of dP/dtmax- versus stroke work (SW)-guided cardiac resynchronization therapy (CRT) optimization and the related acute hemodynamic changes to long-term CRT response.

BACKGROUND: Hemodynamic optimization may increase benefit from CRT. Typically, maximal left ventricular (LV) pressure rise dP/dtmax is used as an index of ventricular performance. Alternatively, SW can be derived from pressure-volume (PV) loops.

METHODS: Forty-one patients underwent CRT implantation followed by invasive PV loop measurements. The stimulation protocol included 16 LV pacing configurations using each individual electrode of the quadripolar lead with 4 atrioventricular (AV) delays. Conventional CRT was defined as pacing from the distal electrode with an AV delay of approximately 120 ms.

RESULTS: Compared with conventional CRT, dP/dtmax-guided optimization resulted in a one-third additional dP/dtmax increase (17 ± 11% vs. 12 ± 9%; p < 0.001). Similarly, SW-guided optimization resulted in a one-third additional SW increase (80 ± 55% vs. 53 ± 48%; p < 0.001). Comparing both optimization strategies, dP/dtmax favored contractility (8 ± 12% vs. 5 ± 10%; p = 0.015), whereas SW optimization improved ventricular-arterial (VA) coupling (45% vs. 32%; p < 0.001). After 6 months, mean LV ejection fraction (LVEF) change was 10 ± 9% with 23 (56%) patients becoming super-responders to CRT (≥10% LVEF improvement). Although acute changes in SW were predictive for long-term CRT response (area under the curve: 0.78; p = 0.002), changes in dP/dtmax were not (area under the curve: 0.65; p = 0.112).

CONCLUSIONS: PV-guided hemodynamic optimization in CRT results in approximately one-third SW improvement on top of conventional CRT, caused by a mechanism of enhanced VA coupling. In contrast, dP/dtmax optimization favored LV contractility. Ultimately, acute changes in SW showed larger predictive value for long-term CRT response compared with dP/dtmax.

Original language	English
Pages (from-to)	1013-1025
Number of pages	13
Journal	JACC: Clinical Electrophysiology
Volume	5
Issue number	9
DOIs	https://doi.org/10.1016/j.jacep.2019.05.020
Publication status	Published - Sept 2019

Keywords

cardiac resynchronization therapy (CRT)
dP/dt(max)
hemodynamic optimization
pressure volume loops
quadripolar LV leads
stroke work
LEFT-VENTRICULAR LEAD
PRESSURE-VOLUME LOOPS
HEART-FAILURE
SYSTOLIC FUNCTION
STIMULATION SITE
CONDUCTION
EFFICIENCY
IMPROVES
LOAD
IMPLANTATION

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Zweerink, A., Salden, O. A. E., van Everdingen, W. M., de Roest, G. J., van de Ven, P. M., Cramer, M. J., Doevendans, P. A., van Rossum, A. C., Vernooy, K., Prinzen, F. W., Meine, M., & Allaart, C. P. (2019). Hemodynamic Optimization in Cardiac Resynchronization Therapy: Should We Aim for dP/dtmax or Stroke Work? JACC: Clinical Electrophysiology, 5(9), 1013-1025. https://doi.org/10.1016/j.jacep.2019.05.020

@article{f8d7c4be3aa640db8f9760f0213fb667,

title = "Hemodynamic Optimization in Cardiac Resynchronization Therapy: Should We Aim for dP/dtmax or Stroke Work?",

abstract = "OBJECTIVES: This study evaluated the acute effect of dP/dtmax- versus stroke work (SW)-guided cardiac resynchronization therapy (CRT) optimization and the related acute hemodynamic changes to long-term CRT response.BACKGROUND: Hemodynamic optimization may increase benefit from CRT. Typically, maximal left ventricular (LV) pressure rise dP/dtmax is used as an index of ventricular performance. Alternatively, SW can be derived from pressure-volume (PV) loops.METHODS: Forty-one patients underwent CRT implantation followed by invasive PV loop measurements. The stimulation protocol included 16 LV pacing configurations using each individual electrode of the quadripolar lead with 4 atrioventricular (AV) delays. Conventional CRT was defined as pacing from the distal electrode with an AV delay of approximately 120 ms.RESULTS: Compared with conventional CRT, dP/dtmax-guided optimization resulted in a one-third additional dP/dtmax increase (17 ± 11% vs. 12 ± 9%; p < 0.001). Similarly, SW-guided optimization resulted in a one-third additional SW increase (80 ± 55% vs. 53 ± 48%; p < 0.001). Comparing both optimization strategies, dP/dtmax favored contractility (8 ± 12% vs. 5 ± 10%; p = 0.015), whereas SW optimization improved ventricular-arterial (VA) coupling (45% vs. 32%; p < 0.001). After 6 months, mean LV ejection fraction (LVEF) change was 10 ± 9% with 23 (56%) patients becoming super-responders to CRT (≥10% LVEF improvement). Although acute changes in SW were predictive for long-term CRT response (area under the curve: 0.78; p = 0.002), changes in dP/dtmax were not (area under the curve: 0.65; p = 0.112).CONCLUSIONS: PV-guided hemodynamic optimization in CRT results in approximately one-third SW improvement on top of conventional CRT, caused by a mechanism of enhanced VA coupling. In contrast, dP/dtmax optimization favored LV contractility. Ultimately, acute changes in SW showed larger predictive value for long-term CRT response compared with dP/dtmax.",

keywords = "cardiac resynchronization therapy (CRT), dP/dt(max), hemodynamic optimization, pressure volume loops, quadripolar LV leads, stroke work, LEFT-VENTRICULAR LEAD, PRESSURE-VOLUME LOOPS, HEART-FAILURE, SYSTOLIC FUNCTION, STIMULATION SITE, CONDUCTION, EFFICIENCY, IMPROVES, LOAD, IMPLANTATION",

author = "Alwin Zweerink and Salden, {Odette A E} and {van Everdingen}, {Wouter M} and {de Roest}, {Gerben J} and {van de Ven}, {Peter M} and Cramer, {Maarten J} and Doevendans, {Pieter A} and {van Rossum}, {Albert C} and Kevin Vernooy and Prinzen, {Frits W} and Mathias Meine and Allaart, {Cornelis P}",

year = "2019",

month = sep,

doi = "10.1016/j.jacep.2019.05.020",

language = "English",

volume = "5",

pages = "1013--1025",

journal = "JACC: Clinical Electrophysiology",

issn = "2405-500X",

publisher = "Elsevier USA",

number = "9",

}

Zweerink, A, Salden, OAE, van Everdingen, WM, de Roest, GJ, van de Ven, PM, Cramer, MJ, Doevendans, PA, van Rossum, AC, Vernooy, K , Prinzen, FW, Meine, M & Allaart, CP 2019, 'Hemodynamic Optimization in Cardiac Resynchronization Therapy: Should We Aim for dP/dtmax or Stroke Work?', JACC: Clinical Electrophysiology, vol. 5, no. 9, pp. 1013-1025. https://doi.org/10.1016/j.jacep.2019.05.020

TY - JOUR

T1 - Hemodynamic Optimization in Cardiac Resynchronization Therapy

T2 - Should We Aim for dP/dtmax or Stroke Work?

AU - Zweerink, Alwin

AU - Salden, Odette A E

AU - van Everdingen, Wouter M

AU - de Roest, Gerben J

AU - van de Ven, Peter M

AU - Cramer, Maarten J

AU - Doevendans, Pieter A

AU - van Rossum, Albert C

AU - Vernooy, Kevin

AU - Prinzen, Frits W

AU - Meine, Mathias

AU - Allaart, Cornelis P

PY - 2019/9

Y1 - 2019/9

N2 - OBJECTIVES: This study evaluated the acute effect of dP/dtmax- versus stroke work (SW)-guided cardiac resynchronization therapy (CRT) optimization and the related acute hemodynamic changes to long-term CRT response.BACKGROUND: Hemodynamic optimization may increase benefit from CRT. Typically, maximal left ventricular (LV) pressure rise dP/dtmax is used as an index of ventricular performance. Alternatively, SW can be derived from pressure-volume (PV) loops.METHODS: Forty-one patients underwent CRT implantation followed by invasive PV loop measurements. The stimulation protocol included 16 LV pacing configurations using each individual electrode of the quadripolar lead with 4 atrioventricular (AV) delays. Conventional CRT was defined as pacing from the distal electrode with an AV delay of approximately 120 ms.RESULTS: Compared with conventional CRT, dP/dtmax-guided optimization resulted in a one-third additional dP/dtmax increase (17 ± 11% vs. 12 ± 9%; p < 0.001). Similarly, SW-guided optimization resulted in a one-third additional SW increase (80 ± 55% vs. 53 ± 48%; p < 0.001). Comparing both optimization strategies, dP/dtmax favored contractility (8 ± 12% vs. 5 ± 10%; p = 0.015), whereas SW optimization improved ventricular-arterial (VA) coupling (45% vs. 32%; p < 0.001). After 6 months, mean LV ejection fraction (LVEF) change was 10 ± 9% with 23 (56%) patients becoming super-responders to CRT (≥10% LVEF improvement). Although acute changes in SW were predictive for long-term CRT response (area under the curve: 0.78; p = 0.002), changes in dP/dtmax were not (area under the curve: 0.65; p = 0.112).CONCLUSIONS: PV-guided hemodynamic optimization in CRT results in approximately one-third SW improvement on top of conventional CRT, caused by a mechanism of enhanced VA coupling. In contrast, dP/dtmax optimization favored LV contractility. Ultimately, acute changes in SW showed larger predictive value for long-term CRT response compared with dP/dtmax.

AB - OBJECTIVES: This study evaluated the acute effect of dP/dtmax- versus stroke work (SW)-guided cardiac resynchronization therapy (CRT) optimization and the related acute hemodynamic changes to long-term CRT response.BACKGROUND: Hemodynamic optimization may increase benefit from CRT. Typically, maximal left ventricular (LV) pressure rise dP/dtmax is used as an index of ventricular performance. Alternatively, SW can be derived from pressure-volume (PV) loops.METHODS: Forty-one patients underwent CRT implantation followed by invasive PV loop measurements. The stimulation protocol included 16 LV pacing configurations using each individual electrode of the quadripolar lead with 4 atrioventricular (AV) delays. Conventional CRT was defined as pacing from the distal electrode with an AV delay of approximately 120 ms.RESULTS: Compared with conventional CRT, dP/dtmax-guided optimization resulted in a one-third additional dP/dtmax increase (17 ± 11% vs. 12 ± 9%; p < 0.001). Similarly, SW-guided optimization resulted in a one-third additional SW increase (80 ± 55% vs. 53 ± 48%; p < 0.001). Comparing both optimization strategies, dP/dtmax favored contractility (8 ± 12% vs. 5 ± 10%; p = 0.015), whereas SW optimization improved ventricular-arterial (VA) coupling (45% vs. 32%; p < 0.001). After 6 months, mean LV ejection fraction (LVEF) change was 10 ± 9% with 23 (56%) patients becoming super-responders to CRT (≥10% LVEF improvement). Although acute changes in SW were predictive for long-term CRT response (area under the curve: 0.78; p = 0.002), changes in dP/dtmax were not (area under the curve: 0.65; p = 0.112).CONCLUSIONS: PV-guided hemodynamic optimization in CRT results in approximately one-third SW improvement on top of conventional CRT, caused by a mechanism of enhanced VA coupling. In contrast, dP/dtmax optimization favored LV contractility. Ultimately, acute changes in SW showed larger predictive value for long-term CRT response compared with dP/dtmax.

KW - cardiac resynchronization therapy (CRT)

KW - dP/dt(max)

KW - hemodynamic optimization

KW - pressure volume loops

KW - quadripolar LV leads

KW - stroke work

KW - LEFT-VENTRICULAR LEAD

KW - PRESSURE-VOLUME LOOPS

KW - HEART-FAILURE

KW - SYSTOLIC FUNCTION

KW - STIMULATION SITE

KW - CONDUCTION

KW - EFFICIENCY

KW - IMPROVES

KW - LOAD

KW - IMPLANTATION

U2 - 10.1016/j.jacep.2019.05.020

DO - 10.1016/j.jacep.2019.05.020

M3 - Article

C2 - 31537329

SN - 2405-500X

VL - 5

SP - 1013

EP - 1025

JO - JACC: Clinical Electrophysiology

JF - JACC: Clinical Electrophysiology

IS - 9

ER -