Home Medicine Left cardiac atrioventricular delay and inter-ventricular delay in cardiac resynchronization therapy responder and non-responder
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Left cardiac atrioventricular delay and inter-ventricular delay in cardiac resynchronization therapy responder and non-responder

  • Matthias Heinke EMAIL logo , Helmut Kühnert , Tobias Heinke , Jonas Tumampos and Gudrun Dannberg
Published/Copyright: September 30, 2016
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Current Directions in Biomedical Engineering
From the journal Current Directions in Biomedical Engineering Volume 2 Issue 1

Abstract

Cardiac resynchronization therapy is an established therapy for heart failure patients. The aim of the study was to evaluate electrical left cardiac atrioventricular delay and interventricular desynchronization in sinus rhythm cardiac resynchronization therapy responder and non-responder. Cardiac electrical desynchronization were measured by surface ECG and focused transesophageal bipolar left atrial and left ventricular ECG before implantation of cardiac resynchronization therapy defibrillators. Preoperative electrical cardiac desynchronization was 195.7 ± 46.7 ms left cardiac atrioventricular delay and 74.8 ± 24.5 ms interventricular delay in cardiac resynchronization therapy responder. Cardiac resynchronization therapy responder New York Heart Association class improved during long term biventricular pacing. Transesophageal left cardiac atrioventricular delay and interventricular delay may be additional useful parameters to improve patient selection for cardiac resynchronization therapy.

Keywords: atrioventricular delay; biventricular pacing; cardiac resynchronization therapy; heart failure; interventricular delay; left atrial ECG; left ventricular ECG; transesophageal ECG

1 Introduction

Cardiac resynchronization therapy is an established therapy for heart failure patients with sinus rhythm, reduced left ventricular ejection fraction, ventricular desynchronization with QRS duration >150 ms and left bundle branch block [1], [2]. Transesophageal focused left heart electrocardiography is a non-invasive method for evaluation of cardiac desynchronization with electrical interatrial delay, left atrial delay, interventricular delay and left ventricular delay in heart failure patients [3], [4].

The aim of the study was to evaluate electrical left cardiac atrioventricular delay and interventricular desynchronization in sinus rhythm cardiac resynchronization therapy responder and non-responder.

2 Methods

Twenty-one heart failure patients with sinus rhythm, New York Heart Association class 3.1 ± 0.3, 26.6 ± 6.1% left ventricular ejection fraction and 170.6 ± 41.4 ms QRS duration were measured by surface ECG and focused transesophageal bipolar left atrial and left ventricular ECG (TO4, TO8 Osypka AG, Rheinfelden, Germany) before implantation of cardiac resynchronization therapy defibrillator (see Figure 1). The mean age of one female and 20 males was 67.7 ± 8.7 years. Left cardiac atrioventricular delay was measured between onset of left atrial signal and onset of left ventricular signal in the transesophageal ECG. Interventricular delay was measured between onset of QRS in the surface ECG and onset of left ventricular signal in the transesophageal ECG. Cardiac resynchronization therapy atrioventricular delay between right atrial and left ventricular electrodes and biventricular pacing delay between right ventricular and left ventricular electrodes were optimized by transthoracic impedance cardiography [5], [6] (see Figure 2).

Figure 1 Cardiac resynchronization therapy responder surface ECG I, II, III, aVR, aVL, aVF, V1, V2, V3, V4, V5, V6, two transesophageal focused bipolar left atrial ECG ESO56, ESO78 and two transesophageal focused bipolar ventricular ECG ESO12, ESO34 before implantation of cardiac resynchronization therapy defibrillator with sinus rhythm, left bundle branch block, long left cardiac atrioventricular delay, long interventricular delay and long. QRS duration. LA, Left atrial signal; LV, left ventricular signal; LAVD, left cardiac atrioventricular delay; IVD, interventricular delay; QRS, QRS duration.
Figure 1

Cardiac resynchronization therapy responder surface ECG I, II, III, aVR, aVL, aVF, V1, V2, V3, V4, V5, V6, two transesophageal focused bipolar left atrial ECG ESO56, ESO78 and two transesophageal focused bipolar ventricular ECG ESO12, ESO34 before implantation of cardiac resynchronization therapy defibrillator with sinus rhythm, left bundle branch block, long left cardiac atrioventricular delay, long interventricular delay and long. QRS duration. LA, Left atrial signal; LV, left ventricular signal; LAVD, left cardiac atrioventricular delay; IVD, interventricular delay; QRS, QRS duration.

Statistical analysis was performed by Origin® 2016 software (OriginLab Corporation, Northampon, MA, USA) using paired and unpaired t-tests, as appropriate, with a statistical significance of p < 0.05 and with Pearson correlation coefficients.

Figure 2 Simulation of cardiac resynchronization therapy with right atrial, right ventricular and left ventricular bipolar pacing and higher left ventricular pacing voltage. RA, Bipolar right atrial electrode; RV, bipolar right ventricular electrode; LV, bipolar left ventricular electrode; V, pacing voltage.
Figure 2

Simulation of cardiac resynchronization therapy with right atrial, right ventricular and left ventricular bipolar pacing and higher left ventricular pacing voltage. RA, Bipolar right atrial electrode; RV, bipolar right ventricular electrode; LV, bipolar left ventricular electrode; V, pacing voltage.

3 Results

Twenty-one heart failure cardiac resynchronization therapy patient left cardiac atrioventricular delay and interventricular delay desynchronization were 200.4 ± 45.4 ms left cardiac atrioventricular delay, 75.3 ± 23.5 ms interventricular delay and 2.35 ± 0.59 QRS duration to interventricular delay ratio.

3.1 Cardiac resynchronization therapy responder

There were 18 cardiac resynchronization therapy responders with 195.7 ± 46.7 ms left cardiac atrioventricular delay, 74.8 ± 24.5 ms interventricular delay and 2.44 ± 0.58 QRS duration to interventricular delay ratio with negative correlation between interventricular delay and QRS duration to interventricular delay ratio (r = −0.54, p = 0.022) (see Figure 3).

Figure 3 Sinus rhythm cardiac resynchronization therapy responder with transesophageal electrical interventricular delay, left cardiac atrioventricular delay and QRS duration to interventricular delay ratio. IVD, Interventricular delay; LAVD, left cardiac atrioventricular delay; QRSD-IVD-ratio, QRS duration to interventricular delay ratio, r; P, Pearson correlation coefficients.
Figure 3

Sinus rhythm cardiac resynchronization therapy responder with transesophageal electrical interventricular delay, left cardiac atrioventricular delay and QRS duration to interventricular delay ratio. IVD, Interventricular delay; LAVD, left cardiac atrioventricular delay; QRSD-IVD-ratio, QRS duration to interventricular delay ratio, r; P, Pearson correlation coefficients.

3.2 Cardiac resynchronization therapy non-responder

There were three cardiac resynchronization therapy non-responders with 228.7 ± 25.8 ms left cardiac atrioventricular delay, 78.0 ± 19.3 ms interventricular delay and 1.81 ± 0.35 QRS duration to interventricular delay ratio (see Figure 4). The left cardiac atrioventricular delay was shorter in cardiac resynchronization therapy responder than in cardiac resynchronization therapy non-responder with negative correlation (r = −0.998, p = 0.037).

Figure 4 Cardiac resynchronization therapy non-responder surface ECG I, V2 and transesophageal focused bipolar left cardiac ECG Oe34 with left atrial signal and left ventricular signal before implantation of cardiac resynchronization therapy defibrillator with sinus rhythm, right bundle branch block, long left cardiac atrioventricular delay, short interventricular delay and long QRS duration. LA, Left atrial signal; LV, left ventricular signal; LAVD, left cardiac atrioventricular delay; IVD, interventricular delay; QRS, QRS duration.
Figure 4

Cardiac resynchronization therapy non-responder surface ECG I, V2 and transesophageal focused bipolar left cardiac ECG Oe34 with left atrial signal and left ventricular signal before implantation of cardiac resynchronization therapy defibrillator with sinus rhythm, right bundle branch block, long left cardiac atrioventricular delay, short interventricular delay and long QRS duration. LA, Left atrial signal; LV, left ventricular signal; LAVD, left cardiac atrioventricular delay; IVD, interventricular delay; QRS, QRS duration.

3.3 Cardiac resynchronization therapy follow-up

During 9.4 ± 11.0 month cardiac resynchronization therapy follow-up, the cardiac resynchronization therapy responder New York Heart Association class improved from 3.1 ± 0.3 to 2.1 ± 0.2 (p = 0.038) (see Figure 5). During 5.7 ± 3.7 month cardiac resynchronization therapy follow-up, the cardiac resynchronization therapy non-responder New York Heart Association class not improved from 2.8 ± 0.3 to 2.7 ± 0.6.

Figure 5 Cardiac resynchronization therapy responder surface ECG I, II, III, aVR, aVL, aVF, V1, V2, V3, V4, V5, V6 and bipolar focused left cardiac ECG ESObip34 with two hemispherical transesophageal electrodes before implantation of cardiac resynchronization therapy defibrillator during sinus rhythm (left side). Simulation of focused transesophageal left atrial electrical pacing field between two 6 mm hemispherical electrodes (right side). LA, Left atrial signal; LV, left ventricular signal; LAVD, left cardiac atrioventricular delay; IVD, interventricular delay; QRS, QRS duration.
Figure 5

Cardiac resynchronization therapy responder surface ECG I, II, III, aVR, aVL, aVF, V1, V2, V3, V4, V5, V6 and bipolar focused left cardiac ECG ESObip34 with two hemispherical transesophageal electrodes before implantation of cardiac resynchronization therapy defibrillator during sinus rhythm (left side). Simulation of focused transesophageal left atrial electrical pacing field between two 6 mm hemispherical electrodes (right side). LA, Left atrial signal; LV, left ventricular signal; LAVD, left cardiac atrioventricular delay; IVD, interventricular delay; QRS, QRS duration.

4 Discussion

Gold and co-workers evaluated the correlation between invasive electrical interventricular delay -measured between QRS onset and peak of left ventricular electrocardiogram- and left ventricular remodelling in 426 patients from the SMART-AV trail [7] with atrioventricular delay optimized cardiac resynchronization therapy [8]. More than 95 ms interventricular delay predicted 6 month cardiac resynchronization therapy response with increasing of left ventricular ejection fraction and decreasing of quality of live, left ventricular end-systolic volume, left ventricular end-diastolic volume. Less than 95 ms interventricular delay predicted 6 month cardiac resynchronization therapy non-response without left ventricular remodelling [8].

Transesophageal electrocardiography can be utilized to analyse interventricular delay and left cardiac atrioventricular delay before implantation of cardiac resynchronization therapy devices. QRS duration to interventricular delay ratio was smaller in cardiac resynchronization therapy non-responder than in cardiac resynchronization therapy responder. Left cardiac atrioventricular delay was shorter in cardiac resynchronization therapy responder than in cardiac resynchronization therapy non-responder. Transesophageal interventricular and atrioventricular delay may be additional useful parameters to improve patient selection for cardiac resynchronization therapy.

Author’s Statement

Research funding: The author state no funding involved. Conflict of interest: Authors state no conflict of interest. Material and methods: Informed consent: Informed consent has been obtained from all individuals included in this study. Ethical approval: The research related to human use complies with all the relevant national regulations, institutional policies and was performed in accordance with the tenets of the Helsinki Declaration, and has been approved by the authors’ institutional review board or equivalent committee.

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Published Online: 2016-9-30
Published in Print: 2016-9-1

©2016 Matthias Heinke et al., licensee De Gruyter.

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License.

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https://doi.org/10.1515/cdbme-2016-0055
Keywords for this article
atrioventricular delay; biventricular pacing; cardiac resynchronization therapy; heart failure; interventricular delay; left atrial ECG; left ventricular ECG; transesophageal ECG
Creative Commons
BY-NC-ND 4.0

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  84. A flexible standalone system with integrated sensor feedback for multi-pad electrode FES of the hand
  85. Smart control for functional electrical stimulation with optimal pulse intensity
  86. Tactile display on the remaining hand for unilateral hand amputees
  87. Effects of sustained electrical stimulation on spasticity assessed by the pendulum test
  88. An improved tracking framework for ultrasound probe localization in image-guided radiosurgery
  89. Improvement of a subviral particle tracker by the use of a LAP-Kalman-algorithm
  90. Learning discriminative classification models for grading anal intraepithelial neoplasia
  91. Regularization of EIT reconstruction based on multi-scales wavelet transforms
  92. Assessing MRI susceptibility artefact through an indicator of image distortion
  93. EyeGuidance – a computer controlled system to guide eye movements
  94. A framework for feedback-based segmentation of 3D image stacks
  95. Doppler optical coherence tomography as a promising tool for detecting fluid in the human middle ear
  96. 3D Local in vivo Environment (LivE) imaging for single cell protein analysis of bone tissue
  97. Inside-Out access strategy using new trans-vascular catheter approach
  98. US/MRI fusion with new optical tracking and marker approach for interventional procedures inside the MRI suite
  99. Impact of different registration methods in MEG source analysis
  100. 3D segmentation of thyroid ultrasound images using active contours
  101. Designing a compact MRI motion phantom
  102. Cerebral cortex classification by conditional random fields applied to intraoperative thermal imaging
  103. Classification of indirect immunofluorescence images using thresholded local binary count features
  104. Analysis of muscle fatigue conditions using time-frequency images and GLCM features
  105. Numerical evaluation of image parameters of ETR-1
  106. Fabrication of a compliant phantom of the human aortic arch for use in Particle Image Velocimetry (PIV) experimentation
  107. Effect of the number of electrodes on the reconstructed lung shape in electrical impedance tomography
  108. Hardware dependencies of GPU-accelerated beamformer performances for microwave breast cancer detection
  109. Computer assisted assessment of progressing osteoradionecrosis of the jaw for clinical diagnosis and treatment
  110. Evaluation of reconstruction parameters of electrical impedance tomography on aorta detection during saline bolus injection
  111. Evaluation of open-source software for the lung segmentation
  112. Automatic determination of lung features of CF patients in CT scans
  113. Image analysis of self-organized multicellular patterns
  114. Effect of key parameters on synthesis of superparamagnetic nanoparticles (SPIONs)
  115. Radiopacity assessment of neurovascular implants
  116. Development of a desiccant based dielectric for monitoring humidity conditions in miniaturized hermetic implantable packages
  117. Development of an artifact-free aneurysm clip
  118. Enhancing the regeneration of bone defects by alkalizing the peri-implant zone – an in vitro approach
  119. Rapid prototyping of replica knee implants for in vitro testing
  120. Protecting ultra- and hyperhydrophilic implant surfaces in dry state from loss of wettability
  121. Advanced wettability analysis of implant surfaces
  122. Patient-specific hip prostheses designed by surgeons
  123. Plasma treatment on novel carbon fiber reinforced PEEK cages to enhance bioactivity
  124. Wear of a total intervertebral disc prosthesis
  125. Digital health and digital biomarkers – enabling value chains on health data
  126. Usability in the lifecycle of medical software development
  127. Influence of different test gases in a non-destructive 100% quality control system for medical devices
  128. Device development guided by user satisfaction survey on auricular vagus nerve stimulation
  129. Empirical assessment of the time course of innovation in biomedical engineering: first results of a comparative approach
  130. Effect of left atrial hypertrophy on P-wave morphology in a computational model
  131. Simulation of intracardiac electrograms around acute ablation lesions
  132. Parametrization of activation based cardiac electrophysiology models using bidomain model simulations
  133. Assessment of nasal resistance using computational fluid dynamics
  134. Resistance in a non-linear autoregressive model of pulmonary mechanics
  135. Inspiratory and expiratory elastance in a non-linear autoregressive model of pulmonary mechanics
  136. Determination of regional lung function in cystic fibrosis using electrical impedance tomography
  137. Development of parietal bone surrogates for parietal graft lift training
  138. Numerical simulation of mechanically stimulated bone remodelling
  139. Conversion of engineering stresses to Cauchy stresses in tensile and compression tests of thermoplastic polymers
  140. Numerical examinations of simplified spondylodesis models concerning energy absorption in magnetic resonance imaging
  141. Principle study on the signal connection at transabdominal fetal pulse oximetry
  142. Influence of Siluron® insertion on model drug distribution in the simulated vitreous body
  143. Evaluating different approaches to identify a three parameter gas exchange model
  144. Effects of fibrosis on the extracellular potential based on 3D reconstructions from histological sections of heart tissue
  145. From imaging to hemodynamics – how reconstruction kernels influence the blood flow predictions in intracranial aneurysms
  146. Flow optimised design of a novel point-of-care diagnostic device for the detection of disease specific biomarkers
  147. Improved FPGA controlled artificial vascular system for plethysmographic measurements
  148. Minimally spaced electrode positions for multi-functional chest sensors: ECG and respiratory signal estimation
  149. Automated detection of alveolar arches for nasoalveolar molding in cleft lip and palate treatment
  150. Control scheme selection in human-machine- interfaces by analysis of activity signals
  151. Event-based sampling for reducing communication load in realtime human motion analysis by wireless inertial sensor networks
  152. Automatic pairing of inertial sensors to lower limb segments – a plug-and-play approach
  153. Contactless respiratory monitoring system for magnetic resonance imaging applications using a laser range sensor
  154. Interactive monitoring system for visual respiratory biofeedback
  155. Development of a low-cost senor based aid for visually impaired people
  156. Patient assistive system for the shoulder joint
  157. A passive beating heart setup for interventional cardiology training
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