SPECIAL ARTICLE
New information about resynchronisation
N.M. van Hemel
Chronic atrio-biventricular pacing appears to become a very attractive and promising additive therapy for congestive heart failure with systolic left ventricular impairment. The best results can only be achieved by an optimal interaction between the cardiologists involved. Untl now no sort of cariac intervenion has ever required such dose and ongoing cooperation to serve the cardiac patient. These efforts are welcomed because congestive heart failure strongly reduces the quality of mental health and physical functioning. By means of questions and answers on new information about crdiac resynchronisation, this special article aims to provide more insight into the role of this complex pacing therapy. (Neth Heart J 2003;11:465-8.) Key words: atrio-biventricular pacing, resynchronisation, congestive heart failure
Chronic atrio-biventricular pacing, consisting of stimulation at the epicardial site of the latest left ventricular activation in conjunction with right ventricular apical pacing while tracking the intrinsic atrial activity, appears to have become a very attractive and promising additive therapy for congestive heart failure with systolic left ventricular impairment. The best results can only be achieved by the mutual interaction between the clinical cardiologist in charge of the patient with heart failure, the cardiologist experienced with device implants and his allied professionals, and the cardiologist specialised in cardiac imaging. Until now no sort ofcardiac intervention has ever required such dose and ongoing cooperation to serve the cardiac patient. These efforts are welcomed because congestive heart failure strongly reduces the quality of mental N.M. van Hemd. Heart Lung Center Utrecht, Department of Cardiology, St. Antonius Hospital, PO Box 2500, 3430 EM Nieuwegein. Address for correspondence: N.M. van Hemel. E-mail: [email protected]
Netherlands Heart Journal, Volume 11, Number 11, November 2003
health and physical functioning.' Congestive heart failure and particularly the phase in which the condition worsens requires a substantial number of hospital admissions:2 approximately 150/100,000 for men and 100/100,000 for women in the Netherlands.3 Because hospitalisations account for about 70% of the healthcare budget for heart failure, admissions exhaust our care expenditure and manpower. Furthermore, congestive heart failure is associated with a high mortality:2 the one-year mortality of these patients observed in the community accounts for approximately 13%.4 The interest for resynchronisation therapy is fuelled by the well-documented improvement of well-being and functional condition of the atrio-biventricular paced patient with congestive heart failure in addition to medical treatment.5'6 However, the initial cardiac resynchronisation studies were all small-sized investigations (15%) and short periods of follow-up (120 ms) can no longer serve as the single criterion for implanting an atrio-biventricular pace467
New information about resynchronisation
maker in the patient with severe congestive heart failure.8 Evidence of left intraventricular and/or probably interventricular asynchrony has become an important diagnostic step but the degree and sites of asynchrony constitute new study targets. In a previous communication we estimated that about 3000 (10%) of the patients with severe congestive heart failure in the Netherlands fulfilled the following criteria: left ventricular ejection fraction 120 ms and NYHA dass III to IV and should be considered candidates for resynchronisation therapy.'9 We also calculated that 750 new candidates for resynchronisation therapy could be expected to emerge in the Netherlands annually. As the request to document clear asynchrony prior to implant becomes a criterion, we can assume that these figures should become smaller. There is a great need for new studies on this subject to permit calculations of the expenditure and requested manpower to provide this therapy nationwide. This article delivers information gathered at the symposium 'Cardiac resynchronisation therapy: how big is the MIRACLE?' organised by Medtronic in Eindhoven on 17 January 2003. The content of this paper represents the personal view ofthe author. The following subjects were presented: the MIRACLE study by W.T. Abraham, Ohio State University Heart Center, Columbus, Ohio, US; Echocardiographic studies by J.J. Bax, Leiden University Medical Centre; Cost-effectiveness by F. Braunschweig, Karolinska Hospital, Stockholm (S); Atrial fibrillation by P. Geelen, Onze Lieve Vrouwe Hospital Aalst (B); Intracardiac dp/dt max measurements by L.M. van Gelder, Catharina Hospital, Eindhoven; Patient selection by N.M. van Hemel, HLCU/St Antonius Hospital, Nieuwegein; ICD therapy by M.J. Schalij, Leiden University Medical Centre. i Refees 1
2
3
Hobbs FDR, Kenkre JE, Roalfe AK, Davis RC, Hare R, Davies MK, ct al. Impact of heart failure and left ventricular systolic dysfunction on quality of life. A cross-sectional study comparing common chronic cardiac and medical disorders and a representative adult population. Eur HeartJ2002;23:1867-76. Cowie MR, Fox KF, Wood DA, Metcalfe C, Thompson SG, Coats AJS, et al. Hospitalization of patients with heart failure: a population-based study. Eur HeartJ2002;23:877-85. Mosterd A, Reitsma JB, Grobbee DE. Angiotensin converting enzyme inhibition and hospitalization rates fbr heart failure in The Netherlands, 1980 to 1999: the end ofthe epidemic? Heart2002; 87:75-6.
468
4
5 6
7
8
9
10 11
12 13
14
15
Muntwyler J, Abetel G, Gruner C, Follath F. One-year mortality among unselected outpatientswith heart failure. EurHeartJ2002; 23:1861-6. Auricchio A, Klein H, Tockman B, Sack S, Stellbrink C, Neuzner J, et al. Transvenous biventricular pacing for heart failure: can the obstades be overcome? Am JCardiol 1999;83:136D-42D. Cazeau S, Ledercq C, Lavergne T, Walker S, Varma C, Linde C, et al. Effects ofmultisite biventricular pacing in patients with heart failure and intraventricular conduction delay. N Engl J Med 2001;344:873-80. Abraham WT, Fisher WG, SmithAL, Delurgio DB, LeonAR, Loh E, et al. Cardiac resynchronization in chronic heart failure. NEngl JMed 2002;346:1845-53. Shamim W, Yousufuddin M, Cicora M, Gibson DG, Coats AJS, Henein MY. Incremental changes of the QRS duration in serial ECGs over time identify high risk elderly patients with heart failure. Heart2002;88:47-52. Bax JJ, Marwick L, Erven L van, Molhoek L, Adriaansche C, Melker, R de, et al. Evaluation of resynchronization of contractile function following biventricular pacing using colour tissue Doppler imaging [abstract]. JAm CoU Cardiol2002;356 A. Bracke F, Gelder B van, Lakerveld L, Meijer A. Importance of interventricular delay to optimize biventricular pacing [abstract]. Neth HeartJ2002;10(Suppl 3):6. Linde C, Leclercq C, Rex S, Garrigue S, Lavergne T, Cazeau S, et al. Long-term benefits of biventricular pacing in congestive heart failure: results from the Multisite Stimulation in Cardiomyopathy (MUSTIC) study. JAm CoU Cardiol 2002;40(1):111-8. Braunschweig F, Linde C, Gadler F, Ryden L. Reduction of hospital days by biventricular pacing. EurJHeart Fail 2000;2:399406. Crijns HJGM, Tjeerdsma G, Kam, PJ de, Boomsma F, Gelder IC van, Berg MP van den, et al. Prognostic value ofthe presence and development ofatrial fibrillation in patients with advanced chronic heart failure. Eur HcartJ2000;21:1238-45. Leclercq C, Walker S, Linde C, Clementy J, Marshall AJ, Ritter P, et al. Comparative effects of permanent biventricular and tightuniventricular pacing in heart failure patients with chronic atrial fibrillation. Eur HeartJ2002;23:1780-7. Bansch D, Antz M, Boczor S, Volmer M, Tebbenjohanns J, et al. Primary prevention of sudden cardiac death in idiopathic dilated cardiomyopathy. The Cardiomyopathy Trial (CAT). Circulation
2002;105:1453-8. 16 Strickenberger AS. Amiodarone vs implantable defibrillator in patients with nonischemic cardiomyopathy and asymptomatic nonsustained ventricular tachycardia [abstract]. Circulation 2000; 102:2794. 17 Domanski MJ, Sakseena S, Epstein AE, Hallstrom AP, Brodsky MA, Kim S, et al. Relative effectiveness if the implantable cardioverter-defibrillator and antiarrhythmic drugs in patients with varying degrees of left ventricular dysfunction who survived malignant ventricular arrhythmias. JAm Coil Cardiol 1999;34: 1090-5. 18 Bristow MR, Feldman AM, Saxon LA. Heart failure management using implantable devices for ventricular resynchronization: comparison of medical therapy, pacing, and defibrillation in chronic heart failure (COMPANION) trial. J Card Fail 2000;6:276-85. 19 Hemel NM van, Mosterd A. Chronische gelijktijdige stimulatie van beide hartkamers, een nieuwe behandelingstherapie voor ermstig hartfalen. Ned Tijdschr Geneeskd 2002;146:158-62.
Nehrlands Hcart Joumal, Volume 11, Number 11, November 2003
New information about resynchronisation
N.M. van Hemel
Chronic atrio-biventricular pacing appears to become a very attractive and promising additive therapy for congestive heart failure with systolic left ventricular impairment. The best results can only be achieved by an optimal interaction between the cardiologists involved. Untl now no sort of cariac intervenion has ever required such dose and ongoing cooperation to serve the cardiac patient. These efforts are welcomed because congestive heart failure strongly reduces the quality of mental health and physical functioning. By means of questions and answers on new information about crdiac resynchronisation, this special article aims to provide more insight into the role of this complex pacing therapy. (Neth Heart J 2003;11:465-8.) Key words: atrio-biventricular pacing, resynchronisation, congestive heart failure
Chronic atrio-biventricular pacing, consisting of stimulation at the epicardial site of the latest left ventricular activation in conjunction with right ventricular apical pacing while tracking the intrinsic atrial activity, appears to have become a very attractive and promising additive therapy for congestive heart failure with systolic left ventricular impairment. The best results can only be achieved by the mutual interaction between the clinical cardiologist in charge of the patient with heart failure, the cardiologist experienced with device implants and his allied professionals, and the cardiologist specialised in cardiac imaging. Until now no sort ofcardiac intervention has ever required such dose and ongoing cooperation to serve the cardiac patient. These efforts are welcomed because congestive heart failure strongly reduces the quality of mental N.M. van Hemd. Heart Lung Center Utrecht, Department of Cardiology, St. Antonius Hospital, PO Box 2500, 3430 EM Nieuwegein. Address for correspondence: N.M. van Hemel. E-mail: [email protected]
Netherlands Heart Journal, Volume 11, Number 11, November 2003
health and physical functioning.' Congestive heart failure and particularly the phase in which the condition worsens requires a substantial number of hospital admissions:2 approximately 150/100,000 for men and 100/100,000 for women in the Netherlands.3 Because hospitalisations account for about 70% of the healthcare budget for heart failure, admissions exhaust our care expenditure and manpower. Furthermore, congestive heart failure is associated with a high mortality:2 the one-year mortality of these patients observed in the community accounts for approximately 13%.4 The interest for resynchronisation therapy is fuelled by the well-documented improvement of well-being and functional condition of the atrio-biventricular paced patient with congestive heart failure in addition to medical treatment.5'6 However, the initial cardiac resynchronisation studies were all small-sized investigations (15%) and short periods of follow-up (120 ms) can no longer serve as the single criterion for implanting an atrio-biventricular pace467
New information about resynchronisation
maker in the patient with severe congestive heart failure.8 Evidence of left intraventricular and/or probably interventricular asynchrony has become an important diagnostic step but the degree and sites of asynchrony constitute new study targets. In a previous communication we estimated that about 3000 (10%) of the patients with severe congestive heart failure in the Netherlands fulfilled the following criteria: left ventricular ejection fraction 120 ms and NYHA dass III to IV and should be considered candidates for resynchronisation therapy.'9 We also calculated that 750 new candidates for resynchronisation therapy could be expected to emerge in the Netherlands annually. As the request to document clear asynchrony prior to implant becomes a criterion, we can assume that these figures should become smaller. There is a great need for new studies on this subject to permit calculations of the expenditure and requested manpower to provide this therapy nationwide. This article delivers information gathered at the symposium 'Cardiac resynchronisation therapy: how big is the MIRACLE?' organised by Medtronic in Eindhoven on 17 January 2003. The content of this paper represents the personal view ofthe author. The following subjects were presented: the MIRACLE study by W.T. Abraham, Ohio State University Heart Center, Columbus, Ohio, US; Echocardiographic studies by J.J. Bax, Leiden University Medical Centre; Cost-effectiveness by F. Braunschweig, Karolinska Hospital, Stockholm (S); Atrial fibrillation by P. Geelen, Onze Lieve Vrouwe Hospital Aalst (B); Intracardiac dp/dt max measurements by L.M. van Gelder, Catharina Hospital, Eindhoven; Patient selection by N.M. van Hemel, HLCU/St Antonius Hospital, Nieuwegein; ICD therapy by M.J. Schalij, Leiden University Medical Centre. i Refees 1
2
3
Hobbs FDR, Kenkre JE, Roalfe AK, Davis RC, Hare R, Davies MK, ct al. Impact of heart failure and left ventricular systolic dysfunction on quality of life. A cross-sectional study comparing common chronic cardiac and medical disorders and a representative adult population. Eur HeartJ2002;23:1867-76. Cowie MR, Fox KF, Wood DA, Metcalfe C, Thompson SG, Coats AJS, et al. Hospitalization of patients with heart failure: a population-based study. Eur HeartJ2002;23:877-85. Mosterd A, Reitsma JB, Grobbee DE. Angiotensin converting enzyme inhibition and hospitalization rates fbr heart failure in The Netherlands, 1980 to 1999: the end ofthe epidemic? Heart2002; 87:75-6.
468
4
5 6
7
8
9
10 11
12 13
14
15
Muntwyler J, Abetel G, Gruner C, Follath F. One-year mortality among unselected outpatientswith heart failure. EurHeartJ2002; 23:1861-6. Auricchio A, Klein H, Tockman B, Sack S, Stellbrink C, Neuzner J, et al. Transvenous biventricular pacing for heart failure: can the obstades be overcome? Am JCardiol 1999;83:136D-42D. Cazeau S, Ledercq C, Lavergne T, Walker S, Varma C, Linde C, et al. Effects ofmultisite biventricular pacing in patients with heart failure and intraventricular conduction delay. N Engl J Med 2001;344:873-80. Abraham WT, Fisher WG, SmithAL, Delurgio DB, LeonAR, Loh E, et al. Cardiac resynchronization in chronic heart failure. NEngl JMed 2002;346:1845-53. Shamim W, Yousufuddin M, Cicora M, Gibson DG, Coats AJS, Henein MY. Incremental changes of the QRS duration in serial ECGs over time identify high risk elderly patients with heart failure. Heart2002;88:47-52. Bax JJ, Marwick L, Erven L van, Molhoek L, Adriaansche C, Melker, R de, et al. Evaluation of resynchronization of contractile function following biventricular pacing using colour tissue Doppler imaging [abstract]. JAm CoU Cardiol2002;356 A. Bracke F, Gelder B van, Lakerveld L, Meijer A. Importance of interventricular delay to optimize biventricular pacing [abstract]. Neth HeartJ2002;10(Suppl 3):6. Linde C, Leclercq C, Rex S, Garrigue S, Lavergne T, Cazeau S, et al. Long-term benefits of biventricular pacing in congestive heart failure: results from the Multisite Stimulation in Cardiomyopathy (MUSTIC) study. JAm CoU Cardiol 2002;40(1):111-8. Braunschweig F, Linde C, Gadler F, Ryden L. Reduction of hospital days by biventricular pacing. EurJHeart Fail 2000;2:399406. Crijns HJGM, Tjeerdsma G, Kam, PJ de, Boomsma F, Gelder IC van, Berg MP van den, et al. Prognostic value ofthe presence and development ofatrial fibrillation in patients with advanced chronic heart failure. Eur HcartJ2000;21:1238-45. Leclercq C, Walker S, Linde C, Clementy J, Marshall AJ, Ritter P, et al. Comparative effects of permanent biventricular and tightuniventricular pacing in heart failure patients with chronic atrial fibrillation. Eur HeartJ2002;23:1780-7. Bansch D, Antz M, Boczor S, Volmer M, Tebbenjohanns J, et al. Primary prevention of sudden cardiac death in idiopathic dilated cardiomyopathy. The Cardiomyopathy Trial (CAT). Circulation
2002;105:1453-8. 16 Strickenberger AS. Amiodarone vs implantable defibrillator in patients with nonischemic cardiomyopathy and asymptomatic nonsustained ventricular tachycardia [abstract]. Circulation 2000; 102:2794. 17 Domanski MJ, Sakseena S, Epstein AE, Hallstrom AP, Brodsky MA, Kim S, et al. Relative effectiveness if the implantable cardioverter-defibrillator and antiarrhythmic drugs in patients with varying degrees of left ventricular dysfunction who survived malignant ventricular arrhythmias. JAm Coil Cardiol 1999;34: 1090-5. 18 Bristow MR, Feldman AM, Saxon LA. Heart failure management using implantable devices for ventricular resynchronization: comparison of medical therapy, pacing, and defibrillation in chronic heart failure (COMPANION) trial. J Card Fail 2000;6:276-85. 19 Hemel NM van, Mosterd A. Chronische gelijktijdige stimulatie van beide hartkamers, een nieuwe behandelingstherapie voor ermstig hartfalen. Ned Tijdschr Geneeskd 2002;146:158-62.
Nehrlands Hcart Joumal, Volume 11, Number 11, November 2003
