Novel insights on effect of atrioventricular programming of biventricular pacemaker in heart failure – a case series
© Naqvi and Rafique; licensee BioMed Central Ltd. 2006
Received: 26 September 2006
Accepted: 16 October 2006
Published: 16 October 2006
Echocardiography plays an integral role in the diagnosis of congestive heart failure including measurement of left heart pressure as well as mechanical dyssynchrony.
In this report we describe novel therapeutic uses of echo pulsed wave Doppler in atrioventricular pacemaker optimization in patients who had either not derived significant symptomatic benefit post biventricular pacemaker implantation or deteriorated after deriving initial benefit. In these patients atrioventricular optimization showed novel findings and improved cardiac output and symptoms.
In 3 patients with Cheyne Stokes pattern of respiration echo Doppler showed worsening of mitral regurgitation during hyperpneac phase in one patient, marked E and A fusion in another patient and exaggerated ventricular interdependence in a third patient thus highlighting mechanisms of adverse effects of Cheyne Stokes respiration in patients with heart failure. All 3 patients required a very short atrioventricular delay programming for best cardiac output. In one patient with recurrent congestive heart failure post cardiac resynchronization, mitral inflow pulse wave Doppler showed no A wave until a sensed atrioventricular delay of 190 ms was reached and showed progressive improvement in mitral inflow pattern until an atrioventricular delay of 290 ms. In 2 patients atrioventricular delay as short as 50 ms was required to allow E and A separation and prevent diastolic mitral regurgitation. All patients developed marked improvement in congestive heart failure symptoms post echo-guided biv pacemaker optimization.
These findings highlight the value of echo-guided pacemaker optimization in symptomatic patients post cardiac resynchronization treatment.
Echocardiography has become the gold standard for non invasive assessment of diastolic function . Besides detecting left ventricular (LV) relaxation abnormality, pulsed wave (PW) Doppler echocardiography allows assessment of LV end diastolic and left atrial pressures accurately [2, 3]. More recently tissue Doppler imaging (TDI) has been shown to allow detection of mechanical asynchrony in patients with congestive heart failure (CHF) and predict improvement in response to cardiac resynchronization treatment (CRT) [4–8]. Patients with advanced CHF have concomitant diastolic dysfunction to varying degree and are very dependent on atrial output to prevent pulmonary venous congestion and maintenance of effective cardiac output. Atrial flutter, tachycardia induced E and A fusion and diastolic mitral regurgitation (MR) markedly compromise ventricular diastolic filling thereby leading to increase in left atrial pressure. Biventricular (biv) pacing has become an effective method to improve diastolic filling as well as LV ejection times . In-coordinated diastolic filling may be one the important reasons why a significant number of patients do not improve or even deteriorate after CRT despite improvement in ventricular synchrony . Since AV delay affects atrial contribution to LV filling, manipulation of AV delays may further improve diastolic filling post biv pacemaker implantation in 12–25% of subjects [9, 10]. PW Doppler is able to detect acute changes in response to pacemaker programming allowing this simple non invasive technique to be used during biv pacemaker programming. Indeed tailored echocardiography guided AV programming has been shown to cause incremental improvement in cardiac function and functional class in patients who undergo CRT [1, 11–13]. In this report we describe our experience with AV optimization by case examples of patients where optimal AV delay varied considerably from the standard AVD of 120 ms that is often programmed empirically post CRT. These case examples are derived from 200 consecutive AV optimizations we performed at our center between Jan 2004 to March 2006. Several patients with findings similar to those presented are not discussed. Besides highlighting the role of echo Doppler in AV optimization, these case examples gave insight into the mechanism of CHF symptoms post CRT. Echo Doppler evaluation of mitral inflow, left ventricular (LV) outflow and pulmonary vein inflow during pacemaker programming was performed using Vivid 7, GE Vingmed ultrasound system using conventional methods. Data was averaged from 5 cardiac cycles for each AV delay.
Effect of Cheyne Stokes respiration on diastolic filling
Effect of Cheyne Stokes respiration on mitral regurgitation
Effect of Cheyne Stokes respiration on ventricular interdependence
Effect of a long atrioventricular delay on late diastolic filling
Effect of a very short atrioventricular delay on diastolic mitral regurgitation
Effect of a very short atrioventricular delay on E and A separation
Our findings describe the utility of AV pacemaker optimization using PW echocardiography in optimizing diastolic mitral inflow in patients who remain symptomatic post CRT. Our report also highlights the mechanisms of adverse effects of Cheyne Stokes pattern of respiration on cardiac performance.
Published Studies on Biventricular Pacemaker Programming
Shawnee NS 
Inoue N 
Mitral PW Doppler
Braunschweig F 
Intracardiac Hemodynamic Monitor
Santos JF 
120–170 vs. 110–190
PW Mitral vs Impedance Cardiography
Meluzin J 
Rt. Heart Cath + Mitral PW Doppler
Butter C 
Invasive Aortic Pressure + FPPG
Braun MU 
Impedance Cardiography S+ VTI
Ishikawa T 
Mitral PW Doppler + Aortic VTI
Scharf C 
Shortening of AV delay has been shown to reduce diastolic MR in patients with right sided pacemaker , and causes hemodynamic improvement in patients with advanced LV systolic dysfunction by optimizing mitral inflow filling . We describe the effect of shortening of AVD in reducing MR in symptomatic patients with biv pacemaker. In addition we report the beneficial effects of a short AVD in systematic patients with biv pacemaker who have Cheyne Stokes respiration.
Central sleep apnea is common among patients with CHF, being present in 30–40% of patients . It contributes to increased mortality among patients with CHF  due to changes in sympathetic activity with respiratory phases  as well as by secondary pulmonary hypertension and right ventricular dysfunction. Rhythmic oscillations in AV node refractoriness occurs with Cheyne Stokes respiration such that a short AV node refractoriness occurs during hyperpnea with a lesser degree of concealed conduction [19, 20]. This explains findings in all 3 of our patients with Cheyne Stokes respiration in whom tachycardia occurred during hyperpneac phase and bradycardia during bradypneac and apneac phases of respiration. Increased heart rate and blood pressure on the average show about a 10-second delay because sympathetic system modulates heart rate at lower frequencies than parasympathetic responses which are greatly diminished in patients with heart failure. Thus our patients showed a systematic delay between onset of respiratory phases and change in heart rate. One of our patients with this respiratory pattern also showed mitral inflow E and A fusion causing impairment in diastolic filling during hyperpneac phase of Cheyne Stokes respiration, another showed an increase in MR severity and another showed exaggerated mitral and tricuspid inflow respiratory variation during hyperpneac phase of respiration. These observations highlight the additional mechanisms whereby Cheyne Stokes respiration causes adverse cardiac effects including worsening of heart failure symptoms as well as increased mortality. Our observations suggest that presence of Cheyne Stokes respiration should be evaluated in patients who are referred for pacemaker optimization due to persistent CHF post biv pacemaker implantation.
Ours is not a consecutive series of patients, rather a collection of patients in whom echo Doppler during AV optimization allowed novel observations that provide insight into the mechanism of failure of CRT and adverse effects of Cheyne Stokes respiration. A systemic study is needed to prospectively evaluate prevalence of Cheyne Stokes respiration in symptomatic patients post CRT and effect of AVD optimization in this group.
We report 3 separate mechanisms whereby Cheyne Stokes respiration can contribute to worsening of heart failure symptoms in patients with CHF post CRT. These include compromised diastolic filling during hyperpneac phase of respiration, increase in diastolic mitral regurgitation during hyperpneac phase and development of a constrictive physiology with enhanced ventricular interdependence. A short AVD helped improve diastolic filling, reduce diastolic MR and reduce ventricular interdependence in all 3 patients. We also report the use of short AVD in abolishing diastolic MR in patients without Cheyne Stokes respiration as well as improvement in diastolic filling by an extraordinarily long AVD in a patient with heart failure post CRT. Our findings extend the use of echo Doppler in evaluation of patients who remain symptomatic post CRT as well as in determining optimal AVD.
= Atrioventricular Delay
= Congestive Heart Failure
= Cardiac Resynchronization Treatment
= Continuous Positive Airway Pressure
= Left Ventricular Ejection Fraction
= Left Ventricle (Ventricular)
= Mitral Regurgitation
= New York Heart Association
= Pulsed wave
= Right Atrium
= Right Ventricle (Ventricular)
= Velocity Times Integral
We thank all sonographers in the cardiac non invasive lab who assisted in image acquisition and colleagues in electrophysiology at Cedars-Sinai Medical Center for patient referral.
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