Transcutaneous electrical diaphragmatic stimulation in mechanically ventilated patients: a randomised study.

BACKGROUND: Few specific methods are available to reduce the risk of diaphragmatic dysfunction for patients under mechanical ventilation. The number of studies involving transcutaneous electrical stimulation of the diaphragm (TEDS) is increasing but none report results for diaphragmatic measurements, and they lack power. We hypothesised that the use of TEDS would decrease diaphragmatic dysfunction and improve respiratory muscle strength in patients in ICU. METHODS: We conducted a controlled trial to assess the impact of daily active electrical stimulation versus sham stimulation on the prevention of diaphragm dysfunction during the weaning process from mechanical ventilation. The evaluation was based on ultrasound measurements of diaphragm thickening fraction during spontaneous breathing trials. We also measured maximal inspiratory muscle pressure (MIP), peak cough flow (PEF) and extubation failure. RESULTS: Sixty-six patients were included and randomised using a 1:1 ratio. The mean number of days of mechanical ventilation was 10 ± 6.8. Diaphragm thickening fraction was > 30% at the SBT for 67% of participants in the TEDS group and 54% of the Sham group (OR1.55, 95% CI 0.47-5.1; p = 0.47). MIP and PEF were similar in the TEDS and Sham groups (respectively 35.5 ± 11.9 vs 29.7 ± 11.7 cmH20; p = 0.469 and 83.2 ± 39.5 vs. 75.3 ± 34.08 L/min; p = 0.83). Rate of extubation failure was not different between groups. CONCLUSION: TEDS did not prevent diaphragm dysfunction or improve inspiratory muscle strength in mechanically ventilated patients. TRIAL REGISTRATION: Prospectively registered on the 20th November 2019 on ClinicalTrials.gov Identifier NCT04171024.

Muscle weakness, functional capacities and recovery for COVID-19 ICU survivors.

BACKGROUND: Few studies have evaluated muscle strength in COVID-19 ICU survivors. We aimed to report the incidence of limb and respiratory muscle weakness in COVID-19 ICU survivors. METHOD: We performed a cross sectional study in two ICU tertiary Hospital Settings. COVID-19 ICU survivors were screened and respiratory and limb muscle strength were measured at the time of extubation. An ICU mobility scale was performed at ICU discharge and walking capacity was self-evaluated by patients 30 days after weaning from mechanical ventilation. RESULTS: Twenty-three patients were included. Sixteen (69%) had limb muscle weakness and 6 (26%) had overlap limb and respiratory muscle weakness. Amount of physiotherapy was not associated with muscle strength. 44% of patients with limb weakness were unable to walk 100 m 30 days after weaning. CONCLUSION: The large majority of COVID-19 ICU survivors developed ICU acquired limb muscle weakness. 44% of patients with limb weakness still had severely limited function one-month post weaning.

Energy conservation technique improves dyspnoea when patients with severe COPD climb stairs: a randomised crossover study.

In this randomised, crossover trial, 22 patients with severe chronic obstructive pulmonary disease climbed six flights of stairs (108 steps) twice, under two test conditions: (1) energy conservation technique (ECT): participants were asked to rest for at least 5 seconds every three steps and (2) control condition: participants climbed the stairs at their own pace. Significant lower dyspnoea (primary outcome), leg discomfort, minute ventilation and capillary blood lactate under the ECT condition were found, with no change in total task time. CLINICAL TRIAL REGISTRATION: NCT03564028.

ICU outcomes can be predicted by noninvasive muscle evaluation: a meta-analysis.

BACKGROUND: The relationship between muscle function in critically ill patients assessed using bedside techniques and clinical outcomes has not been systematically described. We aimed to evaluate the association between muscle weakness assessed by bedside evaluation and mortality or weaning from mechanical ventilation, and the capacity of each evaluation tool to predict outcomes. METHODS: Five databases (PubMed, Embase, CINAHL, Cochrane Library, Science Direct) were searched from January 2000 to December 2018. Data were extracted and random effects meta-analyses were performed. RESULTS: 60 studies were analysed, including 4382 patients. Intensive care unit (ICU)-related muscle weakness was associated with an increase in overall mortality with odds ratios ranging from 1.2 (95% CI 0.60-2.40) to 4.48 (95% CI 1.49-13.42). Transdiaphragmatic twitch pressure had the highest predictive capacity for overall mortality, with a sensitivity of 0.87 (95% CI 0.76-0.93) and a specificity of 0.36 (95% CI 0.27-0.43). The area under the curve (AUC) was 0.74 (95% CI 0.70-0.78). Muscle weakness was associated with an increase in mechanical ventilation weaning failure rate with an odds ratio ranging from 2.64 (95% CI 0.72-9.64) to 19.07 (95% CI 9.35-38.9). Diaphragm thickening fraction had the highest predictive capacity for weaning failure with a sensitivity of 0.76 (95% CI 0.67-0.83) and a specificity of 0.86 (95% CI 0.78-0.92). The AUC was 0.86 (95% CI 0.83-0.89). CONCLUSION: ICU-related muscle weakness detected by bedside techniques is a serious issue associated with a high risk of death or prolonged mechanical ventilation. Evaluating diaphragm function should be a clinical priority in the ICU.

Nasal high flow does not improve exercise tolerance in COPD patients recovering from acute exacerbation: A randomized crossover study.

BACKGROUND AND OBJECTIVE: We hypothesized that by reducing respiratory work and improving gas exchange, nasal high flow (NHF) would improve exercise tolerance in patients with chronic obstructive pulmonary disease (COPD) following respiratory exacerbation. METHODS: This was a monocentric, randomized, controlled crossover study. Patients with severe to very severe COPD carried out two high-intensity constant work-rate exercise tests (CWRET) with and without NHF on two consecutive days. The primary outcome was the mean difference in endurance time between both conditions. The secondary aims included vastus lateralis oxygenation (StO2 ), dyspnoea, leg discomfort, maximal inspiratory pressure (MIP), transcutaneous CO2 pressure (PtcCO2 ), respiratory rate (RR), heart rate (HR) and pulsed O2 saturation (SpO2 ), as well as the patients' opinions of the device. RESULTS: A total of 19 patients were included (mean forced expiratory volume in 1 s = 28.7 ± 10.8%, age = 62.1 ± 9.1 years). No significant differences in endurance time during the CWRET were found between the two test conditions (-66.58 (95% CI: -155.9 to 22.7) s, P = 0.12). StO2 , PtCO2 and HR were reduced at the end of the exercise with NHF (-2.1% (95% CI: -4.3 to -0.0); -1.3 mm Hg (95% CI: -2.5 to -0.2); -2.7 bpm (95% CI: -5.0 to -0.5), respectively, P ≤ 0.05). No significant differences were found for any of the other secondary outcomes. Half of the patients evaluated the device as being moderately to very uncomfortable. CONCLUSION: NHF during exercise did not increase endurance time in patients with COPD following exacerbation. CLINICAL TRIAL REGISTRATION: NCT03058081 at clinicaltrials.gov.

Changes in Cycle-Ergometer Performance during Pulmonary Rehabilitation Predict COPD Exacerbation.

Early diagnosis of COPD exacerbations is vital. Exacerbations are characterised by an increase in dyspnoea that could be affect physical capacity. Changes in the physical capacity of patients with COPD during pulmonary rehabilitation could provide a predictive indication regarding the occurrence of exacerbation. This was a retrospective study of forty for patients with COPD who participated in a pulmonary rehabilitation programme between January 2015 and October 2018. Patients to have experienced at least one exacerbation during their pulmonary rehabilitation programme are included. The performance variable and dyspnoea on the cycle ergometer and the treadmill were collected during the five sessions prior to the exacerbation and the three sessions following the exacerbation. Seventy exacerbations were analysed. We found a significant decrease in the performance on the cycle ergometer during the last session before exacerbation compared with previous sessions (mean difference: 74.5% (95%CI 12.6-136.5); p < 0.01). The optimal threshold value was a 17% decrease in performance compared to the previous training session. Sensitivity was 0.46 (95%CI 0.34-0.59), specificity was 0.83 (95%CI 0.72-0.91) and the area under the curve was 0.65 (95%CI 0.56-0.74) (p < 0.01). The analysis of performance data from cycle ergometer is a potentially useful method to predict the occurrence of exacerbation.

Functional Electrical Stimulation Changes Muscle Oxygenation in Patients with Chronic Obstructive Pulmonary Disease During Moderate-Intensity Exercise: A Secondary Analysis.

We previously showed that functional electrical stimulation during cycle ergometry (FES-cycling) increased oxygen consumption (VO2), indicating that metabolism during exercise was increased. However, the effects on muscle oxygenation have never been studied. The aim of this secondary analysis was to analyse changes in muscle oxygenation during an FES-cycling session. Eight patients with chronic obstructive pulmonary disease who were participating in a pulmonary rehabilitation programme were enrolled. Each participant carried out 30 minutes of cycle ergometry with a constant load at 50% of peak oxygen uptake, either (i) with FES or (ii) without (Placebo-FES). Oxygenation of the vastus lateralis (VL) muscle over time was measured using near-infrared spectroscopy (NIRS) during both sessions. External power output on the cycle ergometer was the same in both conditions. There were no differences in dyspnoea between the groups, although the concentrations of deoxygenated haemoglobin and myoglobin (deoxy(Hb + Mb)) in the VL were significantly greater during Placebo-FES than FES-Cycling (respectively +212 ± 65% vs. +84 ± 29%; p < 0.001), as was the decrease in muscle oxygen saturation (StO2) (p < 0.001). When adjusted for VO2, there was a greater increase over time in the deoxy(Hb + Mb)/VO2 ratio during Placebo-FES than FES-cycling (p < 0.0001). FES-cycling could be a useful strategy to decrease muscular deoxy(Hb + Mb) and limit decreases in muscle StO2, however this should be confirmed in larger studies.

Comparison of exercise intensity during four early rehabilitation techniques in sedated and ventilated patients in ICU: a randomised cross-over trial.

BACKGROUND: In the ICU, out-of-bed rehabilitation is often delayed and in-bed exercises are generally low-intensity. Since the majority of rehabilitation is carried out in bed, it is essential to carry out the exercises that have the highest intensity. The aim of this study was to compare the physiological effects of four common types of bed exercise in intubated, sedated patients confined to bed in the ICU, in order to determine which was the most intensive. METHODS: A randomised, single-blind, placebo-controlled crossover trial was carried out to evaluate the effects of four bed exercises (passive range of movements (PROM), passive cycle-ergometry, quadriceps electrical stimulation and functional electrical stimulation (FES) cycling) on cardiac output. Each exercise was carried out for ten minutes in ventilated, sedated patients. Cardiac output was recorded using cardiac Doppler ultrasound. The secondary aims were to evaluate right heart function and pulmonary and systemic artery pressures during the exercises, and the microcirculation of the vastus lateralis muscle. RESULTS: The results were analysed in 19 patients. FES cycling was the only exercise that increased cardiac output, with a mean increase of 1 L/min (15%). There was a concomitant increase in muscle oxygen uptake, suggesting that muscle work occurred. FES cycling thus constitutes an effective early rehabilitation intervention. No muscle or systemic effects were induced by the passive techniques. CONCLUSION: Most bed exercises were low-intensity and induced low levels of muscle work. FES cycling was the only exercise that increased cardiac output and produced sufficient intensity of muscle work. Longer-term studies of the effect of FES cycling on functional outcomes should be carried out. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02920684 . Registered on 30 September 2016. Prospectively registered.

Functional Electrical Stimulation-A New Therapeutic Approach to Enhance Exercise Intensity in Chronic Obstructive Pulmonary Disease Patients: A Randomized, Controlled Crossover Trial.

OBJECTIVE: To evaluate the effect of quadriceps functional electrical stimulation (FES)-cycling on exertional oxygen uptake (V˙o2) compared with placebo FES-cycling in patients with chronic obstructive pulmonary disease (COPD). DESIGN: A randomized, single-blind, placebo-controlled crossover trial. SETTING: Pulmonary rehabilitation department. PARTICIPANTS: Consecutive patients (N=23) with COPD Global Initiative for Chronic Obstructive Lung Disease stage 2, 3, or 4 (mean forced expiratory volume during the first second, 1.4±0.4L [50.3% predicted]) who had recently begun a respiratory rehabilitation program. INTERVENTION: Two consecutive 30-minute sessions were carried out at a constant load with active and placebo FES-cycling. MAIN OUTCOME MEASURES: The primary outcome was mean V˙o2 during the 30-minute exercise session. The secondary outcomes were respiratory gas exchange and hemodynamic parameters averaged over the 30-minute endurance session. Lactate values, dyspnea, and perceived muscle fatigue were evaluated at the end of the sessions. RESULTS: FES-cycling increased the physiological response more than the placebo, with a greater V˙o2 achieved of 36.6mL/min (95% confidence interval [CI], 8.9-64.3mL/min) (P=.01). There was also a greater increase in lactate after FES-cycling (+1.5mmol/L [95% CI, .05-2.9mmol/L]; P=.01). FES-cycling did not change dyspnea or muscle fatigue compared with the placebo condition. CONCLUSIONS: FES-cycling effectively increased exercise intensity in patients with COPD. Further studies should evaluate longer-term FES-cycling rehabilitation programs.

Cross-comparisons of trending accuracies of continuous cardiac-output measurements: pulse contour analysis, bioreactance, and pulmonary-artery catheter.

We compared the similarity of cardiac-output (CO) estimates between available bolus thermodilution pulmonary-artery catheters (PAC), arterial pulse-contour analysis (LiDCOplus™, FloTrac™ and PiCCOplus™), and bioreactance (NICOM™). Repetitive simultaneous estimates of CO obtained from the above devices were compared in 21 cardiac-surgery patients during the first 2 h post-surgery. Mean and absolute values for CO across the devices were compared by ANOVA, Bland-Altman, Pearson moment, and linear-regression analyses. Twenty-one simultaneous CO measurements were made before and after therapeutic interventions. Mean PAC CO (5.7 ± 1.5 L min) was similar to LiDCO™, FloTrac™, PiCCO™, and NICOM™ CO (6.0 ± 1.9, 5.9 ± 1.0, 5.7 ± 1.8, 5.3 ± 1.0 L min, respectively). Mean CO bias between each paired method was -0.10 (PAC-LiDCO), 0.18 (PAC-PiCCO), -0.40 (PAC-FloTrac), -0.71 (PAC-NICOM), 0.28 (LiDCO-PiCCO), 0.39 (LiDCO-FloTrac), -0.97 (NICOM-LiDCO), 0.61 (PiCCO-FloTrac), -1.0 (NICOM-FloTrac), -0.73 (NICOM-PiCCO) L/min, with limits of agreement (1.96 SD, ±95% CI) of ± 2.01, ±2.35, ±2.27, ±2.70, ±1.97, ±2.17, ±3.51, ±2.87, ±2.40, and ± 3.14 L min, respectively, and the percentage error for each of the paired devices was 35, 41, 40, 47, 33, 36, 59, 50, 42, and 55%, respectively. From Pearson moment analysis, dynamic changes in CO, estimated by each device, showed good cross-correlations. Although all devices studied recorded similar mean CO values, which dynamically changed in similar directions, they have markedly different bias and precision values relative to each other. Thus, results from prior studies that have used one device to estimate CO cannot be used to validate others devices.

Invasive and Noninvasive Evaluation for the Diagnosis of Pulmonary Hypertension: How to Use and How to Combine Them.

The etiologic diagnosis of pulmonary hypertension (PH) may be very challenging. Right-heart catheterization (RHC) in isolation cannot classify a precapillary PH patient into group 1, 3, 4, or 5. Moreover, RHC may be not sufficient for reaching a definitive differential diagnosis of precapillary or postcapillary PH if hemodynamic data are not integrated in clinical context and combined with information gleaned from noninvasive imaging. Therefore, only the integration of risk factors, clinical evaluation, invasive and noninvasive tests allows the physician to distinguish between different forms of PH.

Respiratory weakness after mechanical ventilation is associated with one-year mortality - a prospective study.

BACKGROUND: Diaphragm dysfunction in mechanically ventilated patients is associated with poor outcome. Maximal inspiratory pressure (MIP) can be used to evaluate inspiratory muscle function. However, it is unclear whether respiratory weakness is independently associated with long-term mortality. The aim of this study was to determine if low MIP is independently associated with one-year mortality. METHODS: We conducted a prospective observational cohort study in an 18-bed ICU. Adults requiring at least 24 hours of mechanical ventilation with scheduled extubation and no evidence of pre-existing muscle weakness underwent MIP evaluation just before extubation. Patients were divided into two groups: low MIP (MIP ≤30 cmH2O) and high MIP (MIP >30 cmH2O). Mortality was recorded for one year after extubation. For the survival analysis, the effect of low MIP was assessed using the log-rank test. The independent effect of low MIP on post mechanical ventilation mortality was analyzed using a multivariable Cox regression model. RESULTS: One hundred and twenty-four patients underwent MIP evaluation (median age 66 years (25(th)-75(th) percentile 56-74), Simplified Acute Physiology Score (SAPS) 2 = 45 (33-57), duration of mechanical ventilation 7 days (4-10)). Fifty-four percent of patients had low MIP. One-year mortality was 31 % (95 % CI 0.21, 0.43) in the low MIP group and 7 % (95 % CI 0.02, 0.16) in the high MIP group. After adjustment for SAPS 2 score, body mass index and duration of mechanical ventilation, low MIP was independently associated with one-year mortality (hazard ratio 4.41, 95 % CI 1.5, 12.9, p = 0.007). Extubation failure was also associated with low MIP (relative risk 3.0, 95 % CI 1, -9.6; p = 0.03) but tracheostomy and ICU length of stay were not. CONCLUSION: Low MIP is frequent in patients on mechanical ventilation and is an independent risk factor for long-term mortality in ICU patients requiring mechanical ventilation. MIP is easily evaluated at the patient's bedside. TRIAL REGISTRATION: This study was retrospectively registered in www.clinicaltrials.gov (NCT02363231) in February 2015.

Impact of tracheostomy tube modalities on ventilatory mechanics: a bench study.

PURPOSE: Tracheostomized patients often present with muscle weakness, altered consciousness, or swallowing difficulties. Hence, the literature is scarce regarding the challenging management of tracheostomy weaning. There is a need to strengthen the understanding of respiratory mechanisms with the different tracheostomy tube modalities that compose this weaning pathway. We aimed to evaluate the impact of these modalities on the work of breathing (WOB), total positive end-expiratory pressure (PEEPtot), and tidal volume (VT). METHODS: With a three-dimensional (3D) printed head mimicking human upper airways, we added a tracheal extension, and pierced to allow insertion of a size 7.0 tracheostomy cannula. The whole was connected to an artificial lung. Three lung mechanics were simulated (normal, obstructive and restrictive). We compared five different tracheostomy tube modalities to a control scenario in which the tube was capped and the cuff was deflated. RESULTS: A marginal difference was observed on the WOB within conditions with a slight increase + 0.004 [95% CI (0.003-0.004); p < 0.001] when the cuff was inflated in the normal and restrictive models and a slight decrease in the obstructive model. The highest PEEPtot that was reached was + 1 cmH2O [95% CI (1-1.1); p < 0.001] with high-flow therapy (HFT) with the cuff inflated in the obstructive model. We observed a statistically significant reduction in VT [up to - 57 mL 95% CI (- 60 to - 54); p < 0.001] when the cuff was inflated, in both the normal and obstructive models. CONCLUSIONS: Our results support the use of conditions that involve cuff deflation. Intermediate modalities with the cuff deflated produced similar results than cannula capping.

Riociguat real-world use in patients with chronic thromboembolic pulmonary hypertension: A retrospective, observational cohort study in France.

BACKGROUND: Riociguat is the first approved treatment for inoperable and persistent/recurrent post-surgery chronic thromboembolic pulmonary hypertension (CTEPH). The RetrospectIve Adempas® stuDy (RiAD) aimed to describe the real-world utilization of riociguat in France. METHODS: In this retrospective multicentric study in patients initiating riociguat, dosing regimen, co-treatments and clinical characteristics were collected over a 2-year follow-up period. RESULTS: A total of 173 patients (mean age, 71.4 years; female, 63.0%; NYHA II-III, 80.3%) were included from January 2015 to December 2016 in 18 centers. All patients were diagnosed with CTEPH (75.7% inoperable and 20.8% with persistent/recurrent pulmonary hypertension [pH] after surgery) with mean (SD) right atrial pressure 7.6 (4.2) mmHg, mean pulmonary artery pressure 43.0 (11.4) mmHg and mean cardiac output 4.1 (1.1) L/min. Before riociguat initiation, 32.4% of patients previously received at least one pH-specific therapy. At initiation, 93.1% of patients were receiving anticoagulants and 83.2% were not receiving pH-specific co-treatments. Riociguat was initiated at 1 mg three times daily (t.i.d.) in 85.5% of patients and 82.1% were receiving 2.5 mg dose t.i.d. at 24 months. The maximal daily dose of 7.5 mg was never exceeded. At 24 months, the estimated rate of patients still taking riociguat was 78.8% with an estimated mean (SD) time on treatment of 20.1 (0.5) months per patient. No new safety signals were recorded. CONCLUSIONS: The results of this real-world study show that riociguat is used in France in accordance with its therapeutic indication in patients with inoperable or persistent/recurrent post-operative CTEPH and confirm its long-term safety.

Enoxaparin versus Placebo to Prevent Symptomatic Venous Thromboembolism in Hospitalized Older Adult Medical Patients.

BACKGROUND: Admission to the hospital is a major risk factor for the development of venous thromboembolism (VTE). Whether thromboprophylaxis with low-molecular-weight heparin prevents symptomatic VTE in medically ill, hospitalized older adults remains debated. METHODS: In a prospective, randomized, placebo-controlled, double-blind, multicenter trial, older adults (>70 years of age) hospitalized for acute medical conditions were randomly assigned to receive 40 mg a day of low-molecular-weight heparin (enoxaparin) or placebo for 6 to 14 days. The primary efficacy outcome was the cumulative incidence of symptomatic VTE (distal or proximal deep vein thrombosis, fatal or nonfatal pulmonary embolism) at 30 days. The primary safety outcome was major bleeding. Secondary outcomes included efficacy and safety outcomes at 90 days. RESULTS: The trial was prematurely discontinued in September 2020, 5 years after enrollment began, because of drug supply issues. By the time of trial discontinuation, 2559 patients had been randomly assigned at 47 centers. Median age was 82 years and 60% of patients were female. In the intention-to-treat population, the primary efficacy outcome occurred in 22 out of 1278 (cumulative incidence, 1.8%) patients in the enoxaparin group and in 27 out of 1263 (cumulative incidence, 2.2%) patients in the placebo group (cumulative incidence difference, −0.4 percentage points; 95% confidence interval, −1.5 to 0.7), with no significant difference in time to VTE (P=0.46). The incidence of major bleeding was 0.9% in the enoxaparin group and 1.0% in the placebo group. At 90 days there were 14 symptomatic pulmonary emboli in the enoxaparin group and 25 in the placebo group; all 39 pulmonary embolism events resulted in hospital readmission and/or death, with 5 deaths from pulmonary embolism in the enoxaparin group and 11 deaths in the placebo group. CONCLUSIONS: This trial of thromboprophylaxis in medically ill, hospitalized older adults did not demonstrate that enoxaparin reduced the risk of symptomatic VTE after 1 month. Because the trial was prematurely discontinued, larger trials are needed to definitively address this question. (Funded by the French Ministry of Health Programme Hospitalier de Recherche Clinique, grant number PHRC-N-13-0283; ClinicalTrials.gov number, NCT02379806.)

Physiological relevance of quantifying segmental contraction synchrony.

BACKGROUND: Most current indices of synchrony quantify left ventricular (LV) contraction pattern in terms of a single, global (integrated) measure. We report the development and physiological relevance of a novel method to quantify LV segmental contraction synchrony. METHODS: LV pressure-volume and echocardiographic data were collected in seven anesthetized, opened-chest dogs under several pacing modes: right atrial (RA) (control), right ventricular (RV) (dyssynchrony), and additional LV pacing at either apex (CRTa) or free wall (CRTf). Cross-correlation-based integrated (CCSI(int) ) and segmental (CCSI(seg) ) measures of synchrony were calculated from speckle-tracking derived radial strain, along with a commonly used index (maximum time delay). LV contractility was quantified using either E(es) (ESPVR slope) or ESPVR(area) (defined in the manuscript). RESULTS: RV pacing decreased CCSI(int) at LV base (0.95 ± 0.02 [RA] vs 0.64 ± 0.14 [RV]; P < 0.05) and only CRTa improved it (0.93 ± 0.03; P < 0.05 vs RV). The CCSI(seg) analysis identified anteroseptal and septal segments as being responsible for the low CCSI(int) during RV pacing and inferior segment for poor resynchronization with CRTf. Changes in ESPVR(area) , and not in E(es) , indicated depressed LV contractility with RV pacing, an observation consistent with significantly decreased global LV performance (stroke work [SW]: 252 ± 23 [RA] vs 151 ± 24 [RV] mJ; P < 0.05). Only CRTa improved SW and contractility (SW: 240 ± 19 mJ; ESPVR(area) : 545 ± 175 mmHg•mL; both P < 0.01 vs RV). Only changes in CCSI(seg) and global LV contractility were strongly correlated (R(2) = 0.698, P = 0.005). CONCLUSION: CCSI(seg) provided insights into the changes in LV integrated contraction pattern and a better link to global LV contractility changes.