[Left ventricular pacing and CRT. What CV lead fits into which vein?]. / Linksventrikuläre Stimulation und CRT -- Welche Elektrode passt zu welcher Vene?

The experience of 579 patients with left ventricular pacing specific characteristics of various leads and lead types for left ventricular stimulation are reported. After describing the advantages of coronary vein (CV) leads versus epicardial lead usage for left ventricular stimulation, commercially available CV leads are introduced and discussed. Since there is no universally applicable CV lead, the individual optimal lead choice and the sequelae of erroneous lead choice are described in typical clinical examples.

[Acute hemodynamic effects]. / Akute hämodynamische Effekte.

Several studies on the acute effect of cardiac resynchronization in patients with advanced heart failure (HF) and left bundle branch block (LBBB) have shown that left and biventricular stimulation increase pulse pressure and contractility, while patients with a QRS complex <150 ms may deteriorate during stimulation. Patients with LBBB, severe HF and a QRS width >150 ms underwent right, left and biventricular stimulation at different AV delays. Acute response was defined as > or =10% pulse pressure increase. 165 of 188 patients (88%) in sinus rhythm (47 women, mean age 62.5+/-10 years, ejection fraction 23+/-8%, NYHA class 3.1+/-0.3) were regarded acute responders. 10% of 103 patients with dilated cardiomyopathy and 16.5% of 79 patients with coronary artery disease were considered non-responders. 29 patients (81%) with 2 posterolateral veins were acute responders with 10 of them (33%) being responders in only one vein. 54 patients had a higher pulse pressure increase (10.7+/-10.6%) with atrio-left ventricular stimulation, 48 patients with atrio-biventricular stimulation (9.8+/-6.4%). At one-year follow-up, heart failure had significantly (p<0.0001) improved from NYHA class 3.1+/-0.4 to 2.1+/-0.7, VO(2)peak from 12.7+/-2.8 to 15.9+/-3.6 ml/min/kg. Left ventricular enddiastolic diameter being an indicator of reverse remodeling decreased from 80.5+/-10.5 to 73.3+/-13 (p<0.0001). Hemodynamic testing before CRT allows for the identification of acute non-responders as well as the best mode and site of stimulation and the optimal atrioventricular delay in responders.

Epicardial and nonthoracotomy defibrillation lead systems combined with a cardioverter defibrillator.

The intraoperative and long-term results were reviewed in 67 patients who underwent implantation of the Ventritex Cadence defibrillator with either epicardial patch (EPI, 25 patients) or nonthoracotomy CPI Endotak (ENDO, 42 patients) defibrillation lead systems. In the ENDO group, 35 patients (83%) had a defibrillation threshold (DFT) of < or = 20 joules and did not require a subcutaneous patch. Intraoperatively, the DFT was 13 +/- 9 joules (mean +/- SD) for EPI and 15 +/- 8 joules for ENDO (P = NS). There was no perioperative death in either group. During a mean follow-up of 12 +/- 8 months, there was no sudden death, and four patients died from congestive heart failure (3 EPI, 1 ENDO). During follow-up, 875 spontaneous arrhythmia episodes (AE) occurred in 15 of 25 EPI patients (60%), versus 652 in 28 of 42 ENDO patients (67%; P = NS). Ventricular tachycardia at a rate > or = 222 beats/min or ventricular fibrillation represented 167 AE for EPI (19%) and 182 AE for ENDO (28%), and was terminated by the first shock in 76% and 75% of attempts, respectively. Ventricular tachycardia at a rate < 222 beats/min represented a total of 1,178 AE and antitachycardia pacing was successful in 660 of 708 AE (93%) with EPI and 414 of 470 AE (88%) with ENDO lead systems (P = NS). Therefore, a nonthoracotomy approach using the Cadence V-100 is safe and effective and has clinical results that are not significantly different from epicardial defibrillation lead systems.

[The role of anti-tachycardia stimulation in patients with 3rd-generation defibrillators]. / Die Bedeutung der antitachykarden Stimulation bei Patienten mit Defibrillatoren der 3. Generation.

The most effective antitachycardia pacing mode (ATP) is still a matter of debate. Randomized prospective testing of 5 different ATP modes was performed in 82 patients (pts) prior to and after cardioverter defibrillator (ICD) implantation. The 5 ATP modes included 3-4 stimulation attempts with 4-10 adaptive scanning burst pulses. Adaptive burst coupling interval was 75% in mode A, 81% in mode B, 69% in mode C, 72% in mode D, and 88% in mode E. Auto-decremental scanning within bursts was 8 ms in modi A, B, and C, and 10 ms in modus E; autodecremental scanning between bursts was 8 ms in modi B and C, and 10 ms in modus D. During the pre-op electrophysiologic study (EP), termination (TR) of induced ventricular tachycardia (VT) was possible in 69% and by pre-discharge EP in 53%. Acceleration (AC) rates were 16% pre-op and 32% post-op (p = ns). There were no significant differences in TR or AC between modes A-E. During a mean follow-up of 18 +/- 4 (< 1-41) months, 3182 arrhythmia episodes (AE) occurred: 344 AE (11%) were terminated by primary ICD shocks and ATP was attempted in 2838 AE (89%) and was successful in 2576 AE (91%). AC occurred in 87 AE (3%) and ATP was without effect in 175 AE (6%). Our data show that ATP is helpful in patients with third-generation ICDs and is very effective during follow-up. However, there is no ideal ATP-mode visible in the present study.

[Analysis of inter- and intraventricular asynchrony by tissue Doppler echocardiography]. / Analyse der inter- und intraventrikulären Asynchronie mittels Fluss- und Gewebe-DopplerechokardiographieWas bedeutet kardiale Asynchronie?

BACKGROUND AND INTRODUCTION: Cardiac resynchronization therapy (CRT) is a promising non-pharmacological treatment option for patients (pts) with severe severe heart failure (CHF), systolic left ventricular (LV) dysfunction, and ventricular conduction abnormalities (VCA). Pt selection for CRT, however, is still controversial. Tissue Doppler echocardiography (TDE) can be used to analyze regional wall motion with high temporal resolution. PATIENTS AND METHODS: In 33 CHF pts with VCA (QRS width > or =140 ms) and 20 normal probands, left and right ventricular (RV) filling and emptying were analyzed by flow and tissue Doppler to assess regional (anterior, lateral, inferior, and septal) asynchrony within the LV as well as asynchrony between the RVand LV. All time measurements were corrected for a heart rate of 60 bpm. Results Maximum interventricular and segmental intraventricular delay was 30 ms in the normals. LV asynchrony, defined as a regional delay of > or =40 ms, was found in 29/33 (88%) of the CHF pts, in 4 cases there was synchronous LV contraction despite VCA. In the pts with LV asynchrony, 22 (67%) showed the maximum delay in the lateral wall, 7 (21%) in the septum. Inter- and intra-ventricular asynchrony correlated weakly. CONCLUSIONS: In many CHF pts with VCA, there is a delay both between the two ventricles, and among different LV regions. Predominantly but not exclusively, the LV lateral wall shows the maximum intra-LV delay. Some CHF pts, however, seem to have a synchronous LV contraction despite VCA. TDE thus adds important information for pt selection with respect to CRT.

Implantation and follow-up of a third-generation cardioverter defibrillator: comparison of epicardial and nonthoracotomy defibrillation lead system.

OBJECTIVE: The intraoperative and follow-up results were compared in 67 patients with ventricular tachyarrhythmias who underwent implantation of the Ventritex Cadence defibrillator with either epicardial patch (EPI, 25 patients) or nonthoracotomy CPI Endotak (ENDO, 42 patients) defibrillation lead systems. RESULTS: There was no significant difference between groups in age, sex, structural heart disease, ejection fraction, arrhythmia history, or drug therapy. Successful implantation was accomplished in all patients using either lead system. In the ENDO group, 35 patients (83%) had a defibrillation threshold < or = 550 V and did not require a subcutaneous patch. Intraoperatively, the defibrillation threshold was 453 +/- 139 V (13 +/- 9 J) for EPI and 490 +/- 113 V (15 +/- 8 J) for ENDO (P = NS). There were no perioperative deaths in either group. At predischarge testing, the defibrillation threshold was 445 +/- 183 V (14 +/- 12 J) for EPI and 439 +/- 133 V (13 +/- 7 J) for ENDO (P = NS). During a mean follow-up of 16 +/- 8 months, there were no sudden deaths, and four patients died from congestive heart failure (3 EPI, 1 ENDO). During follow-up, 916 spontaneous arrhythmia episodes occurred in 16 of 25 EPI patients (64%) and 967 episodes occurred in 31 of 42 ENDO patients (74%) (P = NS). The number of episodes detected as ventricular fibrillation were 192 for EPI (21%) and 232 for ENDO (24%), with first shock success in 76% and 75%, respectively; all episodes were successfully terminated by the device. In the remaining episodes detected as ventricular tachycardia, antitachycardia pacing was attempted and was successful in 672 of 724 episodes (93%) with EPI and 666 of 735 episodes (91%) with ENDO lead systems (P = NS). Acceleration of ventricular tachycardia with antitachycardia pacing occurred in 21 episodes (3%) with EPI and in 37 episodes (5%) with ENDO leads (P = NS). CONCLUSIONS: A nonthoracotomy approach using the third generation cardioverter defibrillator Cadence V-100 is safe and effective and has clinical results that are not significantly different from epicardial defibrillation lead systems.

Cardioverter-defibrillator implantation in the catheterization laboratory: initial experiences in 48 patients.

The exponential increase in cardioverter-defibrillator implantations has resulted in a need for safe implantations that do not require long waiting periods. We report intraoperative and follow-up results in 48 patients with ventricular tachyarrhythmias who underwent cardioverter-defibrillator implantation in the catheterization laboratory. Twenty-six (54%) patients had their first cardioverter-defibrillator implant (group 1), and 22 (46%) patients underwent pulse-generator replacement (group 2). In all patients, cardioverter-defibrillator implant or pulse-generator replacement was performed with the patient under general anesthesia. In 25 (96%) of 26 patients in group 1, cardioverter-defibrillator implantation was possible with a mean defibrillation threshold of 13 +/- 8 J. One patient had a defibrillation threshold of > 25 J, and therefore cardioverter-defibrillator implant was not achieved. This patient underwent epicardial device implantation 1 day later. Another patient in group 1 had vessel rupture (vena subclavia) intraoperatively. During a mean follow-up of 2 +/- 1 months, two patients died from congestive heart failure 2 and 4 months after device implantation. An infection occurred in one patient in group 2, 3 months after generator replacement. In conclusion, these data show that in the majority of patients cardioverter-defibrillator implantation in the catheterization laboratory is safe and has a low complication rate and therefore can generally be recommended.

[Cardioverter-defibrillator implantation in the heart catheterization laboratory--observations with 105 patients]. / Kardioverter-Defibrillator-Implantation im Herzkatheterlabor--Beobachtungen bei 105 Patienten.

Today, we are facing an exponential increase in implantation of cardioverter defibrillators (ICD). The intraoperative and follow-up results are reported in 105 patients (pts) with ventricular tachyarrythmias who underwent ICD implantation in the catheterization laboratory. Fifty-seven pts (54%) hat their first ICD implant (G 1), whereas 46 pts (44%) underwent pulse generator replacement or electrode revision (2 pts, 2%) (G 2). In all pts, ICD implant or pulse generator replacement was performed under general anesthesia from the beginning. In 57/58 pts (98%) in G 1, ICD implantation was possible with a mean defibrillation threshold (DFT) of 13 +/- 8 joules. One patient hat a DFT of > 25 joules and ICD implantation was not achieved. This patient underwent epicardial lead implantation 1 day later. One patient in G 1 had a vessel rupture (v. subclavia) intraoperatively. During a mean follow-up of 5 +/- 2 (< 1-13) months, three pts (3%) died from congestive heart failure, 2, 4 and 6 months after device implantation. An infection occurred in 1 patient in G 2, 3 months after generator replacement. Our data show that in the majority of patients ICD implantation in the cath-lab is possible, safe, and the complication rate is low. Therefore, ICD implantation in the cath-lab can generally be recommended.