Acute hemodynamic benefit of multisite ventricular pacing after congenital heart surgery

doi:10.1016/S0003-4975(03)00175-9

The Annals of Thoracic Surgery

Volume 75, Issue 6, June 2003, Pages 1775-1780

https://doi.org/10.1016/S0003-4975(03)00175-9 Get rights and content

Abstract

Background

Cardiac dysfunction after congenital heart surgery is a major cause of morbidity and mortality. Cardiac resynchronization through multisite ventricular pacing (MSVP) improves cardiac index and ventricular function, and lowers systemic vascular resistance (SVR) in adults with heart failure and interventricular conduction delay.

Methods

The acute hemodynamic effects of MSVP after congenital heart surgery were assessed. Twenty-nine patients (aged 1 week to 17 years) with prolonged QRS interval had atrial and ventricular unipolar epicardial temporary pacing leads placed at surgery. Group 1 consisted of patients with a single ventricle (n = 14); group 2 included patients with two-ventricle anatomy (tetralogy of Fallot, ventricular septal defect) undergoing ventricular surgery (n = 10); and group 3 included patients with two-ventricle anatomy undergoing other cardiac surgery (n = 5). At a mean postoperative day 1 (range, 0 to 6), blood pressure, systemic and mixed venous oxygen saturations, electrocardiograms, and echocardiograms were obtained before and after 20 minutes of MSVP.

Results

The QRS duration decreased with MSVP in all patients (mean, 23%, p < 0.005). Systolic blood pressure improved in all patients (mean, 9.7%, p < 0.005). Cardiac index improved in 19 of 21 patients tested, with no change in 2 patients (mean, 15.1%, p = 0.0001). In 2 patients, MSVP facilitated weaning from cardiopulmonary bypass. Echocardiographic mitral or tricuspid valve inflow was not significantly different with MSVP.

Conclusions

Multisite ventricular pacing results in improved cardiac index and increased systolic blood pressure, and it can also facilitate weaning from cardiopulmonary bypass. Multisite ventricular pacing may be used as adjunct to standard postoperative treatment of cardiac dysfunction after congenital heart surgery.

Section snippets

Material and methods

The study was performed at the University of Chicago Children’s Hospital and was approved by the Institutional Review Board. Informed consent was obtained and all procedures were conducted in accordance with institutional guidelines. All patients undergoing surgery for congenital heart disease were screened for this study. We chose to perform this study in the postoperative period to assess the effects of pacing at a time when cardiac dysfunction is most pronounced. Patients were included if

Qrs complex

The QRS duration was prolonged for age in all patients before MSVP (RBBB in 11, left bundle branch block [LBBB] in 4, interventricular conduction delay in 14). Multisite ventricular capture was achieved in all patients. The mean QRS duration before pacing was 106.5 ± 22 msec and during pacing decreased in all patients to a mean of 80 ± 18 msec (23% decrease, p < 0.005; Fig 1). An example of the baseline QRS with RBBB and the QRS morphology with MSVP in a patient after surgery for tetralogy of

Comment

The major findings of this study are that MSVP in patients with bundle branch block or interventricular conduction delay results in improved CI and systolic blood pressure in the postoperative period after surgery for congenital heart disease. This improvement is associated with a decrease in the QRS duration with MSVP. The degree of hemodynamic improvement was not related to anatomic diagnosis, cardiopulmonary bypass time, cross-clamp time, baseline CI, QRS duration, or age, although the

References (17)

H.J Shenkman et al.
Congestive heart failure and QRS durationestablishing prognosis study
Chest
(2002)
J.G Rein et al.
Early and late results of closure of ventricular septal defect in infancy
Ann Thorac Surg
(1977)
W.F Kerwin et al.
Ventricular contraction abnormalities in dilated cardiomyopathyeffect of biventricular pacing to correct interventricular dyssynchrony
J Am Coll Cardiol
(2000)
C Le Rest et al.
Use of left ventricular pacing in heart failureevaluation by gated blood pool imaging
J Nucl Med
(1999)
J Janousek et al.
Resynchronization pacing is a useful adjunct to the management of acute heart failure after surgery for congenital heart defects
Am J Cardiol
(2001)
W.T Abraham et al.
MIRACLE Study Group. Multicenter InSync Randomized Clinical Evaluation. Cardiac resynchronization in chronic heart failure
N Engl J Med
(2002)
S Cazeau et al.
Multisite Stimulation in Cardiomyopathies (MUSTIC) Study Investigators. Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay
N Engl J Med
(2001)
B.G Barratt-Boyes et al.
Repair of ventricular septal defect in the first two years of life using profound hypothermia-circulatory arrest techniques
Ann Surg
(1976)

There are more references available in the full text version of this article.

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Permanent pacemakers have been associated with Fontan-related morbidity and mortality. Longer QRS duration and QRS prolongation over time may be associated with poorer outcomes in Fontans patients. We present a series of eleven Fontan patients with ventricular pacing on serial electrocardiograms (ECGs), including seven with Fontan-related morbidity. Paced QRS duration increased over time in nearly all patients, with several having extremely long QRS durations at the end of the follow-up period. We explore the role that paced QRS duration may play in Fontan-related morbidity and mortality and its potential as a therapeutic target for patient management.
Classic-Pattern Dyssynchrony Is Associated with Outcome in Patients with Fontan Circulation
2022, Journal of the American Society of Echocardiography
Morbidity and mortality increase as Fontan patients age into adulthood. Limited studies have examined cardiac magnetic resonance and echocardiographic parameters to predict death and transplantation in children after the Fontan operation. The aim of this study was to investigate echocardiographic parameters in adolescents and adults after Fontan operation, including myocardial mechanics such as classic-pattern dyssynchrony (CPD), as predictors of transplantation or death.
In a cross-sectional retrospective study, strain analysis was performed on echocardiographic studies performed between 2001 and 2015 on 110 patients with single-ventricle physiology after the Fontan procedure. Strain curves were measured and visually assessed for the presence of CPD. The primary end point was death or transplantation after a follow-up period of 85 ± 35 months after echocardiography.
The median age at the date of echocardiography was 20 years (range, 3-45 years). Of 110 patients, 28 had undergone transplantation. During the study period, three patients died after transplantation and seven patients died without undergoing transplantation. CPD was seen in 16 and protein-losing enteropathy in 21 of 110 patients. On multivariate analysis, CPD (hazard ratio [HR], 9.4; 95% confidence interval [CI], 2.6-34.6), protein-losing enteropathy (HR, 10.6; 95% CI, 3.4-33.2), systolic blood pressure (HR, 0.954; 95% CI, 0.913-0.996), systolic/diastolic duration ratio (HR, 6.83; 95% CI, 1.33-35.0), and E-wave deceleration time (HR, 0.98; 95% CI, 0.97-0.99) were independently associated with the primary end point.
CPD, protein-losing enteropathy, and systolic and diastolic ventricular dysfunction are significantly associated with transplantation or death in Fontan-operated patients. In selected patients, the presence of CPD may be a basis to investigate cardiac resynchronization therapy as a treatment strategy.
Pacemakers are associated with a higher risk of late death and transplantation in the Fontan population
2019, International Journal of Cardiology
The need for permanent pacing has been identified as a predictor of poor outcomes in the late survivors of Fontan surgery. However, it is not clear if the need for a pacemaker is a surrogate marker of a declining Fontan state, or if pacing is deleterious to the Fontan circulation.
We sought to compare the long-term outcomes of propensity-matched Fontan patients with and without a permanent pacemaker.
Patients who have survived Fontan completion with a documented history of cardiac arrhythmia were identified from the Australia and New Zealand Fontan Registry. Pacemaker insertion details, cardiac function and electrophysiological data were obtained for the patients with a permanent pacemaker. Survival analysis was performed with propensity score matching to compare late survival and outcomes in patients with versus without a pacemaker.
There was a total of 310 patients with a history of cardiac arrhythmia, of which 126 (41%) had a permanent pacemaker. After propensity-score matching, 99 pairs were generated (n = 198). Patients with a permanent pacemaker had a higher risk of death (HR 3.32 95% CI 1.60–6.90, p = 0.001) and death or transplantation (HR 3.55 95% CI 1.87–6.73, p < 0.001). Patients who were only paced atrially were not at a significantly increased risk of death or transplantation. However, patients who were ventricular paced >50% of the time were much more likely to encounter late death or transplantation (HR 3.82 95% CI 1.64–8.95, p = 0.002).
Having a permanent pacemaker and needing ventricular pacing is likely associated with an increased risk of death and transplantation in patients with a Fontan circulation.
Cardiac resynchronization therapy in congenital heart disease: Results from the German National Register for Congenital Heart Defects
2018, International Journal of Cardiology
Citation Excerpt :
It has been suggested that a considerable proportion of CHD patients may also fulfil conventional criteria for CRT and be therefore considered potential candidates, albeit without specific data from prospective randomized trials in this population to support this approach [15]. While various case reports, small series and retrospective analysis based on single or selected specialized tertiary multicentre data have been published [16–22], the uptake and indications for this CRT for CHD in the real world remains unclear. Based on a nationwide dataset from the German National Register for Congenital Heart Defects (NR-CHD) we aimed to describe use of CRT in CHD, clarify indications and temporal trends for the use of this device therapy in the community.
Cardiac resynchronization therapy (CRT) is an established option for patients with heart failure. Limited data exists on indications and outcome of CRT in contemporary congenital heart disease (CHD) patients.
All patients with CRT registered in the German National Register for Congenital Heart Defects were systematically identified. We analysed data on demographics, type of congenital defect as well as repair, associated conditions, indication for CRT, heart failure medication, combination with a defibrillator or pacemaker and outcome. Overall, 65 patients with CRT were identified. The most common congenital diagnoses were Tetralogy of Fallot (n = 11), congenitally corrected transposition of the great arteries (ccTGA) (n = 9) and double outlet right ventricle (n = 6). The majority of patients (n = 48, 87%) had conventional antibradycardia pacing or ICD indications. Of these, the majority (n = 44) underwent an upgrade to a CRT system to avoid the detrimental consequences of longstanding conventional ventricular single-site pacing, whereas four patients required an ICD due to heart failure and a history of malignant ventricular tachycardia. During a median follow-up of 6.9 years 19 patients developed complications: 16 patients experienced pacemaker lead dysfunction and 3 patients pacemaker infection.
The current study based on a large national register for CHD shows that CRT is feasible and can be used as an adjunct in the heart failure treatment of selected CHD patients. Uptake of this therapy proved to be low in this nationwide study and CRT implantation was largely used in patients with a pre-existing pacing indication or those requiring an ICD.

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Original article: cardiovascularAcute hemodynamic benefit of multisite ventricular pacing after congenital heart surgery

Abstract

Background

Methods

Results

Conclusions

Section snippets

Material and methods

Qrs complex

Comment

Chest

Ann Thorac Surg

J Am Coll Cardiol

J Nucl Med

Am J Cardiol

MIRACLE Study Group. Multicenter InSync Randomized Clinical Evaluation. Cardiac resynchronization in chronic heart failure

N Engl J Med

Multisite Stimulation in Cardiomyopathies (MUSTIC) Study Investigators. Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay

N Engl J Med

Repair of ventricular septal defect in the first two years of life using profound hypothermia-circulatory arrest techniques

Ann Surg

Original article: cardiovascular
Acute hemodynamic benefit of multisite ventricular pacing after congenital heart surgery