Skip to main content
Erschienen in: Journal of Medical Case Reports 1/2015

Open Access 01.12.2015 | Case report

The clinical benefit of cardiac resynchronization therapy optimization using a device-based hemodynamic sensor in a patient with dilated cardiomyopathy: a case report

verfasst von: Mario Volpicelli, Gregorio Covino, Paolo Capogrosso

Erschienen in: Journal of Medical Case Reports | Ausgabe 1/2015

download
DOWNLOAD
print
DRUCKEN
insite
SUCHEN

Abstract

Introduction

Results on the evolution of the clinical status of patients undergoing cardiac resynchronization therapy with a defibrillator after automatic optimization of their cardiac resynchronization therapy are scarce. We observed a rapid and important change in the clinical status of our non-responding patient following activation of a sensor capable of weekly atrioventricular and interventricular delays' optimization.

Case presentation

A 78-year-old Caucasian man presented with dilated cardiomyopathy, left bundle branch block, a left ventricular ejection fraction of 35 %, New York Heart Association class III/IV heart failure, and paroxysmal atrial fibrillation. Our patient was implanted with a cardiac resynchronization device with a defibrillator and the SonRtip atrial lead. Right ventricular and left ventricular leads were also implanted. Because of the recurrence of atrial fibrillation, the automatic optimization was set off at discharge. Consequently, the device did not optimize atrioventricular and interventricular delays (programming at discharge: 125 ms for the atrioventricular delay and 0 ms for the interventriculardelay). Our patient was treated with an anti-arrhythmic drug. Five months after implantation, his clinical status remained impaired (left ventricular ejection fraction = 30 %). The SonR signal amplitude had also decreased from 0.52 g to 0.29 g. Nevertheless, because our patient was no longer presenting with atrial fibrillation, the anti-arrhythmic treatment was stopped and the SonR optimization system was activated. After 2 months of automatic cardiac resynchronization therapy with defibrillator optimization, our patient’s clinical status had significantly improved (left ventricular ejection fraction = 60 %, New York Heart Association class II) and the SonR signal amplitude had doubled shortly after the first weekly automatic optimization.

Conclusion

In this non-responding patient, device-based automatic cardiac resynchronization therapy optimization was shown to significantly improve his clinical status.
Hinweise

Competing interests

MV and GC have received lecture honorary/travel support from Boston Scientific, Medtronic, St Jude Medical, and Sorin Group. PC has no competing interests to declare.

Authors’ contributions

GC and MV analyzed and interpreted the patient data. All authors read and approved the final manuscript.
Abkürzungen
AF
atrial fibrillation
AV
atrioventricular
CRT
cardiac resynchronization therapy
CRT-D
cardiac resynchronization therapy with a defibrillator
LV
left ventricular
LVEDV
left ventricular end diastolic volume
LVEF
left ventricular ejection fraction
LVESV
left ventricular end systolic volume
NYHA
New York Heart Association
VV
interventricular

Introduction

Cardiac resynchronization therapy (CRT) is an established therapy for patients with heart failure symptoms, left ventricular (LV) systolic dysfunction, and a wide QRS, on top of optimal medical therapy [1, 2]. However, the magnitude of clinical and hemodynamic benefit of CRT among recipients varies and non-responders can account for up to 30 % of treated patients [1]. The non-response can be partly caused by inappropriate settings of atrioventricular (AV) and interventricular (VV) delays leading to persistent AV, VV, and intraventricular dysynchrony. Several methods have been developed to optimize AV and VV delays, including device-based algorithms allowing automatic optimization of delays [3]. Encapsulated in the SonRtip atrial lead (Sorin CRM SAS, Clamart, France), the hemodynamic SonR sensor automatically optimizes AV and VV delays weekly in patients with heart failure in sinus rhythm, at rest, and during exercise [4].
The SonR sensor was clinically evaluated in the CLEAR multicenter, single-blind, randomized (1:1) pilot study (n = 199) using the SonR system integrated in a CRT device with a pacemaker. The primary effectiveness outcome was the response rate based on a hierarchical clinical composite score including (a) death, (b) heart failure-related hospitalization, (c) New-York Heart Association (NYHA) functional classification, and (d) quality of life using the EQ-5D questionnaire. Responders’ rate were 76 % in the SonR arm versus 62 % in the control arm (p = 0.03) at 1 year; this result was driven by improvement of symptoms [5]. A post-hoc analysis of the study showed that systematic optimization (n = 66, three times during one year, whether the method used SonR or echo) was associated with more responders as per the clinical composite score, fewer deaths or heart failure hospitalizations, and fewer symptoms versus non-systematic optimization (n = 133, 48 % of patients never optimized, 29 % optimized once, 23 % optimized twice), suggesting that favorable outcomes were associated with optimization frequency, not with the optimization method used [6]. A recent cost-effectiveness analysis found that this repeated optimization strategy was more cost-effective than the non-systematic optimization arm in most European countries [7]. Finally, Duncker at al. published a prospective, multicenter, non-randomized study designed to assess the safety and electrical performances of the atrial SonRtip lead in 99 patients implanted with a CRT device with a defibrillator (CRT-D) [8].
We describe a case report of a non-responding patient implanted with this atrial lead, who then responded to CRT after activation of the sensor.

Case presentation

A 78-year-old Caucasian man presented with dilated ischemic cardiomyopathy, left bundle branch block, a left ventricular ejection fraction (LVEF) of 35 %, NYHA III/IV heart failure, diabetes, paroxysmal atrial fibrillation (AF), dyspnea when undergoing mild exercise, and edema of his lower limbs.
In December 2012, our patient was implanted with a triple chamber CRT-D device (Paradym RF SonR CRT 9770, Sorin CRM SAS, Clamart, France) and the atrial lead positioned in the lateral wall (560 Ω, 4.5 mV, 0.50 V at 0.35 ms). The right ventricular lead was a single coil implanted in the septum (659 Ω, 15.2 mV, 0.75 V at 0.35 ms) and a bipolar LV lead was inserted through the posterior vein (955 Ω, 0.75 V at 0.35 ms). Because of a recurrence of AF, the automatic optimization was set off at discharge. Consequently, the device recorded the hemodynamic SonR signal, but did not optimize AV and VV delays. Nominal AV and VV delays were programmed at hospital discharge (125 ms for AV and 0 ms for VV). Our patient’s anti-arrhythmic treatment consisted of amiodarone, 200 mg daily. While his QRS width was 195 ms before implant; it decreased down to 120 ms just after implantation. Echocardiography also showed a left ventricular end diastolic volume (LVEDV) of 135 mL and left ventricular end systolic volume (LVESV) of 85 mL.
Five months after implant (in May 2013), our patient’s clinical status remained impaired, with a LVEF of 30 %, NYHA III/IV, QRS width of 96 ms, slight mitral regurgitation, LVEDV of 134 mL, and LVESV of 93 mL. The SonR signal amplitude had also decreased from 0.52 g to 0.29 g (Fig. 1). Nevertheless, because our patient no longer presented with AF (only one 6-day mode switch episode recorded shortly after implant), the anti-arrhythmic treatment was stopped and the SonR optimization system was activated.
After 2 months of automatic CRT-D optimization (7 months after implantation), our patient’s clinical status had significantly improved (LVEF of 60 %, NYHA II, no mitral regurgitation, optimal ventricular filing [E/A timing] with AV optimization, stable QRS width, LVEDV of 104 mL, and LVESV of 42 mL). His symptoms (dyspnea and lower limb edema) had disappeared at the 7-month post-implant visit. Optimized by the device, AV and VV delays at 85 ms and R+L 16 ms, respectively, were confirmed to be optimal both by echo and EA filling time. In addition, the SonR signal amplitude doubled shortly after the first weekly automatic optimization (Fig. 1).
The different echocardiographies of our patient were performed by the same operator.

Discussion

CRT optimization could not initially be performed in our patient because of paroxysmal AF. Once the AF ceased, weekly AV and VV delay optimizations were automatically activated using a hemodynamic device-based sensor. Symptoms and ventricular function (LVEF, mitral regurgitation, ventricular filing) were significantly improved after 2 months of CRT optimization.
Significant clinical improvements after AV and VV optimization have previously been reported in two studies evaluating device-based optimization algorithms [5, 9]. The multicenter, single-blind, randomized (1:1) CLEAR trial compared CRT-P optimized using SonR and CRT optimized according to the centers’ usual practices, mostly by echocardiography. One-year results showed an improvement of symptoms (NYHA functional class) in 83 % of patients versus in 64 % of patients treated with CRT alone (p = 0.002). The evolution of QRS duration, LVESD, and LVEF was similar in both arms from baseline to 1 year [5].
In a recent paper by Oliveira et al., 17 patients implanted with the SonRtip atrial lead and CRT-D device showed a significant increase in LVEF, with a 76.5 % rate of reverse remodeling, defined as an improvement of at least one NYHA functional class and a decrease >15 % of their LVESV at 6 months compared with baseline [10].
These pilot studies and preliminary results warrant an evaluation of the device in a controlled randomized trial. The double-blinded, multicenter, non-inferiority RESPOND- CRT trial will assess the clinical effectiveness and reverse remodeling of systematic automatic optimization versus a single echocardiographic optimization after implantation [11].
In this case report, QRS did not appear to be an index for CRT response, because it remained stable throughout the follow-up.

Conclusions

Device-based automatic AV and VV delay CRT optimization significantly improved symptoms and ventricular function in a non-responding patient after 2 months.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Acknowledgements

We thank Anne Rousseau-Plasse, PhD, and Frédérique Maneval, MSc, for editorial assistance, and Daniela Oliveira for her significant contribution in data collection and interpretation, on behalf of Sorin CRM SAS.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://​creativecommons.​org/​publicdomain/​zero/​1.​0/​) applies to the data made available in this article, unless otherwise stated.

Competing interests

MV and GC have received lecture honorary/travel support from Boston Scientific, Medtronic, St Jude Medical, and Sorin Group. PC has no competing interests to declare.

Authors’ contributions

GC and MV analyzed and interpreted the patient data. All authors read and approved the final manuscript.

Unsere Produktempfehlungen

e.Med Interdisziplinär

Kombi-Abonnement

Für Ihren Erfolg in Klinik und Praxis - Die beste Hilfe in Ihrem Arbeitsalltag

Mit e.Med Interdisziplinär erhalten Sie Zugang zu allen CME-Fortbildungen und Fachzeitschriften auf SpringerMedizin.de.

e.Med Allgemeinmedizin

Kombi-Abonnement

Mit e.Med Allgemeinmedizin erhalten Sie Zugang zu allen CME-Fortbildungen und Premium-Inhalten der allgemeinmedizinischen Zeitschriften, inklusive einer gedruckten Allgemeinmedizin-Zeitschrift Ihrer Wahl.

Literatur
1.
Zurück zum Zitat Abraham WT, Fisher WG, Smith AL, Delurgio DB, Leon AR, Loh E, et al. Cardiac resynchronization in chronic heart failure. N Engl J Med. 2002;346:1845–53.CrossRefPubMed Abraham WT, Fisher WG, Smith AL, Delurgio DB, Leon AR, Loh E, et al. Cardiac resynchronization in chronic heart failure. N Engl J Med. 2002;346:1845–53.CrossRefPubMed
2.
Zurück zum Zitat Young JB, Abraham WT, Smith AL, Leon AR, Lieberman R, Wilkoff B, et al. Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure: the MIRACLE ICD Trial. JAMA. 2003;289:2685–94.CrossRefPubMed Young JB, Abraham WT, Smith AL, Leon AR, Lieberman R, Wilkoff B, et al. Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure: the MIRACLE ICD Trial. JAMA. 2003;289:2685–94.CrossRefPubMed
3.
Zurück zum Zitat Houthuizen P, Bracke FA, van Gelder BM. Atrioventricular and interventricular delay optimization in cardiac resynchronization therapy: physiological principles and overview of available methods. Heart Fail Rev. 2011;16:263–76.CrossRefPubMed Houthuizen P, Bracke FA, van Gelder BM. Atrioventricular and interventricular delay optimization in cardiac resynchronization therapy: physiological principles and overview of available methods. Heart Fail Rev. 2011;16:263–76.CrossRefPubMed
4.
Zurück zum Zitat Sacchi S, Contardi D, Pieragnoli P, Ricciardi G, Giomi A, Padeletti L. Hemodynamic sensor in cardiac implantable electric devices: the endocardial accelaration technology. J Healthc Eng. 2013;4:453–64.CrossRefPubMed Sacchi S, Contardi D, Pieragnoli P, Ricciardi G, Giomi A, Padeletti L. Hemodynamic sensor in cardiac implantable electric devices: the endocardial accelaration technology. J Healthc Eng. 2013;4:453–64.CrossRefPubMed
5.
Zurück zum Zitat Ritter P, Delnoy PP, Padeletti L, Lunati M, Naegele H, Borri-Brunetto A, et al. A randomized pilot study of optimization of cardiac resynchronization therapy in sinus rhythm patients using a peak endocardial acceleration sensor versus standard methods. Europace. 2012;14:1324–33.CrossRefPubMed Ritter P, Delnoy PP, Padeletti L, Lunati M, Naegele H, Borri-Brunetto A, et al. A randomized pilot study of optimization of cardiac resynchronization therapy in sinus rhythm patients using a peak endocardial acceleration sensor versus standard methods. Europace. 2012;14:1324–33.CrossRefPubMed
6.
Zurück zum Zitat Delnoy PP, Ritter P, Naegele H, Orazi S, Szwed H, Zupan I, et al. Association between frequent cardiac resynchronization therapy optimization and long-term clinical response: a post hoc analysis of the Clinical Evaluation on Advanced Resynchronization (CLEAR) pilot study. Europace. 2013;15:1174–81.CrossRefPubMedPubMedCentral Delnoy PP, Ritter P, Naegele H, Orazi S, Szwed H, Zupan I, et al. Association between frequent cardiac resynchronization therapy optimization and long-term clinical response: a post hoc analysis of the Clinical Evaluation on Advanced Resynchronization (CLEAR) pilot study. Europace. 2013;15:1174–81.CrossRefPubMedPubMedCentral
7.
Zurück zum Zitat Banz K, Delnoy PP, Billuart JR. Exploratory cost-effectiveness analysis of cardiac resynchronization therapy with systematic device optimization versus standard (non-systematic) optimization: a multinational economic evaluation. Health. Econ Rev. 2015;5:57. Banz K, Delnoy PP, Billuart JR. Exploratory cost-effectiveness analysis of cardiac resynchronization therapy with systematic device optimization versus standard (non-systematic) optimization: a multinational economic evaluation. Health. Econ Rev. 2015;5:57.
8.
Zurück zum Zitat Duncker D, Delnoy PP, Nagele H, Mansourati J, Mont L, Anselme F, Stengel P, Anselmi F, Oswald H, Leclercq C. 2015. First clinical evaluation of an atrial haemodynamic sensor lead for automatic optimization of cardiac resynchronization therapy. Europace. Epub ahead of print. http://dx.doi.org/10.1093/europace/euv114 Duncker D, Delnoy PP, Nagele H, Mansourati J, Mont L, Anselme F, Stengel P, Anselmi F, Oswald H, Leclercq C. 2015. First clinical evaluation of an atrial haemodynamic sensor lead for automatic optimization of cardiac resynchronization therapy. Europace. Epub ahead of print. http://​dx.​doi.​org/​10.​1093/​europace/​euv114
9.
Zurück zum Zitat Singh JP, Abraham WT, Chung ES, Rogers T, Sambelashvili A, Coles Jr JA, et al. Clinical response with adaptive CRT algorithm compared with CRT with echocardiography-optimized atrioventricular delay: a retrospective analysis of multicentre trials. Europace. 2013;15:1622–8.CrossRefPubMed Singh JP, Abraham WT, Chung ES, Rogers T, Sambelashvili A, Coles Jr JA, et al. Clinical response with adaptive CRT algorithm compared with CRT with echocardiography-optimized atrioventricular delay: a retrospective analysis of multicentre trials. Europace. 2013;15:1622–8.CrossRefPubMed
10.
Zurück zum Zitat Oliveira MM, Branco LM, Galrinho A, da Silva N, Cunha PS, Valente B, et al. Hemodynamic device-based optimization in cardiac resynchronization therapy: concordance with systematic echocardiographic assessment of AV and VV intervals. Res Rep Clin Cardiol. 2015;6:97–103.CrossRef Oliveira MM, Branco LM, Galrinho A, da Silva N, Cunha PS, Valente B, et al. Hemodynamic device-based optimization in cardiac resynchronization therapy: concordance with systematic echocardiographic assessment of AV and VV intervals. Res Rep Clin Cardiol. 2015;6:97–103.CrossRef
11.
Zurück zum Zitat Brugada J, Brachmann J, Delnoy PP, Padeletti L, Reynolds D, Ritter P, et al. Automatic optimization of cardiac resynchronization therapy using SonR-rationale and design of the clinical trial of the SonRtip lead and automatic AV-VV optimization algorithm in the paradym RF SonR CRT-D (RESPOND CRT) trial. Am Heart J. 2014;167:429–36.CrossRefPubMed Brugada J, Brachmann J, Delnoy PP, Padeletti L, Reynolds D, Ritter P, et al. Automatic optimization of cardiac resynchronization therapy using SonR-rationale and design of the clinical trial of the SonRtip lead and automatic AV-VV optimization algorithm in the paradym RF SonR CRT-D (RESPOND CRT) trial. Am Heart J. 2014;167:429–36.CrossRefPubMed
Metadaten
Titel
The clinical benefit of cardiac resynchronization therapy optimization using a device-based hemodynamic sensor in a patient with dilated cardiomyopathy: a case report
verfasst von
Mario Volpicelli
Gregorio Covino
Paolo Capogrosso
Publikationsdatum
01.12.2015
Verlag
BioMed Central
Erschienen in
Journal of Medical Case Reports / Ausgabe 1/2015
Elektronische ISSN: 1752-1947
DOI
https://doi.org/10.1186/s13256-015-0761-y

Weitere Artikel der Ausgabe 1/2015

Journal of Medical Case Reports 1/2015 Zur Ausgabe