Intraoperative Biventricular Pacing. Applications, Techniques, Early Results. Vincent A. Gaudiani, MD Luis J. Castro, MD Audrey L. Fisher, MPH. Published in The Heart Surgery Forum, Volume 6, Issue 6, 2003. Traditional Pacing - What Is It? . Traditional Pacing
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Applications, Techniques, Early Results
Vincent A. Gaudiani, MD
Luis J. Castro, MD
Audrey L. Fisher, MPH
Published in The Heart Surgery Forum, Volume 6, Issue 6, 2003.
What are the common clinical examples of suboptimal ventricular synchronization?
Which patient groups are most likely to suffer reduced cardiac output when poorly synchronized?
Patients with a combination of:
What are the clinical consequences of ventricular dyssynchrony?
ECG depicting cardiac resynchronization
ECG depicting IVCD
Cardiac Resynchronization System
Nelson et al. Circulation 2000;102:3053-3059.
Sinus Rhythm Group; N=12
1,255 ± 1,535
3,394 ± 2,970
1 ± 3
76 ± 147
Ventricular Arrhythmia Duration (min)
17 ± 20
87 ± 142
Walker, et al. Am J Cardiol 2000;86:231-3.
Data from these trials document symptomatic improvement and increased exercise capacity in patients who have moderate to severe heart failure and ventricular dysynchrony when treated with cardiac resynchronization therapy.
NYHA Functional Class
Quality of Life
6-Minute Hall Walk
+ Results consistent with MUSTIC trial results
* Cazeau S, Leclercq C, Lavergne T, et al. N Engl J Med. 2001; 344:873-880.** Abraham WT, et al. ACC/NASPE 2001 Scientific Sessions. Results not yet published.
One-year survival free composite time to death or first hospitalization for CHF
Ventricular Backup Pacing
1-yr free of death or
1-yr free of death or
*p < 0.03
“Dual-chamber pacing offers no clinical advantage over ventricular backup pacing and may be detrimental by increasing… death or hospitalization for CHF,” for patients with standard indications for ICD therapy, EF<40%, and no indication for bradycardic pacing.
1600 patients with active CHF and QRS > 120 ms with maximal medical therapy
Combined All-Cause Mortality and All-Cause Hospitalization
Medical Therapy Only
in Mortality +/-
Biventricular Pacer Only
Biventricular Pacer + ICD
How can biventricular pacing help cardiac surgery patients?
You have now created TWO unipolar pacing dipoles that will activate
the RV + LV simultaneously
The following groups may benefit from a posterolateral LV epicardial electrode placed at the time of cardiac operation:
Sew a steroid eluting epicardial pacing wire posterolaterally on all those with large LVIDd and low EF:
Where is the optimal location for the LV wire?
Mean Age (yrs) 75
NYHA 3+ 80%
Previous MI 40%
Previous Cardiac Surgery 32%
Renal Failure 20%
Cerebrovascular Disease 20%
Peripheral Vascular Disease 20%
Average # Cardiac Procedures 2.2
AVR/Ao Root Recon 48%
LV Remodel 8%
Ascending Ao Recon 8%
Only 1 patient required IABP
Not Paced Preop
(QRS<120 ms & LVIDd<5.7 cm)
If we are to improve our knowledge of who will benefit from permanent LV electrodes, we must