Effekt der biventrikulären und rechtsventrikulären Stimulation bei Patienten mit Left Ventricular Assist Device
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Philipps-Universität Marburg
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Abstract
Heart transplantation remains the gold standard in the treatment of terminal heart
failure. But there is still a shortage of available donor organs wherefore mechanical
cardiovascular assist devices became more important in recent years. Left Ventricular
Assist Devices (LVADs) have been chosen more frequently for patients with
end staged heart failure, who may live with the device for over years (destination therapy).
As part of heart failure therapy, some patients may be candidate for Cardiac Resynchronisation
Therapy (CRT) prior to LVAD implantation. However, LVAD implantation
dramatically alters the anatomy and physiology of the heart. Regarding
this situation, there is no consensus on the use of pacing systems and the optimal
mode of cardiac pacing.
Thus, this controlled, prospective, and randomized study was designed to evaluate
biventricular versus right ventricular pacing for every suitable patient receiving an
LVAD in the department of cardiac surgery at the Campus Bad Neustadt a.d. Saale
from September 7, 2018, until July 15, 2020. Additionally, in patients with sinus
rhythm, right ventricular pacing alone was to be compared with intrinsic rhythm.
In the sense of a pilot study, close attention should be paid to descriptive statistics
in order to able to follow up on possible trends.
For this purpose, data was collected intraoperatively, six and 24 hours postoperatively.
This data was analyzed in all patients (n =37) and in groups divided by QRS
complex width (< 130 ms, n = 18, vs ≥ 130 ms, n = 16) and by the presence of sinus
rhythm (yes, n = 22, vs. no, n = 16). In addition, data collection was performed in
patients with sinus rhythm during intrinsic rhythm and during right ventricular pacing
alone (n = 15).
The parameters evaluated before and after every pacing course were cardiac output
(CO in L/min), mean peripheral blood pressure (RR in mmHg), central venous oxygen
saturation (SVO2 in %), and echocardiographically determined right ventricular
function (RV function).
Comparison between sinus rhythm during intrinsic rhythm with right ventricular
pacing alone showed that all hemodynamic parameters worsened during intraoperative
right ventricular pacing alone, CO even decreased significantly
(p = 0,041), and there were also cardio-vascular related terminations of the pacing
course.
The examination of biventricular versus right ventricular pacing in the overall collective
revealed neither any trends nor significant differences intraoperatively and
early postoperatively. However, 24 hours postoperatively, the group analysis
showed a significant decrease in SVO2 under biventricular pacing. This significant
deterioration of SVO2 occurred in patients with a QRS complex width ≥ 130 ms (p
= 0,019) and in patients without sinus rhythm (p = 0,029).
Furthermore, we were able to demonstrate that cardiac pacing induces arrythmias,
with biventricular pacing leading to more ventricular arrhythmias than right ventricular
pacing (62,5 % vs. 37,5 %).
In the overall collective of LVAD patients investigated in this study, neither biventricular
nor right ventricular pacing is clearly superior. But the group examination
in the late postoperative course showed a trend which leads towards the conclusion
that right ventricular pacing would be more beneficial to LVAD patients than biventricular
pacing under certain conditions.
According to that, the decrease of SVO2, as possibly the most sensitive parameter
during late postoperative course, may indicate that active CRT pacing in LVAD
patients with wide QRS complexes or LVAD patients without sinus rhythm may be
harmful.
Our results suggest reevaluating the indication of CRT systems for LVAD patients
and preserving sinus rhythm if present. Also, in the use of pacing systems
for LVAD patients, attention should be paid to patient-specific cardiac characteristics,
such as the width of the QRS complex, the presence of sinus rhythm, and
the occurrence of arrhythmias.
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Created: 2022Issued: 2023-03-09Updated: 2023-03-09
Faculty
Medizin
Publisher
Philipps-Universität Marburg
Language
ger
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DoctoralThesis
Keywords
Left Ventricular Assist DeviceHear FailureBiventricularStimulationPacingLeft Ventricular Assist DeviceRight VentricularbiventrikulärLVADrechtsventrikulärLVADHerzinsuffizenz
DDC-Numbers
610
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Rehborn, Luzia Maria: Effekt der biventrikulären und rechtsventrikulären Stimulation bei Patienten mit Left Ventricular Assist Device. : Philipps-Universität Marburg 2023-03-09. DOI: https://doi.org/10.17192/z2023.0150.