ACUTE HEMODYNAMIC EFFECT OF CARDIAC RESYNCHRONIZATION THERAPY IN PATIENTS WITH CHRONIC HEART FAILURE

To assess acute hemodynamic effect of cardiac resynchronization therapy (CRT) in patients with chronic heart failure (CHF), 38 patients (including 35 men) aged 52.3±9.8 years were examined and treated. 20 patients had ischemic cardiomyopathy (ICMP) and 18 ones, non-ischemic cardiomyopathy (NCMP) with CHF of functional class III IV (NYHA), depressed left ventricular ejection fraction (LV EF) below 35%, signs of intra-ventricular and/or inter-ventricular dyssynchrony revealed using echocardiography, taken the QRS complex width into the account. Coronary angiography was performed to all patients before the procedure. All patients received medical treatment in accordance with the current guidelines. 27 patients had the sinus rhythm and 11 subjects, chronic atrial fibrillation. In 23 patients, the combined systems were implanted (CRT devices with the cardioverter-defibrillator function). The device implantation was effective in all patients and occurred without complications. Before and after CRT, 6 minute walk test was carried out. To assess hemodynamic parameters, the IE 33 system was used (Philips, USA). Echocardiography was performed before and on the 3rd day after the pacemaker implantation. At the background of CRT the distance walked during 6 minute walk test improved from 328±93 m to 397±75 m, p<0.001; a statistically significant improvement of CHF was revealed (NYHA classification), a significant increase in LV EF from the baseline occurred, the dP/dt index increased, and both end diastolic and end systolic volumes deceased. The CHF functional class (NYHA) improved in 29 patients (76%), an increase in the 6 minute walk test distance of >10% took place in 16 subjects (52%), ejection fraction increased by more than 5% in 27 patients (71%), and a decrease in end systolic volume occurred in 26 patients (68%). The correlation analysis showed an evident significant correlation between changes in end systolic volume and LV EF (r=0.659; p<0.001) and between changes in CHF functional class and LV EF (r=0.324; p=0.047). When analyzing the patient groups with the different QRS complex width, no significant difference was revealed in the CHF functional class (p=0.88), 6 minute walk test distance (p=0.51), changes in LV EF (p=0.74), and the end systolic volume of the left ventricle (p=0.11). Thus, positive changes in the cardiac hemodynamics and physical working capacity are detected after the CRT device implantation even during hospitalization.

cardiac resynchronization therapy, chronic heart failure, dyssynchrony, mitral regurgitation, 6 minute walk test, echocardiography

1. Бокерия Л. А, Бокерия О. Л., Глушко Л. А. Метаанализ современных клинических исследований и отдаленные результаты применения хронической ресинхронизирующей терапии // Анналы аритмологии 2012; № 1. 44-55.

2. Кузнецов В.А., Виноградова Т.О., Енина Т.Н. и соавт. Влияние сердечной ресинхронизирующей терапии на выживаемость пациентов с кардиомиопатией ишемического и неишемического генеза в клинической практике // Терапевтический архив 2012; 8: 52-56.

3. Al-Majed N.S., McAlister F.A., Bakal J.A. et al. Metaanalysis: Cardiac Resynchronization Therapy for Patients With Less Symptomatic Heart Failure // Ann. Intern. Med. 2011. Vol.154: P.401-412.

4. Кузнецов В. А, Колунин Г.В., Харац В.Е. и соавт. Эффект сердечной ресинхронизирующей терапии в лечении хронической сердечной недостаточности // Кардиология 2005; 9: 29-31.

5. Кузнецов В. А., Чуркевич Т.О., Колунин Г.В. и соавт. Отдаленные результаты влияния сердечной ресинхронизирующей терапии на выживаемость пациентов с хронической сердечной недостаточностью и низкой фракцией выброса левого желудочка // Сердечная недостаточность 2010; 4: 203-205.

6. Кузнецов В.А. Сердечная ресинхронизирующая терапия: избранные вопросы. - М.: Абис 2007; 128 с.

7. Steendijk P., Tulner S., Bax J. et al. Hemodynamic effects of long-term cardiac resynchronization therapy: analysis by pressurevolume loops // Circulation 2006; 113: 1295-1304.

8. Клинические рекомендации по применению устройств для сердечной ресинхронизирующей терапии. Национальные клинические рекомендации по проведению электрофизиологических исследований и применению имплантируемых антиаритмических устройств. Новая редакция. М.: ЗАО "ASKON-LINE», 2011; 121-127.

9. Dickstein K., Vardas P.E., Auricchio A. et al. 2010 Focused Update of ESC Guidelines on device therapy in heart failure // Eur. Heart J. 2010; Vol.31. №21. P.2677-2687.

10. Wyman W., Luc L. Mertens, Meryl S. Cohenet al. Echocardiography in Pediatric and Congenital Heart Disease: From Fetus to Adult // 2012; 808 p.

11. Galiuto L., Badano L., Fox K. et al. The EAE Textbook of Echocardiography. Oxford University Press, 2011; 27-30

12. Pitzalis M.V., Iacoviello M., Romito R. et al. Ventricular asynchrony predicts a better outcome in patients with chronic heart failure receiving cardiac resynchronization therapy // J. Am. Coll. Cardiol. 2005; 45(1). 5: 65-69

13. ST. John Sutton M.G., Plappert T., Abraham W.T. et al. Effect of Cardiac Resynchronization Therapy on Left Ventricular Size and Function in Chronic Heart Failure St. John SuttonMG Circulation // 2003; 107: 1985-1990

14. Cazeau S.J., Daubert J.C., Tavazzi L. et al. Responders to cardiac resynchronisation therapy with narrow or intermediate QRS complexes identified by simple echocardiographic indices of dyssynchrony: The DESIRE study // Eur. J. Heart. Fail. 2008; 10: 273-280.

15. Auricchio A, Faletra F.F. Mechanical dyssynchrony in CRT patients: Still searching for the Holy Grail! Eur J Heart Fail 2008; 10(3): 217-219

16. Bax J., Bleeker G., Marwick T. et al. Left ventricular dyssynchrony predicts response and prognosis after cardiac resynchronization therapy. J Am Coll Cardiol. 2004 Nov 2;44(9):1834-40.

17. Рыбакова М.К., Алехин М.Н., Митьков В.В. Практическое руководство по ультразвуковой диагностике. Эхокардиография.- М.: Издательский дом Видар-М, 2008; 512.

18. Foley P., Chalil S., Khadjooi K. et al. Left ventricular reverse remodelling, long-term clinical outcome, and mode of death after cardiac resynchronization therapy // European Journal of Heart Failure (2011) 13,43-51

19. Sipahi I., Chou J.C., Hyden M. et al. Effect of QRS morphology on clinical event reduction with cardiac resynchronization therapy: meta-analysis of randomized controlled trials // Am Heart J. 2012 Feb; 163(2):260-7.e3

20. Stavrakis S, Lazzara R, Thadani U. The benefit of cardiac resynchronization therapy and QRS duration: a meta-analysis // J. Cardiovasc. Electrophysiol. 2012 Feb;23(2):163-8.

21. Saxon L., De Marco T., Schafer J. et al. Effects of long-term biventricular stimulation for resynchronization on echocardiographic measures of remodeling // Circulation. 2002 Mar 19; 105(11):1304-10.

22. Bax J.J., Ansalone G., Breithardt O.A. et al. Echocardiographic evaluation of cardiac resynchronizalion therapy: ready for routine clinical use? // J. Amer. Coll. Cardiol. 2004; 44: 1-9.

23. Cheuk-Man Yu, Sanderson J., Gorcsan J. et al. Echocardiography, dyssynchrony, and the response to cardiac resynchronization therapy // Eur Heart J 2010; 31(19): 2326-2337

24. Marcus G., Rose E., Vilori E. et al. Septal to Posterior Wall Motion Delay Fails to Predict Reverse Remodeling or Clinical Improvement in Patients Undergoing Cardiac Resynchronization Therapy // J Am Coll Cardiol. 2005; 46(12): 2208-2214

25. Pecini R., Kober L. The relationship between mitral regurgitation and ejection fraction as predictors for the prognosis of patients with heart failure // Eur. J. Heart Fail. 2011; 13(10): 1121-1125

26. Porciani M.C., Macioce R., Demarchi G. et al. Effects of cardiac resynchronization therapy on the mechanisms underlying functional mitral regurgitation in congestive heart failure // Eur J Echocardiography 2006;7:31-9.

27. Cleland J.G., Daubert J.C., Erdmann E. et al. Cardiac Resynchronization-Heart Failure (CARE-HF) Study Investigators. The effect of cardiac resynchronization on morbidity and mortality in heart failure // N Engl J Med 2005; 352: 1539-49.