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Ann Thorac Surg 2003;75:1775-1780
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Acute hemodynamic benefit of multisite ventricular pacing after congenital heart surgery

^a Section of Pediatric Cardiology, University of Chicago Children’s Hospital, Chicago, Illinois, USA
^b Pediatric and Congenital Cardiac Surgery, University of Chicago Children’s Hospital, Chicago, Illinois, USA

Accepted for publication January 10, 2002.

^* Address reprint requests to Dr Bacha, Pediatric and Congenital Cardiac Surgery, University of Chicago Children’s Hospital, 5841 S Maryland Ave, MC 5040, Chicago, IL 60637, USA
e-mail: ebacha{at}surgery.bsd.uchicago.edu

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
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.

	Introduction

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Cardiac dysfunction accounts for significant morbidity and mortality in patients undergoing surgery for congenital heart disease. Dysfunction may be present preoperatively, leading to increased surgical risks, or it may occur in the immediate postoperative period. Inotropic agents are typically used treat postoperative cardiac dysfunction, at the cost of significant side effects. Standard pacing can be useful, but usually in the setting of bradyarrhythmias or complete atrioventricular (AV) blockade.

Cardiac resynchronization therapy through multisite ventricular pacing (MSVP) has recently emerged as adjunctive therapy for heart failure in adults [1, 2]. Bundle branch block or interventricular conduction delay occurs in 15% of adults with heart failure and results in asynchronous contraction of the left ventricle and suboptimal mechanical function [3]. A significant number of children with congenital heart disease have either interventricular conduction delay or right bundle branch block (RBBB). For example, RBBB occurs in 30% to 80% of patients during the immediate period after ventricular septal defect repair [4, 5]. Multisite ventricular pacing attempts to reestablish synchronous contraction of the left ventricle by pacing the right and left ventricles simultaneously. In adults, this is achieved with standard placement of a right ventricular (RV) apex pacing lead as well as a transvenous coronary sinus lead to pace the left ventricle. Cardiac resynchronization therapy has been shown to improve cardiac index (CI), quality of life, and VO₂ max in both acute and chronic studies of adults with low ejection fraction and prolonged QRS duration [1, 2, 6–8]. Single and multisite pacing in the pediatric population has been limited to those with RBBB or RV conduction delay but has resulted in increased blood pressure in the acute setting [9].

The objective of this study was to assess the potential acute benefit of MSVP in all patients with prolonged QRS duration after surgery for congenital heart disease.

	Material and methods

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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 they had preexisting bundle branch block or interventricular conduction delay on 12-lead electrocardiograph ([ECG] defined as QRS duration greater than the upper limits for age) or were expected to develop this as a result of the planned surgery. A total of 29 patients, aged 1 week to 17 years, were enrolled and serve as the basis for this study. The patients were grouped by anatomic diagnosis for the purpose of analysis as follows: group 1, single ventricle (n = 14); group 2, two-ventricle anatomy (tetralogy of Fallot, ventricular septal defect) undergoing ventricular surgery (n = 10); and group 3, two-ventricle anatomy undergoing other cardiac surgery (n = 5). Patients were receiving one to three inotropic agents (mean, two inotropic agents) at the time of the study. A summary of patient characteristics and diagnosis is provided in Table 1.

The leads were then attached to a dual chamber temporary pacemaker (Medtronic model 5388 [Medtronic, Minneapolis, MN]). One atrial lead was placed in the negative atrial pole and one in the positive atrial pole for standard bipolar pacing and sensing. Next, one of the ventricular leads was placed in the positive ventricular pole (either the midanterior RV free wall or the midline lead, based on the anatomy) and the remaining two ventricular leads were placed together into the negative ventricular pole. This allowed for simultaneous stimulation of the lateral RV free wall and RVOT for patients with two ventricles, and right and left lateral walls for those patients with single ventricle anatomy.

The second part of the pacing protocol took place in the intensive care unit on mean postoperative day 1 (range, 0 to 6) except in 2 selected patients. In these 2 patients the pacing portion of the protocol was performed in the operating room to assist with weaning from cardiopulmonary bypass. The timing of the study in the postoperative period was performed when the hemodynamic, ventilatory, and sedation status and fluid balance were stable and would not vary during the study period potentially affecting the results. Furthermore, the effects of pacing on the sedation status of each patient was observed during the study to assure that blood pressure and cardiac output were not influenced by any discomfort caused by pacing. Twenty-five of the patients were sedated and ventilated during the study and 4 patients were awake and on minimal sedation. No patient had "traditional" indications for pacing such as AV block or bradycardia. Baseline (nonpaced) data included single lead rhythm strips, blood pressure, systemic oxygen saturations, mixed venous oxygen saturation obtained from existing central lines (atrial lines if atrial septum was intact or internal jugular venous line), and serum lactate level.

Multisite ventricular pacing was then performed for 20 minutes. Using the set-up described, the pacemaker was set in the DDD mode with the lower rate limit less than the intrinsic rate to allow for atrial sensing of the intrinsic rhythm. The AV interval was then adjusted to achieve the narrowest QRS duration with ventricular pacing. Confirmation of ventricular capture from both sites was confirmed by comparing the QRS morphology of each ventricular site separately with the morphology during MSVP. During the pacing period, no changes were made in inotropic medications, sedation, or ventilation/oxygenation. At the conclusion of the pacing period, the baseline data were repeated.

Cardiac index was calculated using the Fick equation; and VO₂ was assumed for each patient based on age, sex, and heart rate.

Echocardiograms were recorded in select patients in the baseline state and during pacing. Echocardiograms could not be obtained in all patients owing to limited echo windows. Mitral (or systemic atrioventricular in single ventricles) and tricuspid valve inflow patterns were recorded to assess E and A wave ratios. Aortic Doppler and area was obtained to calculate cardiac output.

Baseline data were compared with that during pacing using paired t test. Linear regression analysis was used to relate outcomes of cardiac output, change in QRS duration, and systemic blood pressure to each variable. Significance was set at a p value of 0.05.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
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 Fallot is shown in Figure 2.

View larger version (17K): [in this window] [in a new window]   Fig 1. Change in QRS duration with multisite pacing for 29 patients. The QRS duration in the baseline state is shown in the left-hand column; the QRS duration during pacing is shown in the right-hand column. The dark line represents the mean change and the bars represent the standard deviations (106.5 ± 22 msec versus 80 ± 18 msec).

View larger version (131K): [in this window] [in a new window]   Fig 2. Baseline (top) and paced (bottom) rhythm strips (lead II, 50 mm/s) of a patient with tetralogy of Fallot and right bundle branch block. Baseline QRS duration is 120 msec and paced QRS duration is 80 msec. (N = normal beat.)

View larger version (20K): [in this window] [in a new window]   Fig 3. Change in systolic blood pressure (BP) with multisite pacing. For 29 patients, systolic BP in the baseline state is shown in the left-hand column; the systolic BP during pacing is shown in the right-hand column. The dark line represents the mean change and the bars represent the standard deviations (89 ± 22 mm Hg versus 98 ± 21 mm Hg).

View larger version (127K): [in this window] [in a new window]   Fig 4. Paced (left) and baseline (right) rhythm strip (lead II, 25 mm/s) and arterial blood pressure (ABP) recordings in patient no. 9 with hypoplastic left-side heart syndrome after stage 1 Norwood operation. The paced ABP is 67/46 mm Hg and decreases to 52/37 mm Hg in the baseline state. (N = normal beat; M = mixed beat; V= ventricular.)

Cardiac index
Data were available to calculate CI in 22 of 29 patients. The mean baseline CI was 3.5 ± 1.3 L · min^-1 · m^-2 and increased with pacing to 4.1 ± 1.6 L · min^-1 · m^-2 in 20 of 22 patients (15.1% increase, p = 0.0001; Fig 5).

View larger version (24K): [in this window] [in a new window]   Fig 5. Change in cardiac index with multisite pacing. For 22 patients, cardiac index in the baseline state is shown in the left-hand column; cardiac index during pacing is shown in the right-hand column. The dark line represents the mean change and the bars represent the standard deviations (3.5 ± 1.3 [L · min-1 · m-2] versus 4.1 ± 1.6 [L · min-1 · m-2].)

Pr interval
There was no significant change in the PR interval with pacing. Baseline PR intervals were 130 ± 55 msec and with pacing they were 111 ± 25 msec (p = 0.06).

Echocardiography
Echocardiographic data were available for 12 patients. There was no significant change in the mitral, tricuspid, or systemic AV valve inflow pattern, E and A wave ratio, or valve regurgitation with pacing.

Linear regression analysis
The percent change of QRS duration, CI, and systolic blood pressure was not related to age or to grouping of patients younger or older than 3 years of age.

The degree of increase in CI was not related to cross-clamp time, cardiopulmonary bypass time, baseline QRS duration, change in QRS duration, or baseline CI.

There were no complications from the pacing study; no patient demonstrated agitation or muscle twitching during pacing, and no patient had complications from epicardial lead removal.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
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 numbers in each group are small. Echocardiographic analysis did not demonstrate any significant difference in AV valve inflow pattern with pacing to account for the hemodynamic benefit seen. This study has demonstrated improved CI with MSVP after surgery for congenital heart disease and has evaluated MSVP in univentricular hearts.

It is estimated that as many as 15% of adults with heart failure have interventricular conduction delay or bundle branch block [3]. This electrical disturbance is thought to impair the synchronous contraction of the right and left ventricles resulting in paradoxical septal wall motion, decreased LV pressures, reduced diastolic filling times, and increased mitral regurgitation [10]. Furthermore, a prolonged QRS duration has been suggested as an independent predictor of mortality in adults with heart failure as well as in patients after surgery for tetralogy of Fallot [11, 12].

Multisite ventricular pacing attempts to improve coordination of contraction by simultaneous pacing of the right and left ventricles. Acute studies of MSVP have shown improvement of interventricular synchrony, regional LV wall motion and LV dp/dt in adults [6–8]. The benefit of MSVP has been correlated with the degree of QRS prolongation, with some studies suggesting the greatest benefit in patients with QRS more than 150 msec [13]. Our study did not show a correlation between the degree of improvement of CI with QRS duration or with the change in the QRS duration with pacing.

As opposed to the adult population with heart failure and LBBB, patients with congenital heart disease often demonstrate right ventricular conduction delay or RBBB, especially after ventricular surgery. This electrical disturbance is often associated with acute postoperative RV dysfunction or chronic RV dysfunction due to residual defects such as pulmonary regurgitation as a result or previous surgeries or multiple previous surgeries. Our study addressed this issue by locating ventricular pacing sites in an attempt to correct RV conduction disturbances in this population. The acute intraoperative and postoperative hemodynamic benefit of multisite RV pacing in this study was similar to what has been reported in adults with low ejection fraction [8]. Previous studies of multisite or single site RV pacing in patients with congenital heart disease and RBBB have yielded promising results. Janousek and colleagues [9] assessed single or multisite pacing in patients with RBBB or complete AV block and found that interventricular resynchronization resulted in an increase in blood pressure of 5.9% to 9.4% in the acute postoperative setting. In another study, single-site pacing in patients with RBBB and RV dysfunction significantly augmented RV performance and cardiac output in the acute setting; however, the optimal pacing site varied among patients [14].

Our study has demonstrated a potential benefit for MSVP in patients with univentricular hearts. Although the groups were small, we did not detect any difference in the response to pacing between univentricular and biventricular anatomy. As the mechanics of univentricular contraction are not well described, the mechanism responsible for this response to pacing is unclear, but could be related to synchronization of the different wall segments of the single ventricle.

The use of multisite pacing in the immediate postoperative period is appealing because its use may avoid some of the unwanted side effects of increasing doses of inotropic agents used to support cardiac function. A recent study showed that while MSVP and dobutamine infusion both increase LV dp/dt, dobutamine did so at the cost of increasing myocardial O₂ consumption while MSVP actually lowered myocardial O₂ consumption [15]. In the present study, 2 patients had dramatic increases in blood pressure with pacing that allowed weaning from cardiopulmonary bypass. This therapy was continued during the immediate postoperative period in addition to inotropic support. The use of multisite pacing for adjunctive therapy during weaning from cardiopulmonary bypass has been reported in adults and children [16, 17].

The limitations of this study include the lack of comparison of multisite pacing with single-site RV pacing, although MSVP has been shown to be superior to single-site pacing in adults with heart failure. In the 2 patients who were paced in the operating room, multisite pacing was significantly better than single-site pacing. Furthermore, we were not able to identify factors to predict which patients may best benefit from this therapy. A standard placement of pacing leads was used based on the anatomic diagnosis for this study but it is possible that an individualized, optimal arrangement for placement of the pacing leads could be tested in the operating room, albeit time consuming, especially in the critically ill patient. Because our specialty deals with single-ventricle anatomy, we prefer the term "multisite ventricular pacing" over the term "biventricular pacing." Again, as opposed to the finding of LBBB and congestive heart failure in adults, patients with chronic heart disease often develop RBBB, and pacing therapy is used to achieve RV resynchronization. Finally, optimization of the AV interval during pacing was not assessed in this study. Because this population had intact AV conduction, there was a limited range of AV intervals that could be programed. The baseline PR intervals were not significantly different from those with pacing and there was no change in the E and A wave morphology or ratio, suggesting that any change in the AV interval was minimal and did not influence the results of this study.

In conclusion, MSVP has beneficial hemodynamic effects on patients with QRS prolongation or bundle branch block after surgery for congenital heart disease. It can be used as effective adjunct therapy in both weaning from cardiopulmonary bypass and postoperative cardiac dysfunction.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Joanne P. Starr Emile A. Bacha Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Zimmerman, F. J. Articles by Bacha, E. A. Search for Related Content PubMed PubMed Citation Articles by Zimmerman, F. J. Articles by Bacha, E. A.