Central Sleep Apnea and Pacing-Induced Cardiomyopathy

Fabian Barbieri,Agne Adukauskaite,Anna Heidbreder,Elisabeth Brandauer,Melanie Bergmann,Ambra Stefani,Evi Holzknecht,Thomas Senoner,Andrea Rubatscher,Wilfried Schgör,Markus Stühlinger,Bernhard Erich Pfeifer,Axel Bauer,Florian Hintringer,Birgit Högl,Wolfgang Dichtl

doi:10.1016/j.amjcard.2020.09.027

Abstract

The role of central sleep apnea (CSA) in pacing-induced cardiomyopathy (PICM) remains speculative. In a prospective trial entitled UPGRADE, the presence of CSA was assessed by single-night polysomnography (PSG) in 54 PICM patients within 1 month after left ventricular lead implantation (with biventricular stimulation still not activated). CSA was diagnosed in half of patients (n = 27). Patients with moderate or severe CSA were randomized to cardiac resynchronization therapy (CRT) versus right ventricular pacing (RVP) in a double-blinded cross-over design and re-scheduled for a follow-up PSG within 3 to 5 months. After crossing-over of stimulation mode another PSG was conducted 3 to 5 months later. CRT led to a significant increase in left ventricular ejection fraction and significant reduction in left ventricular end systolic volumes and N-terminal pro brain natriuretic peptide plasma levels, whereas no significant effects were observed with ongoing RVP. CSA was significantly improved after 3.9 (3.2 to 4.4) months of CRT: apnea-hypopnea index decreased from 39.1 (32.1 to 54.0) events per hour at baseline to 22.2/h (10.9 to 36.7) by CRT (p <0.001). Central apnea index decreased from 27.1/h (17.7 to 36.1) at baseline to 6.8/h (1.1 to 14.4) after CRT activation (p <0.001). Ongoing RVP yielded only a minor improvement in apnea-hypopnea index and central apnea index. Pre-existent CSA did not affect structural response rate and had no impact on mid-term follow-up (median 2.8 years). In conclusion, CSA is highly prevalent in patients with PICM. CRT upgrading significantly improves CSA leading to a similar outcome in PICM patients without pre-existent CSA.

Highlights

Grant support: O€ NB Jubil€aumsfondsprojekt Nr. 15974
We report four new observations: (1) central sleep apnea (CSA) is very common in pacing-induced cardiomyopathy (PICM), affecting almost half of these patients
(3) cardiac resynchronization therapy (CRT) responder rate is independent from pre-existent sleep apnea (SA) and CSA is improved in PICM patients by CRT upgrading

Summary

Introduction

Grant support: O€ NB Jubil€aumsfondsprojekt Nr. 15974. Unlimited scientific grant from the Boston Scientific Investigator Sponsored Research (ISR) Committee, Boston Scientific, St. PICM is often treated by additional implantation of a left ventricular lead, which results in biventricular instead of right ventricular electrical activation of the heart This procedure is being referred to as upgrading to cardiac resynchronization therapy (CRT).[6] there are still no data from randomized controlled studies on this treatment approach, it accounts for almost a quarter of all CRT implantations as recently shown in a survey throughout Europe involving 11,088 patients.[7] Sleep disordered breathing, in particular central sleep apnea (CSA) is common in heart failure patients,[8] but its role in PICM has not been studied yet. In this study entitled UPGRADE, we set out to evaluate the effect on sleep architecture and sleep disordered breathing in PICM patients receiving biventricular pacing using single-night polysomnography (PSG) This is the first reported randomized controlled trial on CRT upgrading in PICM. Whether CSA is an aggravating factor or just a symptom of PICM, and if CRT response in PICM is influenced by CSA

Methods

Results

Conclusion