The physiological effects of cardiac resynchronization therapy on aortic and pulmonary flow and dynamic and static components of systemic impedance.

Baldeep S Sidhu,Jack Lee,Ye Li,Justin Gould,Tiffany Patterson,Simon Claridge,Tom Jackson,Mark K Elliott,Christopher A Rinaldi,Haotian Gu,Shaumik Adhya,Steven A Niederer,Phil Chowienczyk,Natalia Briceno,Vishal Mehta,Simon Redwood,Bradley Porter

doi:10.1016/j.hroo.2021.05.007

Abstract

BackgroundPatients who improve following cardiac resynchronization therapy (CRT) have left ventricular (LV) remodeling and improved cardiac output (CO). Effects on the systemic circulation are unknown.ObjectiveTo explore the effects of CRT on aortic and pulmonary blood flow and systemic afterload.MethodsAt CRT implant patients underwent a noninvasive assessment of central hemodynamics, including wave intensity analysis (n = 28). This was repeated at 6 months after CRT. A subsample (n = 11) underwent an invasive electrophysiological and hemodynamic assessment immediately following CRT. CRT response was defined as reduction in LV end-systolic volume ≥15% at 6 months.ResultsIn CRT responders (75% of those in the noninvasive arm), there was a significant increase in CO (from 3 ± 2 L/min to 4 ± 2 L/min, P = .002) and LV dP/dtmax (from 846 ± 162 mm Hg/s to 958 ± 194 mm Hg/s, P = .001), immediately after CRT in those in the invasive arm. They demonstrated a significant increase in aortic forward compression wave (FCW) both acutely and at follow-up. The relative change in LV dP/dtmax strongly correlated with changes in the aortic FCW (Rs 0.733, P = .025). CRT responders displayed a significant reduction in afterload, and a decrease in systemic vascular resistance and pulse wave velocity acutely; there was a significant decrease in acute pulmonary afterload measured by the pulmonary FCW and forward expansion wave.ConclusionImproved cardiac function following CRT is attributable to a combination of changes in the cardiac and cardiovascular system. The relative importance of these 2 mechanisms may then be important for optimizing CRT.

Highlights

Cardiac resynchronization therapy (CRT) improves symptoms and reduces mortality in symptomatic patients with left ventricular (LV) systolic impairment and electrical dyssynchrony, who are on optimal medical therapy.[1]
CRT responders displayed a significant reduction in afterload, and a decrease in systemic vascular resistance and pulse wave velocity acutely; there was a significant decrease in acute pulmonary afterload measured by the pulmonary forward compression wave (FCW) and forward expansion wave
We demonstrated that in patients with severe LV systolic impairment who respond with CRT, biventricular pacing resulted in a significant reduction in the FCW and forward expansion wave (FEW)

Summary

Introduction

Cardiac resynchronization therapy (CRT) improves symptoms and reduces mortality in symptomatic patients with left ventricular (LV) systolic impairment and electrical dyssynchrony, who are on optimal medical therapy.[1]. Previous studies have shown that CRT is associated with improved right ventricular function and reduced systolic pulmonary pressures,[3] but the mechanisms through which these effects are seen are not fully understood. Patients who improve following cardiac resynchronization therapy (CRT) have left ventricular (LV) remodeling and improved cardiac output (CO).

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