Biventricular System Research Articles

Treatment of Terminal Heart Failure and Cardiogenic Shock in 36 Children Less than 10 Kg Body Weight Assisted by Berlin Heart Excor Device

Background: Since the first implantation of a pulsatile paediatric ventricular assist device (VAD, Berlin Heart) in a child in 1990 at our institution outcome has significantly improved, with the implementation of optimized cannulas, modified anticoagulation and optimized surgical and intensive care management since 1999. We present our clinical experience with the Berlin Heart Excor device since 1999 in children with a body weight less than 10 kg. Methods: We performed a retrospective case analysis of all children less than 10 kg body weight who were treated with the Berlin Heart Excor since January 1st 1999 until February 5th 2012. Results: Thirty-six infants, age 0 - 27 months (median 6 mo), weight 3.2 - 9.9 kg (median 6.1 kg), were treated with VAD. Median time on support was 35 days (1 - 418 d). Twenty-nine children had left VAD and seven children biventricular VAD support systems. All children suffered from terminal heart failure with multiorgan failure or cardiogenic shock. Twenty-two had cardiomyopathy, five suffered from fulminant myocarditis and nine had a preceding operation on cardiopulmonary bypass. Procedural success was achieved in 72 % of children: 10 could be weaned from the system, another 15 patients received successful heart transplantation, 10 infants died and one is still on mechanical support. All patients with fulminant myocarditis were weaned from the assist system. At follow-up 1 year after explantation (n=24) the statomotoric development was normal or near normal in 21 of the 24 surviving children. In the seven children in whom thromboembolic events occurred two had mild to moderate hemiparesis, two severe statomotoric retardation and two recovered completely at follow-up examination. One child died 11 months after successful heart transplantation due to pneumonia. Conclusion: With a total survival rate of 72% the outcome of VAD support in small children is comparable to that in older children. The Berlin Heart Excor device is now a well-established treatment for small children suffering from cardiogenic shock of any aetiology.

NADH Fluorescence Imaging of Isolated Biventricular Working Rabbit Hearts

Since its inception by Langendorff1, the isolated perfused heart remains a prominent tool for studying cardiac physiology2. However, it is not well-suited for studies of cardiac metabolism, which require the heart to perform work within the context of physiologic preload and afterload pressures. Neely introduced modifications to the Langendorff technique to establish appropriate left ventricular (LV) preload and afterload pressures3. The model is known as the isolated LV working heart model and has been used extensively to study LV performance and metabolism4-6. This model, however, does not provide a properly loaded right ventricle (RV). Demmy et al. first reported a biventricular model as a modification of the LV working heart model7, 8. They found that stroke volume, cardiac output, and pressure development improved in hearts converted from working LV mode to biventricular working mode8. A properly loaded RV also diminishes abnormal pressure gradients across the septum to improve septal function. Biventricular working hearts have been shown to maintain aortic output, pulmonary flow, mean aortic pressure, heart rate, and myocardial ATP levels for up to 3 hours8. When studying the metabolic effects of myocardial injury, such as ischemia, it is often necessary to identify the location of the affected tissue. This can be done by imaging the fluorescence of NADH (the reduced form of nicotinamide adenine dinucleotide)9-11, a coenzyme found in large quantities in the mitochondria. NADH fluorescence (fNADH) displays a near linearly inverse relationship with local oxygen concentration12 and provides a measure of mitochondrial redox state13. fNADH imaging during hypoxic and ischemic conditions has been used as a dye-free method to identify hypoxic regions14, 15 and to monitor the progression of hypoxic conditions over time10. The objective of the method is to monitor the mitochondrial redox state of biventricular working hearts during protocols that alter the rate of myocyte metabolism or induce hypoxia or create a combination of the two. Hearts from New Zealand white rabbits were connected to a biventricular working heart system (Hugo Sachs Elektronik) and perfused with modified Krebs-Henseleit solution16 at 37 °C. Aortic, LV, pulmonary artery, and left & right atrial pressures were recorded. Electrical activity was measured using a monophasic action potential electrode. To image fNADH, light from a mercury lamp was filtered (350±25 nm) and used to illuminate the epicardium. Emitted light was filtered (460±20 nm) and imaged using a CCD camera. Changes in the epicardial fNADH of biventricular working hearts during different pacing rates are presented. The combination of the heart model and fNADH imaging provides a new and valuable experimental tool for studying acute cardiac pathologies within the context of realistic physiological conditions.

NADH Fluorescence Imaging of Isolated Biventricular Working Rabbit Hearts

Since its inception by Langendorff1, the isolated perfused heart remains a prominent tool for studying cardiac physiology2. However, it is not well-suited for studies of cardiac metabolism, which require the heart to perform work within the context of physiologic preload and afterload pressures. Neely introduced modifications to the Langendorff technique to establish appropriate left ventricular (LV) preload and afterload pressures3. The model is known as the isolated LV working heart model and has been used extensively to study LV performance and metabolism4-6. This model, however, does not provide a properly loaded right ventricle (RV). Demmy et al. first reported a biventricular model as a modification of the LV working heart model7, 8. They found that stroke volume, cardiac output, and pressure development improved in hearts converted from working LV mode to biventricular working mode8. A properly loaded RV also diminishes abnormal pressure gradients across the septum to improve septal function. Biventricular working hearts have been shown to maintain aortic output, pulmonary flow, mean aortic pressure, heart rate, and myocardial ATP levels for up to 3 hours8.When studying the metabolic effects of myocardial injury, such as ischemia, it is often necessary to identify the location of the affected tissue. This can be done by imaging the fluorescence of NADH (the reduced form of nicotinamide adenine dinucleotide)9-11, a coenzyme found in large quantities in the mitochondria. NADH fluorescence (fNADH) displays a near linearly inverse relationship with local oxygen concentration12 and provides a measure of mitochondrial redox state13. fNADH imaging during hypoxic and ischemic conditions has been used as a dye-free method to identify hypoxic regions14, 15 and to monitor the progression of hypoxic conditions over time10.The objective of the method is to monitor the mitochondrial redox state of biventricular working hearts during protocols that alter the rate of myocyte metabolism or induce hypoxia or create a combination of the two. Hearts from New Zealand white rabbits were connected to a biventricular working heart system (Hugo Sachs Elektronik) and perfused with modified Krebs-Henseleit solution16 at 37 °C. Aortic, LV, pulmonary artery, and left & right atrial pressures were recorded. Electrical activity was measured using a monophasic action potential electrode. To image fNADH, light from a mercury lamp was filtered (350±25 nm) and used to illuminate the epicardium. Emitted light was filtered (460±20 nm) and imaged using a CCD camera. Changes in the epicardial fNADH of biventricular working hearts during different pacing rates are presented. The combination of the heart model and fNADH imaging provides a new and valuable experimental tool for studying acute cardiac pathologies within the context of realistic physiological conditions.

Cardiac resynchronization therapy in clinical responders: right ventricular echocardiographic changes at mid-term follow-up

Objective The objective of this study was to assess the mid-term eff ects of cardiac resynchronization therapy on systolic function and remodelling of the right ventricle in clinical responders and non-responders.Methods A biventricular system was implanted between July 2005 and May 2008 in 58 patients with heart failure NYHA class II-IV. At baseline, three and 15 months after implantation, the following parameters were determined: NYHA class, quality of life, six-minute walk test, echocardiography including assessment of right ventricular systolic function by tricuspid annular plane systolic excursion and by pulsed tissue Doppler imaging (myocardial peak systolic velocity was measured at the tricuspid annulus). We also assessed the presence of ventricular dyssynchrony.Results There were no signifi cant changes after three months of cardiac resynchronization therapy on right ventricular systolic function and remodelling in responders and non-responders. Among responders, we found a statistically signifi cant improvement of right ventricular systolic function and also a signifi cant decrease in the size of the right ventricle after 15 months of therapy (systolic excursion before therapy 17.8 ± 4.0 mm vs 19.4 ± 3.7 mm, P< 0.05, after therapy; peak systolic velocity initially 11.9 ± 2.9 cm/s vs 12.7 ± 3.2 cm/s; right ventricle size before therapy 29.3 ± 5.0 mm vs 27.8 ± 4.2 mm, P< 0.05, after therapy. These changes were not observed in non-responders.Conclusions Fifteen months after cardiac resynchronization therapy, we found a statistically signifi cant improvement of right ventricular systolic function and a signifi cant reduction of right ventricular size in responders to cardiac resynchronization therapy.

Mechanical heart support at the Deutsches Herzzentrum Berlin: Recent developments (2011)

Since the inception of the mechanical circulatory support (MCS) program at the Deutsches Herzzentrum Berlin (DHZB) in 1987, more than 1600 patients have received support with 18 different designs of technical blood pump systems, in accordance with the respective state of the art. At the beginning, pulsatile pneumatic extracorporeal ventricular assist devices (VAD) and implantable pneumatic total artificial hearts (TAH) were available, followed by pulsatile electromechanical implantable devices. At this time the assist program was based on three objectives: bridging to recovery, bridging to heart transplantation (HTx) and for permanent support. Very soon (in 1995) patients of advanced age – over 65 years – were included in the program. In 1998 rotary blood pumps with continuous flow entered the program, from 2006 edging out step by step the pulsatile systems. Today the implantable pulsatile systems have disappeared from the DHZB program, with the exception of the extracorporeal uni- or biventricular pneumatic EXCOR systems (Berlin Heart GmbH), which are the only systems available for newborns and children. The only approved total artificial heart is the CardioWest device, implanted in rare cases after explantation of the natural heart. Miniaturized rotary blood pumps, axial flow turbines or centrifugal radial flow pumps are leading today's market. The size and configuration of one of these pumps, the hydrodynamically and magnetically levitated HeartWare HVAD, allowed its application as a biventricular implantable assist device. The worldwide first clinical implantation of this system was performed at the DHZB in 2009. With the increasing number of patients needing immediate circulatory support and the stagnating or even decreasing number of donor hearts available for HTx, the extreme discrepancy means that other therapies are gaining increasing importance. The objectives of the MCS program therefore had to focus on permanent VADs, thus creating a growing population of long-term outpatients with implanted systems, living with their families a near-normal life. Within a quarter century VAD implantation has grown from an experimental procedure into an established and generally accepted therapy. Facing the rapidly increasing population of patients with end-stage heart failure and the stagnating number of heart transplants, the use of VAD technology may represent the most advanced progress in cardiac care in the coming years. Further minaturization of the devices will allow the treatment of patients with a wide age spectrum, from newborn children to the elderly, even with biventricular support. The ultimate goal will be the development of a durable total artificial heart, based on the rotary blood pump technology, with transcutaneous energy transfer through the intact skin, guaranteeing the patients optimal quality of life for many years of support.

Correlation between T-Wave Alternans and Cardiac Volume Status via Intrathoracic Impedance Measurements.

Introduction. The presence of T-wave alternans (TWA) has been shown to correlate with a higher risk for sudden cardiac death. The mechanism of TWA may be related to abnormalities in intracellular calcium handling, which is a mechanism in heart failure and associated arrhythmias as well. However, an association between TWA and cardiac volume status has not been demonstrated. Methods Used. We report the case of a 54-year-old man with a dilated cardiomyopathy who had a biventricular defibrillator system implanted with intrathoracic impedance measurement capability. We performed baseline TWA testing, which was normal and was associated with normal clinical status and normal intrathoracic impedance. We followed intrathoracic impedance measurements, and when the measurement suggested volume overload eight months later, we repeated the TWA test. TWA was grossly positive, and volume overload was corroborated with clinical heart failure. The patient was diuresed, and when clinical status and intrathoracic impedance returned to normal a month later, we repeated TWA, which was again negative. Conclusion. This case demonstrates a correlation between cardiac volume status, as measured by intrathoracic impedance measurements, and TWA status. This data suggests that conditions of volume overload such as heart failure could be causally related to increased TWA, perhaps by the common mechanism of altered intracellular calcium handling.

Biventricular Levitronix CentriMag Assist Device: A “Bridge to Recovery” Solution in Patients with Acute Fulminant Myocarditis

Fulminant myocarditis (FM) represents a crucial cardiac pathology with extensive hemodynamic compromise occurring in a previously healthy patient. Early death occurs because of acute cardiac decompensation from inflammation, necrosis, and myocytolysis. Nevertheless, in this situation implantation of an extracorporeal circulatory support system may ensure cardiac recovery. We herein report our experience using a biventricular Levitronix CentriMag system for bridge to recovery.

Quantitative Assessment of Artifacts on Cardiac Magnetic Resonance Imaging of Patients With Pacemakers and Implantable Cardioverter-Defibrillators

The safety and clinical utility of MRI at 1.5 T in patients with cardiac implantable devices such as pacemakers (PM) and implantable cardioverter-defibrillators (ICD) have been reported. This study aims to evaluate the extent of artifacts on cardiac magnetic resonance (CMR) in patients with PM and ICD (PM/ICD). A total of 71 CMR studies were performed with an established safety protocol in patients with prepectoral PM/ICD. The artifact area around the PM/ICD generator was measured in all short-axis (SA), horizontal (HLA), and vertical long-axis (VLA) SSFP cine planes. The location and extent of artifacts were also assessed in all SA (20 sectors per plane), HLA, and VLA (6 sectors per plane) late gadolinium-enhanced CMR (LGE-CMR) planes. The artifact area on cine CMR was significantly larger with ICD versus PM generators in each plane (P<0.001, respectively). In patients with left-sided ICD or biventricular ICD systems, the percentages of sectors with any artifacts on LGE-CMR were 53.7%, 48.0%, and 49.2% in SA, HLA, and VLA planes, respectively. Patients with left-sided PM or right-sided PM/ICD had fewer artifacts. Anterior and apical regions were severely affected by artifact caused by left-sided PM/ICD generators. In contrast to patients with right-sided PM/ICD and left-sided PM, the anterior and apical left ventricle can be affected by susceptibility artifacts in patients with left-sided ICD. Artifact reduction methodologies will be necessary to improve the performance of CMR in patients with left sided ICD systems.

Use of a biventricular implantable cardioverter defibrillator in a patient with a neurostimulator: is it a safe combination?

The coincident use of neurostimulators and devices such as ICDs and pacemakers is increasing. This is because of the expanding indications for both devices. The manufacturers of ICDs caution against the combined use of ICDs and neurostimulators because of possible device interaction [1]. A 55-year-old woman was referred because of drug-refractory heart failure. In 2009, a neurostimulator (Synergy Versitrel, Medtronic, Inc, Minneapolis, Minnesota, USA) was implanted because of intractable back pain. She was admitted because of heart failure in the presence of dilating cardiomyopathy. Implantation of a biventricular implantable cardioverter defibrillator was indicated. A CRT-D (Consulta D234TRK, Medtronic, Inc, Minneapolis, Minnesota, USA) was implanted in the left pectoral region. Peri-procedural testing, with the ICD set to maximum sensitivity and the neurostimulator set to maximum therapeutic output, showed no interaction between the two devices (Fig. 1). A chest X-ray after the implantation showed adequate positioning of the leads (Fig. 2). The combination of cardiac resynchronisation therapy defibrillator and neurostimulators can be safe. However, extensive peri-operative testing is essential in preventing device interaction [1–3]. Fig. 1 Post-procedural electrocardiographic registration. Showing leads I and II (surface ECG), Farfield-ECG (from coil to can) and EGM2 (right ventricle). Note that there is no neurostimulator signal present, even though the neurostimulator output is set to ... Fig. 2 Anterior and lateral X-ray images, demonstrating the biventricular ICD system and the neurostimulator electrode (black arrows)

Modified implantation technique of the HeartWare continuous flow pump as biventricular support system

Modified implantation technique of the HeartWare continuous flow pump as biventricular support system

The Thoratec System Implanted as a Modified Total Artificial Heart: the Bad Oeynhausen Technique

The CardioWest™ total artificial heart (SynCardia Systems, Tuscon, AZ, USA) is the only FDA-approved total artificial heart determined as a bridge to human heart transplantation for patients dying of biventricular heart failure. Implantation provides immediate hemodynamic restoration and clinical stabilization, leading to end-organ recovery and thus eventually allowing cardiac transplantation. Occasionally, implantation of a total artificial heart is not feasible for anatomical reasons. For this patient group, we have developed an alternative technique using the paracorporeal Thoratec biventricular support system (Thoratec, Pleasanton, CA, USA) as a modified total artificial heart. A detailed description of the implantation technique is presented.

Pacemaker-Mediated Tachycardia over the Upper Rate Limit in a Biventricular Pacemaker System: What is the Mechanism?

Pacemaker-Mediated Tachycardia over the Upper Rate Limit in a Biventricular Pacemaker System: What is the Mechanism?

DOES THE RESYNCHRONIZATION THERAPY LEAD TO REDUCTION OF SYMPTOMS AND TO IMPROVEMENT OF LEFT VENTRICULAR FUNCTIONS IN PATIENTS WITH CHRONIC HEART FAILURE?

To evaluate the therapeutic effect of resynchronization in patients with chronic heart failure who are symptomatic despite adequate pharmacological medication. 118 patients with chronic heart failure, mostly dilated cardiomyopathy and ischaemic heart disease, with depressed systolic function, decreased left ventricular ejection fraction (LVEF) and left bundle branch block wide QRS complex, underwent implantation of the biventricular system between the years 2000-2006. We assessed changes in the NYHA functional class, hemodynamic parameters acquired during right heart catheterization, the maximum oxygen consumption during stress spiroergometric examination, as well as echocardiographic parameters. A statistically significant improvement was found in the NYHA functional class (from 2.8 +/- 0.4 to 2.3 +/- 0.5 after 3 m, p < 0,001 and to 2.5 +/- 0.6 after 12 m, p < 0,01 respectively), as well as an increase in the maximum oxygen consumption during spiroergometric examination (VO2 max from 14.1 +/- 3.1 ml/kg/min to 15.3 +/- 3.1 ml/kg/ min, p < 0,001 and to 15.3 +/- 2.5 ml/kg/min, p = NS respectively). In regard to hemodynamic parameters, there were increases in cardiac output and cardiac index after three months. After 12 months the change was not statistically significant (CO from 3.9 +/- 1 l/min to 4.2 +/- 0.9 l/min, p < 0,05, and to 4.1 +/- 0.9 l/min, p = NS, CI from 2 +/- 0.5 l/kg/min to 2.2 +/- 0.4 l/kg/min, p < 0,05, and to 2.1 +/- 0.4 l/kg/min, p = NS). Mean pulmonary artery pressure, as well as pulmonary capillary wedge pressure was reduced after 3, as well as after 12 months to a statistically significant degree (MPA from 29.1 +/- 11.5 mm Hg to 23.9 +/- 10.3 mm Hg, p< 0,001, and to 24.9 +/- 11.8 mm Hg, p < 0,01 respectively, and PCWP from 19.9 +/- 9.5 mm Hg to 15.2 +/- 9.2 mm Hg, p < 0,01, and to 15.6 +/- 9 mm Hg, p < 0,01 respectively). In regard to echocardiographic parameters, there was an increase in LVEF, a reduction in the end-diastolic diameter of the left ventricle, as well as a statistically significant reduction in severity of mitral regurgitation after 3, as well as 12 months (LVEF from 20.5 +/- 5.3%, to 23 +/- 6.5%, p < 0,001, and to 24.5 +/- 8%, p < 0,001, LVEDD from 69 +/- 9 mm to 68 +/- 9 mm, p < 0.01 and to 65 +/- 12 mm, p< 0.01 respectively, mitral regurgitation from 2.2 +/- 0.8 to 1.9 +/- 0.8, p< 0.001, and to 2 +/- 0.8, p < 0.001. In patients with chronic heart failure, resynchronization therapy leads to reduced symptoms, reduction in dyspnea and to improvements in cardiac performance due to increase in the systolic function of the left ventricle and hemodynamic changes.

Conventional Versus Biventricular Pacing in Heart Failure and Bradyarrhythmia: The COMBAT Study

Background Worsening in clinical and cardiac status has been noted after chronic right ventricular pacing, but it is uncertain whether atriobiventricular (BiVP) is preferable to atrio-right ventricular pacing (RVP). Conventional versus Multisite Pacing for BradyArrhythmia Therapy study (COMBAT) sought to compare BiVP versus RVP in patients with symptomatic heart failure (HF) and atrioventricular (AV) block. Methods and Results COMBAT is a prospective multicenter randomized double blind crossover study. Patients with New York Heart Association functional class (FC) II-IV, left ventricular ejection fraction (LVEF) <40%, and AV block as an indication for pacing were enrolled. All patients underwent biventricular system implantation and then were randomized to receive successively (group A) RVP-BiVP-RVP, or (group B) BiVP-RVP-BiVP. At the end of each 3-month crossover period, patients were evaluated according to Quality of Life (QoL), FC, echocardiographic parameters, 6-Minute Walk Test (6MWT), and peak oxygen consumption (VO 2max). Sixty patients were enrolled, and the mean follow-up period was 17.5 ± 10.7 months. There were significant improvements in QoL, FC, LVEF, and left ventricular end-systolic volume with BiVP compared with RVP. The effects of pacing mode on 6MWT and VO 2max were not significantly different. Death occurred more frequently with RVP. Conclusion In patients with systolic HF and AV block requiring permanent ventricular pacing, BiVP is superior to RVP and should be considered the preferred pacing mode.

Contrôler la fréquence ventriculaire ?

The objectives of rate control in patients with atrial fibrillation is to reduce symptoms, improve quality of live and minimize the risk of heart failure development. Based upon results of large randomized studies, this strategy can be chosen as a first line therapy in some patients including those with heart failure. The target ventricular rate is ≤85 bpm at rest and ≤115bpm during moderate exercise. Drugs slowing the atrioventricular conduction are usually used alone or in combination to achieve this goal. Failure to control ventricular rate using drugs may lead to AV nodal ablation and pacemaker implantation with a conventional or a biventricular system according to patient initial hemodynamic conditions.

Lung Physiology During ECS Resuscitation of DCD Donors Followed by In Situ Assessment of Lung Function

Extracorporeal cardiopulmonary support (ECS) of donors after cardiac death (DCD) has been shown to improve abdominal organs for transplantation. This study assesses whether pulmonary congestion occurs during ECS with the heart arrested and describes an in vivo method to assess if lungs are suitable for transplantation from DCD donors after ECS resuscitation. Cardiac arrest was induced in 30 kg pigs, followed by 10 min of warm ischemia. Cannulae were placed into the right atrium (RA) and iliac artery, and veno-arterial ECS was initiated for 90 min with lungs inflated, group 1 (n = 5) or deflated, group 2 (n = 3). Left atrial pressures were measured as a marker for pulmonary congestion. After 90 min of ECS, lung function was evaluated. Cannulae were placed into the pulmonary artery (PA) and left ventricle (LV). A second pump was included, and ECS was converted to a bi-ventricular (bi-VAD) system. The RVAD drained from the RA and pumped into the PA, and the LVAD drained the LV and pumped into the iliac. This brought the lungs back into circulation for a 1-hr assessment period. The oxygenator was turned off, and ventilation was restarted. Flows, blood gases, PA and left atrial pressures, and compliance were recorded. In both the groups, LA pressure was <15 mm Hg during ECS. During the lung assessment period, PA flows were 1.4-2.2 L/min. PO2 was >300 mm Hg, with normal PCO2. Extracorporeal cardiopulmonary support resuscitation of DCD donors is feasible and allows for assessment of function before procurement. Extracorporeal cardiopulmonary support does not cause pulmonary congestion, and the lungs retain adequate function for transplantation. Compliance correlated with lung function.

Effect of Long-Term Resynchronization Therapy on Left Ventricular Remodeling in Pacemaker Patients Upgraded to Biventricular Devices

Right ventricular pacing resulted in abnormal ventricular depolarization and an activation pattern similar to left branch bundle block. In some circumstances, it may exacerbate symptoms of heart failure and increase hospital admission rates. The objective of this study was to assess the effects of long-term ventricular resynchronization therapy on echocardiographic parameters of left ventricular (LV) remodeling in patients with moderate to severe heart failure who were upgraded from single- to biventricular pacing. Twenty-six consecutive pacemaker-dependent patients (20 men; mean age 61 +/- 20 years) who underwent placement of an LV lead to upgrade their conventional pacing system to biventricular pacing were included in the study. All patients had heart failure symptoms, received the maximum tolerated medical therapy, and were stable for >or=1 month before the upgrade. Echocardiography and electrocardiography were performed before the pacemaker upgrade and at follow-up (mean duration 15 +/- 9 months). QRS duration decreased significantly from 176 +/- 23 to 154 +/- 19 ms (p <0.001). LV end-diastolic volume (p = 0.006) and LV end-systolic volume (p = 0.004) decreased at follow-up compared with baseline. The decrease in LV volumes observed during follow-up was accompanied by a significant increase in ejection fraction (39 +/- 11% to 46 +/- 10%; p = 0.001) and decrease in LV myocardial performance index (0.84 +/- 0.18 to 0.68 +/- 0.14; p = 0.001). The upgrade of conventional pacing to biventricular pacing resulted in significant prolongation of normalized LV filling time (p = 0.01) and shortening of isovolumic contraction time (p 0.002). In addition, biventricular pacing significantly (V-V interval = 0) reduced intra- (44 +/- 11 vs 18 +/- 12 ms; p <0.001) and interventricular dyssynchrony (78 +/- 33 vs 49 +/- 22 ms; p <0.001). In conclusion, these findings suggested that in patients with advanced heart failure and continuous right ventricular pacing, upgrading to biventricular system resulted in significant reverse LV remodeling in the long-term follow-up and improvement in overall synchronicity of ventricular function.

220: Improvement in Survival with Implantation of Levitronix CentriMag Biventricular Circulatory Support in Patients with Acute ST-Elevation Myocardial Infarction (STEMI) and Refractory Cardiogenic Shock

Mortality of subjects with ST-elevation myocardial infarction (STEMI) and cardiogenic shock refractory to maximal therapy including inotropes, pressors, intra-aortic balloon pump (IABP), and early revascularization (ERV) approaches 100%. We have expanded the usual treatment paradigm for such patients with implantation of a biventricular circulatory support system that completely unloads both ventricles. Here we report our early experience with this approach.

Valve of Vieussens: An obstacle for left ventricular lead placement

An 80-year-old woman was upgraded from a dual-chamber to a biventricular pacemaker system. Sinus node disease was the indication for conventional atrioventricular pacing, which was associated with deterioration of cardiomyopathy over the previous three years. To facilitate left ventricular pacemaker lead implantation, an 8 Fr guiding sheath was placed into the coronary sinus. Contrast injection opacified only the proximal coronary sinus draining a prominent vein of Marshall. The initial venogram taken in the 30° left anterior oblique projection (Figure 1) gave the appearance of an atypical coronary sinus course that was unfavourable for left ventricular lead placement. The presence of a valve of Vieussens was considered to be impeding the advancement of the coronary sinus guiding sheath in the present case (1). Entry into the great cardiac vein was achieved using a hydrophilic guidewire to avoid coronary sinus dissection. After successful cannulation of the complex valve of Vieussens (Figure 2), the complete coronary sinus system, including the desired posterolateral tributary, was visualized with occlusive venography in 30° left anterior oblique projection. Figure 1) Initial venogram taken showing an atypical coronary sinus (CS) draining a prominent vein of Marshall (VOM). A Atrial pacemaker lead; V Ventricular pacemaker lead Figure 2) The complete coronary sinus (CS) system, including the posterolateral vein (PLV), could be visualized on venography after succesful cannulation of the complex valve of Vieussens (arrow). GCV Great cardiac vein; VOM Vein of Marshall

Deleterious effect of unintentional pacing from the middle cardiac vein in a patient with congenitally corrected transposition of the great arteries and ventricular septal defect. The beneficial effect of cardiac resynchronization therapy after heart surgery

This report presents a case of a 31-year-old male with congenitally corrected transposition of the great arteries, ventricular septal defect (VSD) and complete heart block who was admitted to our institution because of an exacerbation of heart failure after pacemaker implantation. The ECG and chest radiograph revealed that the ventricular lead was placed in the middle cardiac vein. After cardiosurgical procedure (VSD closure and atrioventricular valves replacement), the clinical symptoms of heart failure were still present. They diminished while the patient was on escape rhythm (40-70 bpm). Therefore, the previously implanted leads were removed and the transvenous, biventricular system was implanted, which resulted in a significant clinical improvement.