title: Pacemaker optimization in nonresponders to cardiac resynchronization therapy: left ventricular pacing as an available option.
abstract: BACKGROUND
  Echocardiographic (ECHO)-guided pacemaker optimization (PMO) in cardiac resynchronization therapy (CRT) nonresponders acutely improves left ventricular (LV) function. However, the chronic results of LV pacing in this group are less understood.
  
  
  METHODS
  We retrospectively studied 28 CRT nonresponders optimized based on ECHO to LV pacing and compared them to 28 age- and gender-matched patients optimized to biventricular (BiV) pacing. ECHOs with tissue Doppler imaging assessed LV hemodynamics before, immediately after, and 29 ± 16 months after PMO. Also, 56 age- and gender-matched CRT responders were included for comparison of clinical outcomes.
  
  
  RESULTS
  PMO resulted in acute improvements in longitudinal LV systolic function and several measures of dyssynchrony, with greater improvements in the LV paced group. Chronic improvements in ejection fraction (EF) (3.2 ± 7.7%), and left ventricle end-systolic volume (LVESV) (-11 ± 36 mL) and one dyssynchrony measure were seen in the combined group. Chronically, both LV and BiV paced patients improved some measures of systolic function and dyssynchrony although response varied between the groups. Survival at 3.5 years was similar (P = 0.973) between the PMO (58%) and nonoptimized groups (58%) but survival free of cardiovascular hospitalization was significantly (P = 0.037) better in the nonoptimized group.
  
  
  CONCLUSIONS
  CRT nonresponders undergoing PMO to either LV or BiV pacing have acute improvements in longitudinal systolic function and some measures of dyssynchrony. Some benefits are sustained chronically, with improvements in EF, LVESV, and dyssynchrony. A strategy of ECHO-guided PMO results in survival for CRT nonresponders similar to that of CRT patients not referred for PMO.
authors.affiliation: United Heart & Vascular Clinic, St. Paul, Minnesota 55102, USA. Ryan.Gage@allina.com
authors.forename: Ryan M
authors.initials: RM
authors.lastname: Gage
authors.forename: Kevin V
authors.initials: KV
authors.lastname: Burns
authors.forename: Daniel B
authors.initials: DB
authors.lastname: Vatterott
authors.forename: Spencer H
authors.initials: SH
authors.lastname: Kubo
authors.forename: Alan J
authors.initials: AJ
authors.lastname: Bank
mesh_terms: D000368:Aged; D058406:Cardiac Resynchronization Therapy / Q000379:methods*; D002648:Child; D005260:Female; D006333:Heart Failure / Q000517:prevention & control*; D006352:Heart Ventricles; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D017211:Treatment Failure; D016896:Treatment Outcome