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Angelo Auricchio

Publications and source records attributed to Angelo Auricchio.

10 recordsLinked to original sources
PubMed2003

The promise of resynchronization therapy. Who (and how many) will benefit?

It has been estimated that about 320,000 to 400,000 patients in the USA alone are possible candidates to cardiac resynchronization therapy according to the recently published AHA/ACC/NASPE guidelines for pacing and the results of the COMPANION trial. The selection of the most suitable candidate for CRT/CRTD is a crucial issue, but still a matter of debate. A large variety of clinical, invasive and non-invasive criteria have been proposed for appropriately selecting candidates for CRT. However, in all the studies the parameters have been retrospectively identified and none has reported their results in the form of a multivariate regression model. We have now well characterized the patients in sinus rhythm who most likely benefit from this non-pharmacological approach. The fact that the COMPANION trial was able to single out a specific subgroup of heart failure patients that can be treated better than what was very short time ago best medical therapy validates the large body of research that investigators worldwide have created about this therapy. Finally, the concept that any patients that require ventricular pacing, who have heart failure class II/III or IV may benefit from receiving biventricular rather than right ventricular pacing as much as the other patients with more classical indication for CRT is still open to discussion and needs to be tested in a randomized multicenter trial.

Arrhythmias, Cardiac↗
PubMed2002

Echocardiographic quantification of left ventricular asynchrony predicts an acute hemodynamic benefit of cardiac resynchronization therapy.

OBJECTIVES: We sought to determine whether radial left ventricular (LV) asynchrony in patients with heart failure predicts systolic function improvement with cardiac resynchronization therapy (CRT). BACKGROUND: We quantified LV wall motion by echocardiography to correlate the effects of CRT on LV systolic function with wall motion synchrony. METHODS: Thirty-four patients underwent echocardiographic phase analysis of LV septal and lateral wall motion and hemodynamic testing before CRT. Phase relationships were measured by the difference between the lateral (Phi(L)) and septal (Phi(S)) wall motion phase angles: Phi(LS) = Phi(L) - Phi(S). The absolute value of Phi(LS) was used as an order-independent measure of synchrony: the absolute value Phi(LS) = the absolute value of Phi(L) - Phi(S). RESULTS: Three phase relationships were identified (mean +/- SD): type 1 (n = 4; peak positive LV pressure [dP/dt(max)] 692 +/- 310 mm Hg/s; Phi(LS) = 5 +/- 6 degrees, synchronous wall motion); type 2 (n = 17; dP/dt(max) 532 +/- 148 mm Hg/s; Phi(LS) = 77 +/- 33 degrees, delayed lateral wall motion); and type 3 (n = 13; dP/dt(max) 558 +/- 154 mm Hg/s; Phi(LS) = -115 +/- 33 degrees, delayed septal wall motion, triphasic). A large absolute value of Phi(LS) predicted a larger increase in dP/dt(max) with CRT (r = 0.74, p < 0.001). Sixteen patients were studied during right ventricular (RV), LV and biventricular (BV) pacing. Cardiac resynchronization therapy acutely reduced the absolute value of Phi(LS) from 104 +/- 41 degrees (OFF) to 86 +/- 45 degrees (RV; p = 0.14 vs. OFF), 71 +/- 50 degrees (LV; p = 0.001 vs. OFF) and 66 +/- 42 degrees (BV; p = 0.001 vs. OFF). A reduction in the absolute value of Phi(LS) predicted an improvement in dP/dt(max) in type 2 patients for LV (r = 0.87, p = 0.005) and BV CRT (r = 0.73, p = 0.04). CONCLUSIONS: Echocardiographic quantification of LV asynchrony identifies patients likely to have improved systolic function with CRT. Improved synchrony is directly related to improved hemodynamic systolic function in type 2 patients.

Aged↗
PubMed2002

Long-term clinical effect of hemodynamically optimized cardiac resynchronization therapy in patients with heart failure and ventricular conduction delay.

OBJECTIVES: We sought to compare the short- and long-term clinical effects of atrial synchronous pre-excitation of one (univentricular) or both ventricles (biventricular), that provide cardiac resynchronization therapy (CRT). BACKGROUND: In patients with heart failure (HF) who have a ventricular conduction delay, CRT improves systolic hemodynamic function. The clinical benefit of CRT is still being investigated. METHODS: Forty-one patients were randomized to four weeks of first treatment with biventricular or univentricular stimulation, followed by four weeks without treatment, and then four weeks of a second treatment with the opposite stimulation. The best CRT stimulation was continued for nine months. Cardiac resynchronization therapy was optimized by hemodynamic testing at implantation. The primary end points were exercise capacity measures. Data were analyzed by two-way repeated-measures analysis of variance. RESULTS: The left ventricle was selected for univentricular pacing in 36 patients. The clinical effects of univentricular and biventricular CRT were not significantly different. The results of each method were pooled to assess sequential treatment effects. Oxygen uptake during bicycle exercise increased from 9.48 to 10.4 ml/kg/min at the anaerobic threshold (p = 0.03) and from 12.5 to 14.3 ml/kg/min at peak exercise (p < 0.001) with the first treatment, and from 10.0 to 10.7 ml/kg/min at the anaerobic threshold (p = 0.2) and from 13.4 to 15.2 ml/kg/min at peak exercise (p = 0.002) with the second treatment. The 6-min walk distance increased from 342 m at baseline to 386 m after the first treatment (p < 0.001) and to 416 m after the second treatment (p = 0.03). All improvements persisted after 12 months of therapy. CONCLUSIONS: Cardiac resynchronization therapy produces a long-term improvement in the clinical symptoms of patients with HF who have a ventricular conduction delay. The differences between optimized biventricular and univentricular therapy appear to be small for short-term treatment.

Arrhythmias, Cardiac↗
PubMed2002

Cardiac resynchronization therapy restores optimal atrioventricular mechanical timing in heart failure patients with ventricular conduction delay.

We characterized the relationship between systolic ventricular function and left ventricular (LV) end-diastolic pressure (LVEDP) in patients with heart failure (HF) and baseline asynchrony during ventricular stimulation. The role of preload in the systolic performance improvement that can be obtained in HF patients with LV stimulation is uncertain.We measured the maximum rate of increase of LV pressure, LVEDP, aortic pulse pressure (PP) and the atrioventricular mechanical latency (AVL) between left atrial systole and LV pressure onset in 39 patients with HF. Two subgroups were identified: "responder" if PP improved, or "nonresponder."Maximum hemodynamic improvement occurred at an atrioventricular (AV) delay that did not decrease LVEDP. Left ventricular and biventricular (BV) stimulation increased systolic hemodynamics significantly, despite no significant increase in LVEDP. All parameters decreased when the LVEDP was decreased by shorter AV delay. Left ventricular and BV stimulation provided better hemodynamics than right ventricular (RV) stimulation. For the nonresponder subgroup, systolic hemodynamics only worsened during AV delay shortening. For the responder subgroup, optimum PP was achieved when AVL was near zero. Restoration of optimal left atrial-ventricular mechanical timing partly contributes to the hemodynamic improvements observed in this patient subgroup. However, preload alone cannot explain the differences seen between RV and BV stimulation and the contradictory PP decreases even at maximal preload in the nonresponder subgroup. These results may be explained by a site-dependent mechanism such as the degree of ventricular synchrony. Caution should be taken in these patients when optimizing AV delays using echocardiography techniques that focus on LV inflow.

Atrial Function, Left↗
PubMed2002

Exercise performance following cardiac resynchronization therapy in patients with heart failure and ventricular conduction delay.

Patients with heart failure (HF) frequently have an impaired heart rate response to exercise and reduced oxygen consumption (VO(2)). Cardiac resynchronization therapy (CRT) has been shown to increase functional capacity in patients with HF and conduction delay. However, detailed analysis of improvement in functional capacity after CRT is still lacking. This study aimed to provide a detailed analysis of the changes in metabolic, ventilation parameters, and heart rate profiles in patients with HF and ventricular conduction delay following implantation with resynchronization devices. We provided a retrospective review on 50 patients in New York Heart Association functional class >II, with left ventricular ejection fraction <35%, on optimal medical therapy, and whose functional capacity was evaluated by cardiopulmonary exercise testing before and after CRT. Detailed analysis of VO(2), carbon dioxide production (VCO(2)), heart rate, minute ventilation (V(E) [liters per minute]), tidal volume (V(T)), respiratory rate, and heart rate profile during exercise were performed. Following CRT, peak VO(2) increased significantly from 14 +/- 4 to 17 +/- 4 (p <0.0001), and VO(2) at anaerobic threshold increased from 9 +/- 2 to 12 +/- 3 (p <0.001). All ventilation and metabolic parameters significantly increased following CRT. Similarly, heart rate at rest significantly decreased after CRT (76 +/- 12 vs 72 +/- 12 beats/min, p <0.05), whereas the maximum achieved heart rate increased significantly from 119 +/- 20 to 125 +/- 24 beats/min (p <0.05). The proportion of patients with chronotropic incompetence was significantly reduced after CRT (50% before CRT vs 34.7 after CRT; p <0.05). Patients with the baseline peak VO(2) <14 ml/kg/min benefited most from the implantation of a CRT device. In conclusion, CRT significantly improves all ventilation and metabolic parameters of patients with HF and conduction delay. Patients with more depressed metabolic and ventilation parameters and higher heart rate at baseline seem to benefit most from this therapeutic approach.

Adaptation, Physiological↗
PubMed2002

Cardiac resynchronization therapy.

Despite advances in medical therapy for patients with congestive heart failure, morbidity and mortality remain high. Conventional atrioventricular pacing with a short atrioventricular delay was first introduced as a nonpharmacologic treatment for patients with severe heart failure. Further development of this new therapeutic approach led to biventricular pacing, also known as cardiac resynchronization therapy. Many studies have been published and many are still ongoing. This review summarizes the results reported in randomized trials and focuses on questions that have not yet been answered.

Cardiac Pacing, Artificial↗
PubMed2002

Effect of cardiac resynchronization therapy on ventricular remodeling.

Cardiac resynchronization therapy (CRT) is a new non-pharmacological option for patients with advanced heart failure and ventricular conduction delay. Four randomized prospective studies have provided evidence that CRT increases exercise capacity, improves functional class and quality of life. There is also increasing evidence that CRT may trigger an inverse remodeling process leading to reduction of ventricular diameter and eventually of the atrial size. The pathophysiological mechanism throughout CRT may promote inverse remodeling is: (1) reduction of systolic and diastolic mitral regurgitation; (2) reduction of sympathetic/parasympathetic imbalance as well as reduction of neurohumoral activation due to increased systolic blood pressure and improved filling time; (3) reduction of regional wall stress. The structural changes taking place during CRT are directly related to continuous pacing, because lack of pacing immediately shows the new onset of remodeling. The duration of the reported changes of ventricular diameter is still unknown, and it is also unknown whether such reverse remodeling process of the ventricle and of the atria will lead to a reduction of cardiac death and incidence of ventricular arrhythmias.

Cardiac Pacing, Artificial↗
PubMed2002

Acute effects of cardiac resynchronization therapy on left ventricular Doppler indices in patients with congestive heart failure.

BACKGROUND: Patients with heart failure frequently exhibit intraventricular conduction delays, which contribute to asynchronous contraction patterns and impaired hemodynamic performance. Cardiac resynchronization therapy (CRT) with biventricular (BV) and left ventricular (LV) pacing has been shown to improve both hemodynamic and clinical performance. This study investigated the effects of CRT on LV Doppler indices in these patients. METHODS AND RESULTS: Thirty-two patients with advanced heart failure (New York Heart Association class > or =III, QRS >120 milliseconds, PR interval >150 milliseconds) were studied 4 weeks after implantation of a CRT system. Doppler echocardiography was conducted in 3 separate CRT modes, right ventricular, LV, and BV stimulation at 3 different atrioventricular delays. CRT resulted in significant improvement of Doppler parameters such as filling time (FT, 313 +/- 111 milliseconds at baseline --> 363 +/- 154 milliseconds [BV], P <.05), aortic velocity time integral (AO(VTI) 23.2 +/- 7.4 cm at baseline --> 26.8 +/- 8.8 cm [LV], P <.05), and the myocardial performance index (MPI, 1.21 +/- 0.51 at baseline --> 0.85 +/- 0.34 [BV], P <.05). The most improvement was observed with LV and BV stimulation at short and intermediate atrioventricular delays (80-120 milliseconds), independent of ischemic or idiopathic origin. CONCLUSIONS: CRT improves hemodynamic performance in patients with heart failure with intraventricular conduction delays. Doppler echocardiography allows noninvasive evaluation of acute CRT effects in patients with heart failure. In particular, FT, AO(VTI), and MPI are useful parameters for noninvasive follow-up and optimization of pacing parameters.

Analysis of Variance↗