Effect of Cardiac Resynchronization Therapy on Ventricular Repolarization Parameters and Ventricular Arrhythmias

Abstract

Objective: Cardiac resynchronization therapy (CRT) is commonly used in patients with heart failure (HF) along with left ventricular mechanic and electrical dyssencrony. Left ventricular epicardial pacing in CRT patients changes the normal myocardial activation and increases the transmural dispersion of repolarization. We aimed to investigate the impact of CRT on repolarization parameters and reveal its consequences on arrhythmic events. Materials and Methods: The study consisted of 54 patients treated with CRT. Repolarization parameters; QT, T peak-to-T end and JT, Tpe/QT, QT dispersion and Tpe dispersion were measured. The patients were also investigated in two subgroups according to the presence of ventricular arrhythmias at the end of follow-up. Subgroups were compared in terms of repolarization parameters. Results The change in repolarization parameters according to baseline values were also compared in the whole group.In the whole study group, all of the repolarization parameters significantly increased in the acute phase. In the chronic phase, these abnormalities were significantly diminished. The comparison of the two subgroups did not show any significant difference in respect of repolarization parameters. Conclusion: Epicardial pacing prolongs myocardial repolarization time and increases transmural dispersion of repolarization. However, these abnormalities were transient and were not associated with ventricular arrhythmias.

Keywords

• Cardiac resynchronization therapy
• New repolarization parameters
• Heart failure

Kardiyak Resenkronizasyon Tedavisinin Ventriküler Repolarizasyon Parametreleri ve Ventriküler Aritmiler Üzerindeki Etkisi

Abstract

Giriş ve Amaç: Kardiyak re senkronizasyon tedavisi (KRT), sol ventrikül mekanik ve elektriksel dissenkronisi olan kalp yetmezliği (KY) hastalarında yaygın olarak kullanılmaktadır. KRT hastalarında sol ventrikül epikardiyal pacing, normal miyokardiyal aktivasyonu değiştirir ve repolarizasyonun transmural dağılımını arttırmaktadır. KRT'nin repolarizasyon parametreleri üzerindeki etkisini araştırmayı ve aritmik olaylar üzerindeki sonuçlarını ortaya çıkarmayı amaçladık. Gereç ve Yöntemler: Çalışma, KRT ile tedavi edilen 54 hastadan oluşmaktaydı. Repolarizasyon parametreleri; QT, T tepeden T sonuna geçen süre (Tpe), JT, Tpe/QT, QT dispersiyonu ve Tpe disperisyonu ölçüldü. Hastalar ayrıca takip sonundaki ventriküler aritmi varlığına göre iki alt grupta incelendi. Alt gruplar repolarizasyon parametreleri açısından karşılaştırıldı. Başlangıç değerlerine göre repolarizasyon parametrelerinin değişimi de tüm grupta karşılaştırıldı. Bulgular: Tüm çalışma grubunda akut fazda repolarizasyon parametrelerinin tamamı anlamlı olarak artmıştır. Kronik fazda, bu anormallikler önemli ölçüde azalmıştır. İki alt grubun karşılaştırılmasında ise repolarizasyon parametreleri açısından anlamlı bir fark saptanmamıştır. Sonuç: Epikardiyal pacing, miyokardiyal repolarizasyon süresini uzatmakta ve repolarizasyonun transmural dağılımını arttırmaktadır. Ancak bu anormallikler geçici olup ventriküler aritmilerle ilişkili bulunmamıştır.

Keywords

• Kardiyak resenkronizasyon tedavisi
• Yeni repolarizasyon parametreleri
• Kalp yetmezliği

References

1. Ponikowski, P, Voors, A.A, Anker, S.D, Bueno, H, Cleland, J.G.F, Coats, A.J.S, et al., ESC Committee for Practice Guidelines, ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2016: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology, Developed in collaboration with the Heart Failure Association (HFA) of the ESC, European Heart Journal, 2016, 37, 2129–2200.
2. Moss, A.J, Hall, W.J, Cannom, D.S, Klein, H, Brown, M.W, Daubert, J.P, et al., Cardiac-resynchronization therapy for the prevention of heart-failure events, New England Journal of Medicine, 2009, 361, 1329–1338.
3. Medina-Ravell, V.A, Lankipalli, R.S, Yan, G.X, Antzelevitch, C, Medina-Malpica, N.A, MedinaMalpica, O.A, et al., Effect of epicardial or biventricular pacing to prolong QT interval and increase transmural dispersion of repolarization: Does resynchronization therapy pose a risk for patients predisposed to long QT or torsade de pointes? Circulation, 2003, 107, 740-746.
4. Fish, J.M, Di Diego, J.M, Nesterenko, V, Antzelevitch, C, Epicardial activation of left ventricular wall prolongs QT interval and transmural dispersion of repolarization: implications for biventricular pacing, Circulation, 2004, 109, 2136-2142.
5. Antzelevitch, C, Shimizu, W, Cellular mechanisms underlying the long QT syndrome, Current Opinions in Cardiology, 2002, 17, 43–51.
6. Barbhaiya, C, Po, J.R, Hanon, S, Schweitzer, P. T(peak) - T(end) and T(peak) - T(end) /QT Ratio as Markers of Ventricular Arrhythmia Risk in Cardiac Resynchronization Therapy Patients, Pacing Clinical Electrophysiology, 2013, 36, 103-8.
7. Castro Hevia, J, Antzelevitch, C, Tornes Barzaga, F, Dorantes Sanchez, M, Dorticos Balea, F, Zayas Molina, R et al., Tpeak-Tend and Tpeak-Tend dispersion as risk factorsfor ventricular tachycardia/ventricular fibrillation in patients with the Brugada syndrome, Journal of American College of Cardiology, 2006, 47, 1828–1834.
8. Zhao, X, Xie, Z, Chu, Y, Yang, L, Xu, W, Yang, X, et al., Association between Tp-e/QT ratio and prognosis in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction, Clinical Cardiology, 2012, 35, 559–564.

9. Panikkath, R, Reinier, K, Uy-Evanado, A, Teodorescu, C, Hattenhauer, J, Mariani, R, et al., Prolonged Tpeak-to-Tend interval on the resting ECG is associated with increased risk of sudden cardiac death, Circulation Arrhythmia Electrophysiology, 2011, 4, 441–447.
10. Gocer, H, Durukan, A.B, Unlu, A, Unal, M, Comparison of P-Wave Duration and Dispersion in Mitral Valve Replacement Surgery Via Right Atrial Transseptal or Left Atrial Approach in Rheumatic Mitral Stenosis Patients, Heart Surgery Forum, 2020, 23, 118-122.
11. Kelvin, C.M.C, Carmen, R, Kyndaron, R, Audrey, U, Harpriya, C, et al., Tpeak-to-Tend interval corrected for heart rate: A more precise measure of increased sudden death risk? Heart Rhythm, 2016, 13, 2181- 2185.
12. Gocer, H, Durukan, A.B, Naseri, E, Unal, M, Determination of acute changes in new ECG parameters during veno-venous ECMO support, Kardiochirurgia i torakochirurgia polska, 2020, 17 (4), 189-192.
13. Van Gelder, B.M, Scheffer, M.G, Meijer, A, Bracke, F.A, Transseptal endocardial left ventricular pacing: An alternative technique for coronary sinus lead placement in cardiac resynchronization therapy, Heart Rhythm, 2007, 4, 454-460.
14. Fish, J.M, Brugada, J, Antzelevitch, C, Potential proarrhythmic effects of biventricular pacing, Journal of American College of Cardiology, 2005, 46, 2340–2347.
15. Gocer, H, Turkyılmaz, E, Unlu, A, Durukan, A.B, Evaluation of arrhythmic effects of clarithromycin usage in patients with acute coronary syndrome via new parameters of 12 lead electrocardiography, Turkish Journal of Clinics and Laboratory, 2019, 10, 324-328.
16. Scott, P.A, Yue, A.M, Watts, E, Zeb, M, Roberts, P.R, Morgan, J.M, Transseptal left ventricular endocardial pacing reduces dispersion of ventricular repolarization, Pacing Clinical Electrophysiology, 2011, 34, 1258-1266.
17. Yamaguchi, M, Shimizu, M, Ino, H, Terai, H, Uchiyama, K, Oe, K, et al., T wave peak-to-end interval and QT dispersion in acquired long QT syndrome: a new index for arrhythmogenicity, Clinical science, (Lond), 2003, 105, 671-676.
18. Tabatabaei, P, Keikhavani, A, Haghjoo, M, Fazelifar, A, Emkanjoo, Z, Zeighami, M, Bakhshandeh, H, Ghadrdoost, B, Alizadeh, A, Assessment of QT and JT Intervals in Patients With Left Bundle Branch Block, Research in cardiovascular medicine, 2016, 5:e31528.
19. Bazett, H.C, An analysis of the time-relations of electrocardiograms, Heart Journal, 1920, 7, 353–370.
20. Letsas, K, Weber, R, Astheimer, K, Kalusche, D, Arentz, T, Tpeak–Tend interval and Tpeak– Tend/QT ratio as markers of ventricular tachycardia inducibility in subjects with Brugada ECG phenotype, Europace, 2010, 12, 271-274.
21. Xue, C, Hua, W, Cai, C, Ding, L.G, Liu, Z.M, Fan, X.H, et al., Acute and Chronic Changes and Predictive Value of Tpeak-Tend for Ventricular Arrhythmia Risk in Cardiac Resynchronization Therapy Patients, Chinese medical journal (Engl), 2016, 129, 2204-2211.
22. Ogiso, M, Suzuki, A, Shiga, T, Nakai, K, Shoda, M, Hagiwara, N, Effect of intravenous amiodarone on QT and T peak-T end dispersions in patients with nonischemic heart failure treated with cardiac resynchronization-defibrillator therapy and electrical storm, Journal of Arrhythmia, 2015, 31, 1-5.
23. Roque, C, Trevisi, N, Silberbauer, J, Oloriz, T, Mizuno, H, Baratto, F, et al., Electrical storm induced by cardiacresynchronization therapy is determined by pacing on epicardialscar and can be successfully managed by catheter ablation, Circulation. Arrhythmia and electrophysiology, 2014, 7, 1064–1069.
24. Bogossian, H, Frommeyer, G, Ninios, I, Hasan, F, Nguyen, Q.S, Karosiene, Z, et al., New formula for evaluation of the QT interval in patients with left bundle branch block, Heart Rhythm, 2014, 11, 2273–2273.
25. Itoh, M, Yoshida, A, Fukuzawa, K, Kiuchi, K, Imamura, K, Fujiwara, R, et al., Time-dependent effect of cardiac resynchronization therapy on ventricular repolarization and ventricular arrhythmias, Europace, 2013, 15, 1798- 1804.
26. Thijssen, J, Borleffs, C.J.W, Delgado, V, van Rees, J.B, Mooyaart, E.A.Q, van Bommel, R.J, et al., Implantable cardioverter-defibrillator patients who are upgraded and respond to cardiac resynchronization therapy have less ventricular arrhythmias compared with nonresponders, Journal of American College of Cardiology, 2011, 58, 2282-2289.
27. Gold, M.R, Linde, C, Abraham, W.T, Gardiwal, A, Daubert, J.C, The impact of cardiac resynchronization therapy on the incidence of ventricular arrhythmias in mild heart failure, Heart Rhythm, 2011, 8, 679-684.