Importance of ventricular function in the election of electro heart mode

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Nicolás-Franco, F.J. Rodríguez-González, A. Nicolás-Boluda, A. Sánchez-Martos" "autores" => array:4 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Nicolás-Franco" "email" => array:1 [ 0 => "silvestre.nicolas@carm.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "F.J." "apellidos" => "Rodríguez-González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Nicolás-Boluda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "A." 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(B) Chest X-ray view showing the electrode in the left ventricle." ] ] ] "textoCompleto" => "IntroductionThe integration of ventricular function is essential when making decisions regarding patients subjected to cardiac electrostimulation in order to understand how the new cardiac stimulation and resynchronizing therapy guides are structured.<a class="elsevierStyleCrossRef" href="#bib0180">1</a> In relation to the present review, it must be taken into account that when we speak of left ventricular dysfunction, we are actually referring to left ventricular systolic dysfunction, not to left ventricular diastolic dysfunction, which is a also a cause of cardiovascular symptoms. Furthermore, cardiac electrostimulation not only comprises conventional pacemakers but also implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy without defibrillation (CRT-P) or with defibrillation (CRT-D). On the other hand, cardiac electrostimulation has presently extended beyond the “stimulation of survival” principle, which aims to achieve a certain heart rate regarded as adequate, and has become a form of “physiological stimulation” designed to secure adequate cardiac function, and which can be analyzed through the concepts of “atrioventricular synchrony” and “intraventricular synchrony”.On the other hand, consideration is required of three premises, described below, which underscore the “importance of ventricular function in cardiac electrostimulation”.Deleterious effect of pacing from the right ventricular apexSince the 1980s, studies conducted in humans<a class="elsevierStyleCrossRef" href="#bib0185">2</a> have shown pacing in sinus rhythm to be characterized by a left ventricle stimulation sequence with early depolarization zones that start at lower septal level and on the anterior aspect, together with other late depolarization zones at apical level and in the basal segments of the inferolateral region. However, when pacing is made from the right ventricular apex there is a significant delay in left ventricular activation, with the observation of early stimulation zones located in the middle septal region and other late activation zones at the inferolateral base. The total left ventricular activation time is prolonged, thereby resulting in a “loss of the normal left ventricular activation sequence” that simulates complete left branch block, with clinical repercussions.A number of clinical studies have demonstrated the inconveniences of pacing from the right ventricular apex. Andersen et al.,<a class="elsevierStyleCrossRef" href="#bib0190">3</a> in patients with sick sinus syndrome, paced one group of subjects exclusively from the atrium (AAI)–a pacing mode that preserves the “left ventricular activation sequence”–and another group exclusively from the right ventricular apex (VVI)–a pacing mode that loses the “left ventricular activation sequence”. This second group of patients showed an increase in mortality of cardiovascular origin and a greater incidence of atrial fibrillation episodes.The MOST study,<a class="elsevierStyleCrossRef" href="#bib0195">4</a> also carried out in patients with sick sinus syndrome, used two pacing modes: (a) dual chamber (DDD), with one electrode in the right atrium and another in the right ventricular apex, in which the left ventricular activation sequence was lost with a high percentage of ventricular pacing (% pacing); and (b) single chamber, with an electrode in the right ventricular apex (VVI) programmed with a low lower frequency limit, implying a low percentage of ventricular pacing. A greater number of hospital admissions due to heart failure and/or atrial fibrillation episodes was recorded in those patients with a higher percentage of ventricular pacing when the latter exceeded 80%.Lastly, the DAVID study<a class="elsevierStyleCrossRef" href="#bib0200">5</a> involved patients with left ventricular dysfunction subjected to ICD implantation as primary prevention measure. The subjects were divided into two groups: a DDD pacing group (receiving a high percentage of ventricular pacing) and a VVI pacing group (receiving a low percentage of ventricular pacing). The trial had to be suspended prematurely because of high mortality among the patients in the group with a greater percentage of stimulation.In addition to these clinical findings, the following functional alterations related to pacing from the right ventricular apex have been described:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-Paradoxical septal motion.<a class="elsevierStyleCrossRef" href="#bib0205">6</a></li><li class="elsevierStyleListItem" id="lsti0010">-Shortened relaxation and filling times.<a class="elsevierStyleCrossRef" href="#bib0210">7</a></li><li class="elsevierStyleListItem" id="lsti0015">-Mitral valve regurgitation.<a class="elsevierStyleCrossRef" href="#bib0215">8</a></li><li class="elsevierStyleListItem" id="lsti0020">-Increased left atrial size.<a class="elsevierStyleCrossRef" href="#bib0220">9</a></li><li class="elsevierStyleListItem" id="lsti0025">-Reduced global and regional left ventricular ejection fraction.<a class="elsevierStyleCrossRef" href="#bib0225">10</a></li></ul>A number of structural<a class="elsevierStyleCrossRef" href="#bib0230">11</a> and molecular alterations have also been described<a class="elsevierStyleCrossRef" href="#bib0235">12</a> that reaffirm the deleterious effects of pacing from the right ventricular apex as a condition or entity in its own right–hence the descriptive term “pacing-induced myocardiopathy”.<a class="elsevierStyleCrossRef" href="#bib0240">13</a>Effect of complete left branch block upon left ventricular functionComplete left branch block (CLBB) causes a delay in contraction of the lateral wall of the left ventricle with respect to the right ventricle and the interventricular septum–producing inefficient contraction that lowers cardiac output and the left ventricular ejection fraction (LVEF). This situation defines a clinical condition characterized by: CLBB (QRS >120ms), LVEF <35% and New York Heart Association (NYHA) functional class II–III. These patients can benefit from specific cardiac electrostimulation known as cardiac resynchronization therapy (CRT).<a class="elsevierStyleCrossRef" href="#bib0245">14</a>On the basis of a DDD pacemaker (if the patient is not in permanent atrial fibrillation), the usual technique involves placing an electrode from the endocardium through the coronary sinus to the epicardium of the left ventricle–preferentially in the basal inferolateral and lateral segments. Occlusive retrograde venography through the coronary sinus is performed during the procedure to visualize the coronary venous system and select the appropriate vein. Synchronized pacing from this position neutralizes the delay produced by the CLBB (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The MIRACLE trial<a class="elsevierStyleCrossRef" href="#bib0245">14</a> compared patients with the above described clinical profile assigned to either conventional medical treatment or resynchronization therapy. The CRT group was seen to present a significant percentage of asymptomatic patients.We now know that patients who respond to CRT have a longer duration QRS, and those with a duration of over 150ms are the most responsive individuals. When echocardiography evidences a delay in the inferolateral segments with respect to the septum (ventricular dyssynchrony), in the absence of associated QRS prolongation, CRT is not indicated.<a class="elsevierStyleCrossRef" href="#bib0250">15</a>Left ventricular dysfunction as arrhythmogenic substrateMyocardial dysfunction gives rise to electrical remodeling independently of whether the origin of the disorder is ischemic or non-ischemic. When a trigger (electrolytic alterations, neurohormonal disorders, alcohol, etc.) acts upon this substrate, ventricular arrhythmias can be triggered that may result in sudden death (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). These circumstances have been known since the 1980s, with the observation of an increase in mortality in patients with myocardial dysfunction<a class="elsevierStyleCrossRef" href="#bib0255">16</a> secondary to the appearance of ventricular arrhythmias (ventricular tachycardia and ventricular fibrillation).<a class="elsevierStyleCrossRef" href="#bib0260">17</a> The placement of a defibrillator in patients with this clinical profile therefore could contribute to reduce the mortality rate (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia>The MADIT II study<a class="elsevierStyleCrossRef" href="#bib0265">18</a> showed that in patients with left ventricular dysfunction of ischemic origin and LVEF <35%, the implantation of an ICD results in lesser mortality than in patients treated only with antiarrhythmic drugs.On the other hand, according to the DEFINITIVE trial,<a class="elsevierStyleCrossRef" href="#bib0270">19</a> carried out in patients with ventricular dysfunction of non-ischemic origin and LVEF <35%, defibrillatory implantation was likewise seen to result in lesser mortality, though in these cases the benefit was less pronounced due to an increase in fatalities more attributable to cardiac contractility failure than to arrhythmias.In terms of mortality, patients with left ventricular dysfunction secondary to complete left branch block also benefit from resynchronization therapy to which defibrillation is moreover added.<a class="elsevierStyleCrossRef" href="#bib0275">20</a>The three profiles described above correspond to indications of ICD for the primary prevention of sudden death. Furthermore, between 15–20% of these patients require anti-bradycardia treatment. It is currently debated whether LVEF should be used as the sole criterion for deciding defibrillator implantation.<a class="elsevierStyleCrossRef" href="#bib0280">21</a> On one hand there are patients with moderate LVEF who suffer sudden death, and who could have benefited from such therapy had they been identified on time. On the other hand, of the patients with severely depressed ventricular function (LVEF <35%) that carry an ICD, approximately 60% receive no treatment during the first three years after implantation. Cardiac MRI with late gadolinium enhancement performed in the first days after acute myocardial infarction is viewed as a technique that will provide new criteria for defining those patients who stand to benefit most from ICD implantation as a primary prevention measure.<a class="elsevierStyleCrossRefs" href="#bib0285">22,23</a>CommentBased on the analysis of the three abovementioned profiles, alternatives have been sought to neutralize or avoid the deleterious effects of pacing from the right ventricular apex. On one hand, considering the hypothesis that “pacing from the right ventricular apex simulates complete left branch block” and that the latter can be corrected by cardiac resynchronization therapy, this technique would appear to be useful for neutralizing such deleterious effects. In this regard, the PACE trial,<a class="elsevierStyleCrossRef" href="#bib0295">24</a> conducted in patients with normal LVEF and bradycardia, compared two pacing modes: resynchronization in one group and pacing from the right ventricular apex in the other. After one year of follow-up, a decrease in mean LVEF was observed in the patients paced from the right ventricular apex that persisted after a period of two years.<a class="elsevierStyleCrossRef" href="#bib0300">25</a> However, on carrying out an individualized analysis in the group of patients paced from the right ventricular apex, only 9% were found to have depressed LVEF (<50%).The DANPACE study,<a class="elsevierStyleCrossRef" href="#bib0305">26</a> designed to assess the benefit of dual chamber stimulation in patients with sick sinus syndrome and preserved LVEF, recorded no clinical differences in terms of hospital admission due to atrial fibrillation or heart failure between patients paced from the apex and individuals with a low percentage of stimulation.On examining the prevalence of ventricular dysfunction in patients paced from the right ventricular apex and starting with normal LVEF (>50%), a 9% ventricular dysfunction rate was observed after one year of pacing,<a class="elsevierStyleCrossRef" href="#bib0295">24</a> versus 13% in patients paced for 15 years<a class="elsevierStyleCrossRef" href="#bib0305">26</a> and 15% in patients paced for 24 years.<a class="elsevierStyleCrossRef" href="#bib0240">13</a> It therefore can be affirmed that the deleterious effects of pacing from the right ventricular apex in patients with normal LVEF (>50%) are seen in only a small number of patients (in general terms 1/10), and there are no criteria allowing us to identify such individuals beforehand.The situation is different when the patients start with LVEF <50%. In this regard, the BLOCK trial<a class="elsevierStyleCrossRef" href="#bib0310">27</a> evaluated subjects with LVEF <50% and complete atrioventricular block (requiring high percentages of ventricular pacing) subjected to two cardiac electrostimulation treatments (pacing from the right ventricular apex/cardiac resynchronization). The patients subjected to pacing from the right ventricular apex showed increased mortality, more admissions due to heart failure, and an increase in left ventricle end-systolic volume (LVESV).Another proposal for minimizing the deleterious effect of pacing from the right ventricular apex is to perform pacing from a point of the conduction system that does not result in loss of the “normal left ventricular activation sequence”–a situation known as “pacing from sites alternative to the right ventricular apex”. Two pacing points have been proposed: (a) the ventricular septum, which includes the right ventricle outflow tract (RVOT) at different levels (high and middle); and (b) the bundle of His. A number of studies involving small patient samples have been published on this subject.<a class="elsevierStyleCrossRefs" href="#bib0315">28–32</a> In general terms, when the patients have a normal LVEF (>50%), no benefits with respect to pacing from the apex are observed. In contrast, when LVEF is depressed (<50%), the ejection fraction experiences less worsening than when pacing is performed from the apex–though no clinical improvements in terms of exercise capacity, quality of life or survival are observed.On the other hand, implantation in the bundle of His or in para-Hisian zones is scantly effective, since only about 50% of the patients can be controlled with this procedure, and high thresholds are moreover required.<a class="elsevierStyleCrossRef" href="#bib0340">33</a> In turn, when pacing from the RVOT, the electrode is effectively placed in the septum in only one-third of the cases. In the rest of the cases it is positioned in the anterior wall or right ventricle free wall. In this regard, positioning of the electrode in the anterior wall or lateral wall of the right ventricle affords no functional benefits.<a class="elsevierStyleCrossRef" href="#bib0345">34</a>Lastly, in patients paced from the right ventricular apex and who require “replacement”, it is considered that those individuals with depressed LVEF, high percentages of right ventricle stimulation (>80%) and no symptoms or only moderate symptoms of heart failure could benefit from an upgrade to resynchronization therapy–improvements being observed in both functional (increased LVEF) and clinical terms (improved functional capacity and quality of life).<a class="elsevierStyleCrossRef" href="#bib0350">35</a>In sum, when deciding the cardiac electrostimulation mode to be used in a given patient, we first must analyze the required percentage of ventricular pacing. If this percentage is low, as in the case of neurologically mediated syndromes, sinus dysfunction syndrome or paroxysmal atrioventricular block, we can pace from the right ventricular apex using algorithms that minimize ventricular pacing (not been addressed in this review).In contrast, when a high percentage of pacing is contemplated (>60–80%), we must assess ventricular function. If the latter is found to be normal (LVEF >50%), we can pace from the right ventricular apex, taking into account that about 10% of the patients will develop left ventricular dysfunction, and these individuals will have to be identified by echocardiography after one year, with the assessment of possible upgrading to resynchronization. Alternatively, we can pace from other sites such as the ventricular septum (provided we are sure that pacing really takes place from the septum), or resort to Hisian or para-Hisian pacing.However, in patients with LVEF less than 50% and over 35%, we can opt for cardiac resynchronization therapy. In patients with ischemic heart disease it is advisable to use cardiac MRI to make sure that there is no scarring in the left ventricle segments used for pacing, thereby minimizing the number of non-responders. Lastly, if LVEF <35%, we should add ICD to resynchronization therapy in order to protect the patient against the risk of sudden death. It must be remembered that these indications are to be established on an individualized basis, taking into account the life expectancy of the patient as conditioned by the existing non-cardiac morbidities. In this respect, a life expectancy of over one year is recommended (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).<elsevierMultimedia ident="fig0020"></elsevierMultimedia>Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres475187" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec497268" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres475188" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec497267" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Deleterious effect of pacing from the right ventricular apex" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Effect of complete left branch block upon left ventricular function" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Left ventricular dysfunction as arrhythmogenic substrate" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Comment" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-04-10" "fechaAceptado" => "2014-09-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec497268" "palabras" => array:5 [ 0 => "Cardiac electrostimulation" 1 => "Pacemakers" 2 => "Cardioverter-defibrillation" 3 => "Biventricular pacing" 4 => "Ventricular function" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec497267" "palabras" => array:5 [ 0 => "Electroestimulación cardiaca" 1 => "Marcapasos" 2 => "Desfibriladores" 3 => "Resincronización cardiaca" 4 => "Función ventricular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The integration of the ventricular function is essential when making decisions over a patient subjected to cardiac electrostimulation in order to understand the structure followed in the new cardiac stimulation and resynchronizing therapy guides. To support the importance of ventricular function in cardiac electrostimulation it is important to know: (a) the deleterious effect of stimulation on the right ventricle apex; (b) the effect over the left ventricular function produced by complete blockage of the left branch, and (c) left ventricular disfunction as arrythmogenic substrate. When it comes to decide what type of cardiac electrostimualtion to apply we will know: the percentage of ventricular stimulation needed and its ventricular function. A normal ventricular function will enable electrostimulation from the right ventricle apex or alternative site. On the contrary, if this value is lower than 50% the most recommended electrostimulation is cardiac resynchronization (CRT-P), which will be accompanied by defibrillation (CRT-D) if FEVI is lower than 35%." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La integración de la función ventricular en la toma de decisiones del paciente sometido a electroestimulación cardiaca resulta fundamental para comprender la estructuración de las nuevas guías sobre estimulación cardiaca y terapia de resincronización. Para argumentar la importancia de la función ventricular en la electroestimulación cardiaca es necesario conocer: a) el efecto deletéreo de la estimulación desde el ápex del ventrículo derecho; b) el efecto del bloqueo completo de rama izquierda sobre la función ventricular izquierda, y c) la disfunción ventricular izquierda como sustrato arritmogénico. Así, cuando decidimos el modo de electroestimulación cardiaca a aplicar debemos conocer el porcentaje de estimulación ventricular que precisará y su función ventricular. Si esta es normal, permitirá estimular desde el ápex del ventrículo derecho o desde sitios alternativos al ápex. Por el contrario, si es menor del 50% es recomendable la resincronización cardiaca (CRT-P) acompañada de desfibrilación (CRT-D) si la FEVI es menor del 35%." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Nicolás-Franco S, Rodríguez-González FJ, Nicolás-Boluda A, Sánchez-Martos A. Importancia de la función ventricular en la elección del modo de electroestimulación cardiaca. Med Intensiva. 2015;39:172–178." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1072 "Ancho" => 2332 "Tamanyo" => 154191 ] ] "descripcion" => array:1 [ "en" => "(A) Occlusive retrograde venography. (B) Chest X-ray view showing the electrode in the left ventricle." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1373 "Ancho" => 2531 "Tamanyo" => 135705 ] ] "descripcion" => array:1 [ "en" => "Myocardial dysfunction as an arrhythmogenic substrate in sudden death." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 982 "Ancho" => 999 "Tamanyo" => 111437 ] ] "descripcion" => array:1 [ "en" => "Ventricular electrode placed in the septum of the right ventricle outflow tract." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1663 "Ancho" => 3006 "Tamanyo" => 204640 ] ] "descripcion" => array:1 [ "en" => "Selection of cardiac electrostimulation mode. *Follow-up during the first year, detecting the group of patients who develop ventricular dysfunction. **Under revision, pending introduction of new criteria fundamentally based on cardiac imaging (late gadolinium enhancement). CRT-D: cardiac resynchronization with defibrillation; CRT-P: cardiac resynchronization without defibrillation; LVEF: left ventricular ejection fraction." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:35 [ 0 => array:3 [ "identificador" => "bib0180" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2013 ESC guideline on cardiac pacing and cardiac resynchronization therapy" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "The Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC)" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/eht150" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2013" "volumen" => "34" "paginaInicial" => "2281" "paginaFinal" => "2324" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23801822" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0185" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Endocardial mapping in humans in sinus rhythm with normal left ventricles: activation patterns and characteristics of electrograms" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D.M. 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Importance of ventricular function in the election of electro heart mode

Importancia de la función ventricular en la elección del modo de electroestimulación cardiaca

S. Nicolás-Francoa,

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silvestre.nicolas@carm.es

Corresponding author.

, F.J. Rodríguez-Gonzáleza, A. Nicolás-Boludab, A. Sánchez-Martosa

a Cardiac Pacing Unit, Hospital General Universitario Rafael Méndez, Lorca, Murcia, Spain

b Biotechnology, Universidad Politécnica de Valencia, Valencia, Spain

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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Occlusive retrograde venography&#46; &#40;B&#41; Chest X-ray view showing the electrode in the left ventricle&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The integration of ventricular function is essential when making decisions regarding patients subjected to cardiac electrostimulation in order to understand how the new cardiac stimulation and resynchronizing therapy guides are structured&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">1</span></a> In relation to the present review&#44; it must be taken into account that when we speak of <span class="elsevierStyleItalic">left ventricular dysfunction</span>&#44; we are actually referring to left ventricular systolic dysfunction&#44; not to left ventricular diastolic dysfunction&#44; which is a also a cause of cardiovascular symptoms&#46; Furthermore&#44; <span class="elsevierStyleItalic">cardiac electrostimulation</span> not only comprises conventional pacemakers but also implantable cardioverter-defibrillators &#40;ICDs&#41; and cardiac resynchronization therapy without defibrillation &#40;CRT-P&#41; or with defibrillation &#40;CRT-D&#41;&#46; On the other hand&#44; cardiac electrostimulation has presently extended beyond the &#8220;stimulation of survival&#8221; principle&#44; which aims to achieve a certain heart rate regarded as adequate&#44; and has become a form of &#8220;physiological stimulation&#8221; designed to secure adequate cardiac function&#44; and which can be analyzed through the concepts of &#8220;atrioventricular synchrony&#8221; and &#8220;intraventricular synchrony&#8221;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">On the other hand&#44; consideration is required of three premises&#44; described below&#44; which underscore the &#8220;importance of ventricular function in cardiac electrostimulation&#8221;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Deleterious effect of pacing from the right ventricular apex</span><p id="par0015" class="elsevierStylePara elsevierViewall">Since the 1980s&#44; studies conducted in humans<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">2</span></a> have shown pacing in sinus rhythm to be characterized by a left ventricle stimulation sequence with early depolarization zones that start at lower septal level and on the anterior aspect&#44; together with other late depolarization zones at apical level and in the basal segments of the inferolateral region&#46; However&#44; when pacing is made from the right ventricular apex there is a significant delay in left ventricular activation&#44; with the observation of early stimulation zones located in the middle septal region and other late activation zones at the inferolateral base&#46; The total left ventricular activation time is prolonged&#44; thereby resulting in a &#8220;loss of the normal left ventricular activation sequence&#8221; that simulates complete left branch block&#44; with clinical repercussions&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A number of clinical studies have demonstrated the inconveniences of pacing from the right ventricular apex&#46; Andersen et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">3</span></a> in patients with sick sinus syndrome&#44; paced one group of subjects exclusively from the atrium &#40;AAI&#41;&#8211;a pacing mode that preserves the &#8220;left ventricular activation sequence&#8221;&#8211;and another group exclusively from the right ventricular apex &#40;VVI&#41;&#8211;a pacing mode that loses the &#8220;left ventricular activation sequence&#8221;&#46; This second group of patients showed an increase in mortality of cardiovascular origin and a greater incidence of atrial fibrillation episodes&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The MOST study&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">4</span></a> also carried out in patients with sick sinus syndrome&#44; used two pacing modes&#58; &#40;a&#41; dual chamber &#40;DDD&#41;&#44; with one electrode in the right atrium and another in the right ventricular apex&#44; in which the left ventricular activation sequence was lost with a high percentage of ventricular pacing &#40;&#37; pacing&#41;&#59; and &#40;b&#41; single chamber&#44; with an electrode in the right ventricular apex &#40;VVI&#41; programmed with a low lower frequency limit&#44; implying a low percentage of ventricular pacing&#46; A greater number of hospital admissions due to heart failure and&#47;or atrial fibrillation episodes was recorded in those patients with a higher percentage of ventricular pacing when the latter exceeded 80&#37;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Lastly&#44; the DAVID study<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">5</span></a> involved patients with left ventricular dysfunction subjected to ICD implantation as primary prevention measure&#46; The subjects were divided into two groups&#58; a DDD pacing group &#40;receiving a high percentage of ventricular pacing&#41; and a VVI pacing group &#40;receiving a low percentage of ventricular pacing&#41;&#46; The trial had to be suspended prematurely because of high mortality among the patients in the group with a greater percentage of stimulation&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In addition to these clinical findings&#44; the following functional alterations related to pacing from the right ventricular apex have been described&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">Paradoxical septal motion&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">6</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">Shortened relaxation and filling times&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">7</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Mitral valve regurgitation&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">8</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Increased left atrial size&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">9</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Reduced global and regional left ventricular ejection fraction&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">10</span></a></p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">A number of structural<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">11</span></a> and molecular alterations have also been described<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">12</span></a> that reaffirm the deleterious effects of pacing from the right ventricular apex as a condition or entity in its own right&#8211;hence the descriptive term &#8220;pacing-induced myocardiopathy&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Effect of complete left branch block upon left ventricular function</span><p id="par0070" class="elsevierStylePara elsevierViewall">Complete left branch block &#40;CLBB&#41; causes a delay in contraction of the lateral wall of the left ventricle with respect to the right ventricle and the interventricular septum&#8211;producing inefficient contraction that lowers cardiac output and the left ventricular ejection fraction &#40;LVEF&#41;&#46; This situation defines a clinical condition characterized by&#58; CLBB &#40;QRS &#62;120<span class="elsevierStyleHsp" style=""></span>ms&#41;&#44; LVEF &#60;35&#37; and New York Heart Association &#40;NYHA&#41; functional class II&#8211;III&#46; These patients can benefit from specific cardiac electrostimulation known as cardiac resynchronization therapy &#40;CRT&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">14</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">On the basis of a DDD pacemaker &#40;if the patient is not in permanent atrial fibrillation&#41;&#44; the usual technique involves placing an electrode from the endocardium through the coronary sinus to the epicardium of the left ventricle&#8211;preferentially in the basal inferolateral and lateral segments&#46; Occlusive retrograde venography through the coronary sinus is performed during the procedure to visualize the coronary venous system and select the appropriate vein&#46; Synchronized pacing from this position neutralizes the delay produced by the CLBB &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The MIRACLE trial<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">14</span></a> compared patients with the above described clinical profile assigned to either conventional medical treatment or resynchronization therapy&#46; The CRT group was seen to present a significant percentage of asymptomatic patients&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">We now know that patients who respond to CRT have a longer duration QRS&#44; and those with a duration of over 150<span class="elsevierStyleHsp" style=""></span>ms are the most responsive individuals&#46; When echocardiography evidences a delay in the inferolateral segments with respect to the septum &#40;ventricular dyssynchrony&#41;&#44; in the absence of associated QRS prolongation&#44; CRT is not indicated&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Left ventricular dysfunction as arrhythmogenic substrate</span><p id="par0090" class="elsevierStylePara elsevierViewall">Myocardial dysfunction gives rise to electrical remodeling independently of whether the origin of the disorder is ischemic or non-ischemic&#46; When a trigger &#40;electrolytic alterations&#44; neurohormonal disorders&#44; alcohol&#44; etc&#46;&#41; acts upon this substrate&#44; ventricular arrhythmias can be triggered that may result in sudden death &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; These circumstances have been known since the 1980s&#44; with the observation of an increase in mortality in patients with myocardial dysfunction<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">16</span></a> secondary to the appearance of ventricular arrhythmias &#40;ventricular tachycardia and ventricular fibrillation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">17</span></a> The placement of a defibrillator in patients with this clinical profile therefore could contribute to reduce the mortality rate &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The MADIT II study<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">18</span></a> showed that in patients with left ventricular dysfunction of ischemic origin and LVEF &#60;35&#37;&#44; the implantation of an ICD results in lesser mortality than in patients treated only with antiarrhythmic drugs&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">On the other hand&#44; according to the DEFINITIVE trial&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">19</span></a> carried out in patients with ventricular dysfunction of non-ischemic origin and LVEF &#60;35&#37;&#44; defibrillatory implantation was likewise seen to result in lesser mortality&#44; though in these cases the benefit was less pronounced due to an increase in fatalities more attributable to cardiac contractility failure than to arrhythmias&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In terms of mortality&#44; patients with left ventricular dysfunction secondary to complete left branch block also benefit from resynchronization therapy to which defibrillation is moreover added&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">20</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The three profiles described above correspond to indications of ICD for the primary prevention of sudden death&#46; Furthermore&#44; between 15&#8211;20&#37; of these patients require anti-bradycardia treatment&#46; It is currently debated whether LVEF should be used as the sole criterion for deciding defibrillator implantation&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">21</span></a> On one hand there are patients with moderate LVEF who suffer sudden death&#44; and who could have benefited from such therapy had they been identified on time&#46; On the other hand&#44; of the patients with severely depressed ventricular function &#40;LVEF &#60;35&#37;&#41; that carry an ICD&#44; approximately 60&#37; receive no treatment during the first three years after implantation&#46; Cardiac MRI with late gadolinium enhancement performed in the first days after acute myocardial infarction is viewed as a technique that will provide new criteria for defining those patients who stand to benefit most from ICD implantation as a primary prevention measure&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">22&#44;23</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Comment</span><p id="par0115" class="elsevierStylePara elsevierViewall">Based on the analysis of the three abovementioned profiles&#44; alternatives have been sought to neutralize or avoid the deleterious effects of pacing from the right ventricular apex&#46; On one hand&#44; considering the hypothesis that &#8220;pacing from the right ventricular apex simulates complete left branch block&#8221; and that the latter can be corrected by cardiac resynchronization therapy&#44; this technique would appear to be useful for neutralizing such deleterious effects&#46; In this regard&#44; the PACE trial&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">24</span></a> conducted in patients with normal LVEF and bradycardia&#44; compared two pacing modes&#58; resynchronization in one group and pacing from the right ventricular apex in the other&#46; After one year of follow-up&#44; a decrease in mean LVEF was observed in the patients paced from the right ventricular apex that persisted after a period of two years&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">25</span></a> However&#44; on carrying out an individualized analysis in the group of patients paced from the right ventricular apex&#44; only 9&#37; were found to have depressed LVEF &#40;&#60;50&#37;&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The DANPACE study&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">26</span></a> designed to assess the benefit of dual chamber stimulation in patients with sick sinus syndrome and preserved LVEF&#44; recorded no clinical differences in terms of hospital admission due to atrial fibrillation or heart failure between patients paced from the apex and individuals with a low percentage of stimulation&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">On examining the prevalence of ventricular dysfunction in patients paced from the right ventricular apex and starting with normal LVEF &#40;&#62;50&#37;&#41;&#44; a 9&#37; ventricular dysfunction rate was observed after one year of pacing&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">24</span></a> versus 13&#37; in patients paced for 15 years<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">26</span></a> and 15&#37; in patients paced for 24 years&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">13</span></a> It therefore can be affirmed that the deleterious effects of pacing from the right ventricular apex in patients with normal LVEF &#40;&#62;50&#37;&#41; are seen in only a small number of patients &#40;in general terms 1&#47;10&#41;&#44; and there are no criteria allowing us to identify such individuals beforehand&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The situation is different when the patients start with LVEF &#60;50&#37;&#46; In this regard&#44; the BLOCK trial<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">27</span></a> evaluated subjects with LVEF &#60;50&#37; and complete atrioventricular block &#40;requiring high percentages of ventricular pacing&#41; subjected to two cardiac electrostimulation treatments &#40;pacing from the right ventricular apex&#47;cardiac resynchronization&#41;&#46; The patients subjected to pacing from the right ventricular apex showed increased mortality&#44; more admissions due to heart failure&#44; and an increase in left ventricle end-systolic volume &#40;LVESV&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Another proposal for minimizing the deleterious effect of pacing from the right ventricular apex is to perform pacing from a point of the conduction system that does not result in loss of the &#8220;normal left ventricular activation sequence&#8221;&#8211;a situation known as &#8220;pacing from sites alternative to the right ventricular apex&#8221;&#46; Two pacing points have been proposed&#58; &#40;a&#41; the ventricular septum&#44; which includes the right ventricle outflow tract &#40;RVOT&#41; at different levels &#40;high and middle&#41;&#59; and &#40;b&#41; the bundle of His&#46; A number of studies involving small patient samples have been published on this subject&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">28&#8211;32</span></a> In general terms&#44; when the patients have a normal LVEF &#40;&#62;50&#37;&#41;&#44; no benefits with respect to pacing from the apex are observed&#46; In contrast&#44; when LVEF is depressed &#40;&#60;50&#37;&#41;&#44; the ejection fraction experiences less worsening than when pacing is performed from the apex&#8211;though no clinical improvements in terms of exercise capacity&#44; quality of life or survival are observed&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">On the other hand&#44; implantation in the bundle of His or in para-Hisian zones is scantly effective&#44; since only about 50&#37; of the patients can be controlled with this procedure&#44; and high thresholds are moreover required&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">33</span></a> In turn&#44; when pacing from the RVOT&#44; the electrode is effectively placed in the septum in only one-third of the cases&#46; In the rest of the cases it is positioned in the anterior wall or right ventricle free wall&#46; In this regard&#44; positioning of the electrode in the anterior wall or lateral wall of the right ventricle affords no functional benefits&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">34</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Lastly&#44; in patients paced from the right ventricular apex and who require &#8220;replacement&#8221;&#44; it is considered that those individuals with depressed LVEF&#44; high percentages of right ventricle stimulation &#40;&#62;80&#37;&#41; and no symptoms or only moderate symptoms of heart failure could benefit from an upgrade to resynchronization therapy&#8211;improvements being observed in both functional &#40;increased LVEF&#41; and clinical terms &#40;improved functional capacity and quality of life&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">35</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In sum&#44; when deciding the cardiac electrostimulation mode to be used in a given patient&#44; we first must analyze the required <span class="elsevierStyleItalic">percentage of ventricular pacing</span>&#46; If this percentage is low&#44; as in the case of neurologically mediated syndromes&#44; sinus dysfunction syndrome or paroxysmal atrioventricular block&#44; we can pace from the right ventricular apex using algorithms that minimize ventricular pacing &#40;not been addressed in this review&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In contrast&#44; when a high percentage of pacing is contemplated &#40;&#62;60&#8211;80&#37;&#41;&#44; we must assess <span class="elsevierStyleItalic">ventricular function</span>&#46; If the latter is found to be <span class="elsevierStyleItalic">normal</span> &#40;LVEF &#62;50&#37;&#41;&#44; we can pace from the right ventricular apex&#44; taking into account that about 10&#37; of the patients will develop left ventricular dysfunction&#44; and these individuals will have to be identified by echocardiography after one year&#44; with the assessment of possible upgrading to resynchronization&#46; Alternatively&#44; we can pace from other sites such as the ventricular septum &#40;provided we are sure that pacing really takes place from the septum&#41;&#44; or resort to Hisian or para-Hisian pacing&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">However&#44; in patients with <span class="elsevierStyleItalic">LVEF less than 50&#37; and over 35&#37;</span>&#44; we can opt for cardiac resynchronization therapy&#46; In patients with ischemic heart disease it is advisable to use cardiac MRI to make sure that there is no scarring in the left ventricle segments used for pacing&#44; thereby minimizing the number of non-responders&#46; Lastly&#44; if <span class="elsevierStyleItalic">LVEF &#60;35&#37;</span>&#44; we should add ICD to resynchronization therapy in order to protect the patient against the risk of sudden death&#46; It must be remembered that these indications are to be established on an individualized basis&#44; taking into account the life expectancy of the patient as conditioned by the existing non-cardiac morbidities&#46; In this respect&#44; a life expectancy of over one year is recommended &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "xres475187"
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          "titulo" => "Introduction"
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          "identificador" => "sec0010"
          "titulo" => "Deleterious effect of pacing from the right ventricular apex"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Effect of complete left branch block upon left ventricular function"
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        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Left ventricular dysfunction as arrhythmogenic substrate"
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        8 => array:2 [
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          "titulo" => "Comment"
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            0 => "Cardiac electrostimulation"
            1 => "Pacemakers"
            2 => "Cardioverter-defibrillation"
            3 => "Biventricular pacing"
            4 => "Ventricular function"
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            0 => "Electroestimulaci&#243;n cardiaca"
            1 => "Marcapasos"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The integration of the ventricular function is essential when making decisions over a patient subjected to cardiac electrostimulation in order to understand the structure followed in the new cardiac stimulation and resynchronizing therapy guides&#46; To support the importance of ventricular function in cardiac electrostimulation it is important to know&#58; &#40;a&#41; the deleterious effect of stimulation on the right ventricle apex&#59; &#40;b&#41; the effect over the left ventricular function produced by complete blockage of the left branch&#44; and &#40;c&#41; left ventricular disfunction as arrythmogenic substrate&#46; When it comes to decide what type of cardiac electrostimualtion to apply we will know&#58; the percentage of ventricular stimulation needed and its ventricular function&#46; A normal ventricular function will enable electrostimulation from the right ventricle apex or alternative site&#46; On the contrary&#44; if this value is lower than 50&#37; the most recommended electrostimulation is cardiac resynchronization &#40;CRT-P&#41;&#44; which will be accompanied by defibrillation &#40;CRT-D&#41; if FEVI is lower than 35&#37;&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La integraci&#243;n de la funci&#243;n ventricular en la toma de decisiones del paciente sometido a electroestimulaci&#243;n cardiaca resulta fundamental para comprender la estructuraci&#243;n de las nuevas gu&#237;as sobre estimulaci&#243;n cardiaca y terapia de resincronizaci&#243;n&#46; Para argumentar la importancia de la funci&#243;n ventricular en la electroestimulaci&#243;n cardiaca es necesario conocer&#58; a&#41; el efecto delet&#233;reo de la estimulaci&#243;n desde el &#225;pex del ventr&#237;culo derecho&#59; b&#41; el efecto del bloqueo completo de rama izquierda sobre la funci&#243;n ventricular izquierda&#44; y c&#41; la disfunci&#243;n ventricular izquierda como sustrato arritmog&#233;nico&#46; As&#237;&#44; cuando decidimos el modo de electroestimulaci&#243;n cardiaca a aplicar debemos conocer el porcentaje de estimulaci&#243;n ventricular que precisar&#225; y su funci&#243;n ventricular&#46; Si esta es normal&#44; permitir&#225; estimular desde el &#225;pex del ventr&#237;culo derecho o desde sitios alternativos al &#225;pex&#46; Por el contrario&#44; si es menor del 50&#37; es recomendable la resincronizaci&#243;n cardiaca &#40;CRT-P&#41; acompa&#241;ada de desfibrilaci&#243;n &#40;CRT-D&#41; si la FEVI es menor del 35&#37;&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Nicol&#225;s-Franco S&#44; Rodr&#237;guez-Gonz&#225;lez FJ&#44; Nicol&#225;s-Boluda A&#44; S&#225;nchez-Martos A&#46; Importancia de la funci&#243;n ventricular en la elecci&#243;n del modo de electroestimulaci&#243;n cardiaca&#46; Med Intensiva&#46; 2015&#59;39&#58;172&#8211;178&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Occlusive retrograde venography&#46; &#40;B&#41; Chest X-ray view showing the electrode in the left ventricle&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Ventricular electrode placed in the septum of the right ventricle outflow tract&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Selection of cardiac electrostimulation mode&#46; &#42;Follow-up during the first year&#44; detecting the group of patients who develop ventricular dysfunction&#46; &#42;&#42;Under revision&#44; pending introduction of new criteria fundamentally based on cardiac imaging &#40;late gadolinium enhancement&#41;&#46; CRT-D&#58; cardiac resynchronization with defibrillation&#59; CRT-P&#58; cardiac resynchronization without defibrillation&#59; LVEF&#58; left ventricular ejection fraction&#46;</p>"
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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2015.03.001

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Year/Month	Html	Pdf	Total

2024 November	8	10	18
2024 October	40	44	84
2024 September	42	35	77
2024 August	84	44	128
2024 July	40	26	66
2024 June	71	44	115
2024 May	47	31	78
2024 April	64	45	109
2024 March	42	30	72
2024 February	51	38	89
2024 January	37	31	68
2023 December	36	38	74
2023 November	50	35	85
2023 October	35	26	61
2023 September	49	36	85
2023 August	38	20	58
2023 July	39	33	72
2023 June	36	21	57
2023 May	53	33	86
2023 April	66	23	89
2023 March	84	40	124
2023 February	80	30	110
2023 January	77	18	95
2022 December	80	33	113
2022 November	98	34	132
2022 October	67	39	106
2022 September	81	30	111
2022 August	66	36	102
2022 July	59	31	90
2022 June	50	27	77
2022 May	74	45	119
2022 April	135	38	173
2022 March	135	39	174
2022 February	128	29	157
2022 January	155	32	187
2021 December	67	39	106
2021 November	103	46	149
2021 October	115	66	181
2021 September	53	51	104
2021 August	44	44	88
2021 July	31	41	72
2021 June	47	31	78
2021 May	83	42	125
2021 April	134	67	201
2021 March	110	30	140
2021 February	97	29	126
2021 January	73	31	104
2020 December	57	28	85
2020 November	62	21	83
2020 October	80	23	103
2020 September	149	18	167
2020 August	52	15	67
2020 July	51	21	72
2020 June	68	17	85
2020 May	56	13	69
2020 April	36	32	68
2020 March	39	17	56
2020 February	118	38	156
2020 January	80	29	109
2019 December	64	21	85
2019 November	73	25	98
2019 October	68	30	98
2019 September	60	20	80
2019 August	43	25	68
2019 July	37	20	57
2019 June	38	15	53
2019 May	62	29	91
2019 April	41	25	66
2019 March	36	18	54
2019 February	37	34	71
2019 January	45	27	72
2018 December	93	54	147
2018 November	173	41	214
2018 October	169	30	199
2018 September	68	7	75
2018 August	39	5	44
2018 July	46	6	52
2018 June	76	7	83
2018 May	10	4	14
2018 April	167	6	173
2018 March	83	4	87
2018 February	20	6	26
2018 January	29	8	37
2017 December	37	4	41
2017 November	24	6	30
2017 October	26	9	35
2017 September	19	5	24
2017 August	14	7	21
2017 July	21	6	27
2017 June	39	28	67
2017 May	39	6	45
2017 April	35	6	41
2017 March	11	28	39
2017 February	17	6	23
2017 January	8	2	10
2016 December	33	6	39
2016 November	61	11	72
2016 October	60	20	80
2016 September	44	7	51
2016 August	46	4	50
2016 July	31	12	43

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