新的起搏技术提供了更多的左心室起搏部位选择和更个性化的心脏再同步治疗(CRT)。通常使用急性血液动力学测量的多搏动平均值来比较新型起搏配置对心脏功能的影响。在对iPot试验的分析中,我们探索这是否足够。
iSpot试验是一项国际性的试验,prospective,评估七种CRT配置的急性血流动力学试验:标准CRT,MultiSpot(后外侧静脉),和MultiVein(前后静脉)起搏。有创和无创血压,记录左心室(LV)dP/dtmax。在从AAI交替到测试的起搏配置之前和之后记录了八次搏动,反之亦然。在五个房室延迟中的每一个,每个配置进行了八个交替。
25名患者接受了8次交替的完整方案。仅有4例(16%)患者在统计学上比常规CRT配置改善>3mmHg(后外侧静脉,远端电极)。然而,如果只分析了一个交替(标准的多拍平均协议),15例(60%)患者错误地出现了优越的非常规构型。对起搏的反应在不同的血流动力学指标之间显着相关:有创收缩压(SBP)与非有创收缩压r=0.82(P<.001);有创SBP与LVdP/dtr=0.57,r2=0.32(P<.001)。
不幸的是,当前的标准多拍采集协议无法防止个体患者出现的最佳错误印象。除了平均多个搏动之外,个性化过程还需要包括到测试的起搏配置的不同重复转变。需要不仅在研究阶段,而且在临床实施期间。
New pacing technologies offer a greater choice of left ventricular pacing sites and greater personalization of cardiac resynchronization therapy (CRT). The effects on cardiac function of novel pacing configurations are often compared using multi-beat averages of acute hemodynamic measurements. In this analysis of the iSpot trial, we explore whether this is sufficient.
The iSpot trial was an international, prospective, acute hemodynamic trial that assessed seven CRT configurations: standard CRT,
MultiSpot (posterolateral vein), and MultiVein (anterior and posterior vein) pacing. Invasive and noninvasive blood pressure, and left ventricular (LV) dP/dtmax were recorded. Eight beats were recorded before and after an alternation from AAI to the tested pacing configuration and vice-versa. Eight alternations were performed for each configuration at each of the five atrioventricular delays.
Twenty-five patients underwent the full protocol of eight alternations. Only four (16%) patients had a statistically significant >3 mm Hg improvement over conventional CRT configuration (posterolateral vein, distal electrode). However, if only one alternation was analyzed (standard multi-beat averaging protocol), 15 (60%) patients falsely appeared to have a superior nonconventional configuration. Responses to pacing were significantly correlated between the different hemodynamic measures: invasive systolic blood pressure (SBP) vs noninvasive SBP r = 0.82 (P < .001); invasive SBP vs LV dP/dt r = 0.57, r2 = 0.32 (P < .001).
Current standard multibeat acquisition protocols are unfortunately unable to prevent false impressions of optimality arising in individual patients. Personalization processes need to include distinct repeated transitions to the tested pacing configuration in addition to averaging multiple beats. The need is not only during research stages but also during clinical implementation.