Norbert M van Hemel

Publications of Norbert M van Hemel

• Long-term outcome of cardiac pacing in octogenarians and nonagenarians.

  Authors: Erik O Udo, Norbert M van Hemel, Nicolaas P A Zuithoff, Johannes C Kelder, Har A Crommentuijn, Atie M Koopman-Verhagen, Theo Voskuil, Pieter A F M Doevendans, Karel G M Moons

  Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 10/2011;

  AimsThe number of patients >80 years receiving pacemakers (PMs) is increasing. Little is known about survival and complications in this specific subgroup. We aim to determine predictors of long-termAimsThe number of patients >80 years receiving pacemakers (PMs) is increasing. Little is known about survival and complications in this specific subgroup. We aim to determine predictors of long-term survival.Methods and resultsPacemaker-related complications and death occurring in patients receiving a first PM for conventional bradycardia indications were systematically documented (the FollowPace registry). This report describes 481 patients ≥80 years during a mean follow-up of 5.8 (SD 1.2) years. Within 2 months 54 PM complications occurred in 47 patients (9.8%). During follow-up, 35 adverse PM events were reported in 33 patients (6.9%). Complication rates in patients ≥80 years were comparable with those for patients <80 years. Survival rates were 86, 75, and 49% after 1, 2, and 5 years, respectively, and were comparable with survival for age- and sex-matched controls from the general Dutch population. Most patients died of non-cardiac causes. Age at the time of implantation, male gender, the presence of congestive heart failure, coronary pathology, and diabetes mellitus were independent predictors of all-cause mortality.ConclusionThis large study of long-term cardiac pacing for bradycardia in octogenarians and nonagenarians showed a cumulative 5-year survival of ∼50%, which compares with that of age- and sex-matched controls. These data suggest a beneficial impact of bradycardia pacing, restoring life expectancy to previous levels. The occurrence of PM complications during long-term follow-up is not infrequent with 18.1% of patients experiencing a PM-related complication during a mean of 5.8 years follow-up. The complication rate was not higher than in younger PM patients.ClinicalTrials.gov Identifier: NCT00135174 http://www.clinicaltrials.gov/ct2/show/NCT00135174.

• Increased amount of atrial fibrosis in patients with atrial fibrillation secondary to mitral valve disease.

  Authors: Guillaume S C Geuzebroek, Shirley C M van Amersfoorth, Mark G Hoogendijk, Johannes C Kelder, Norbert M van Hemel, Jacques M T de Bakker, Ruben Coronel

  The Journal of thoracic and cardiovascular surgery. 10/2011;

  OBJECTIVE: Atrial fibrosis is related to atrial fibrillation but may differ in patients with mitral valve disease or lone atrial fibrillation. Therefore, we studied atrial fibrosis in patients withOBJECTIVE: Atrial fibrosis is related to atrial fibrillation but may differ in patients with mitral valve disease or lone atrial fibrillation. Therefore, we studied atrial fibrosis in patients with atrial fibrillation + mitral valve disease or with lone atrial fibrillation and compared it with controls. METHODS: Left and right atrial appendages amputated during Maze III surgery for lone atrial fibrillation (n = 85) or atrial fibrillation + mitral valve disease (n = 26) were embedded in paraffin, sectioned, and stained with picrosirius red. Atria from 10 deceased patients without a cardiovascular history served as controls. A total of 1048 images (4-μm sections, 10-fold magnification, 4 images per appendage) were obtained and digitized. The percentage of fibrous tissue was calculated by quantitative morphometry. RESULTS: Irrespective of the presence or absence of atrial fibrillation or mitral valve disease, more fibrous tissue was present in right atrial appendages than in left atrial appendages (12.7% ± 5.7% vs 8.2% ± 3.9%; P < .0001). The mean amount of fibrous tissue in the atria was significantly larger in patients with atrial fibrillation + mitral valve disease than in patients with lone AF and controls (13.6% ± 5.8%, 9.7% ± 3.2%, and 8.8% ± 2.4%, respectively; P < .01). No significant differences existed between patients with lone atrial fibrillation and patients without a cardiovascular history (controls). CONCLUSIONS: Atria of patients with atrial fibrillation and mitral valve disease have more fibrosis than atria of patients with lone atrial fibrillation. However, patients with lone atrial fibrillation have an equal amount of atrial fibrosis compared with controls. These findings support the notion that fibrosis plays a more important role in the pathogenesis of atrial fibrillation secondary to mitral valve disease than in lone atrial fibrillation and potentially explains the relatively poor success of antiarrhythmic surgery in patients with mitral valve disease.

• Effects of pacing rates on global and regional myocardial blood flow.

  Authors: Tim J F Ten Cate, Paul Knaapen, Adriaan A Lammertsma, Carel C De Cock, Norbert M Van Hemel, J Fred Verzijlbergen

  Pacing and clinical electrophysiology : PACE. 05/2011; 34(5):587-92.

  Information is scarce on the effects of right ventricular apical (RVA) pacing on regional and global myocardial blood flow (MBF). The purpose of this study was to assess the relationship betweenInformation is scarce on the effects of right ventricular apical (RVA) pacing on regional and global myocardial blood flow (MBF). The purpose of this study was to assess the relationship between pacing rate and both regional and global MBF. Four patients with exclusive atrial pacing and six patients with exclusive RVA pacing underwent three consecutive H(2) (15)O positron emission tomography scans at 60, 90, and 130 pulses per minute (ppm). For each pacing rate, regional and global MBF was determined. In all patients, the left ventricular (LV) function was normal. By varying the atrial pacing rate from 60 to 130 ppm, the mean global MBF increased from 0.94 to 1.40 mL/g/min, whereas the mean septal to lateral MBF ratio decreased from 1.09 to 0.83. In ventricular-paced patients at corresponding rates, the mean global MBF also increased from 1.07 to 1.52 mL/g/min but here the mean septal to lateral MBF ratio increased from 0.83 to 1.0. During both acute atrial and RVA pacing, regional and global MBF increases with higher pacing rates. However, the septal to lateral MBF ratio decreases with atrial pacing and increases with RVA pacing in patients with normal LV function. In RVA pacing, these different rate-dependent effects on regional MBF can be considered as a favorable factor that helps to understand why in some long-term paced patients, LV function is preserved.

• Upgrading to biventricular pacing guided by pressure-volume loop analysis during implantation.

  Authors: Peter Paul H M Delnoy, Jan Paul Ottervanger, Dick H S Vos, Arif Elvan, Anand R Ramdat Misier, Willem P Beukema, Paul Steendijk, Norbert M van Hemel

  Journal of cardiovascular electrophysiology. 12/2010; 22(6):677-83.

  cardiac resynchronization therapy (CRT) may improve prognosis in patients with chronic right ventricular (RV) pacing, and optimal lead position can decrease nonresponders. We evaluated the clinicalcardiac resynchronization therapy (CRT) may improve prognosis in patients with chronic right ventricular (RV) pacing, and optimal lead position can decrease nonresponders. We evaluated the clinical and echocardiographic response to CRT in patients with previous chronic RV pacing, using pressure-volume loop analyses to determine the optimal left ventricular (LV) lead position during implantation. In this single-blinded, randomized, controlled crossover study, 40 patients with chronic RV apical pacing and symptoms of heart failure, decreased LV ejection fraction (LVEF) or dyssynchrony were included. During implantation, stroke work (SW), LVEF, cardiac output, and LV dP/dt(max) were assessed by a conductance catheter. Clinical and echocardiographic response was studied during a 3-month period of RV pacing (RV period, LV lead inactive) and a 3-month period of biventricular pacing (CRT period). At the optimal LV lead position, SW (37 ± 41%), LVEF (16 ± 13%), cardiac output (29 ± 16%), and LV dP/dt(max) increased (11 ± 11%) significantly during biventricular pacing compared to baseline. Additional benefit could be achieved by pressure-volume loop guided selection of the best left-sided pacing location. RV outflow tract pacing did not improve hemodynamics. During follow-up, symptoms improved during CRT, VO(2,max) increased 10% and significant improvements in LVEF, LV volumes, and mitral regurgitation were observed as compared to the RV period. CRT in patients with chronic RV pacing causes significant improvement of both LV function as measured by pressure-volume loops during implantation and clinical and echocardiographic improvement during follow-up. Pressure-volume loops during implantation may facilitate selection of the most optimal pacing site.

• Radiological and electrocardiographic characterization of right ventricular outflow tract pacing.

  Authors: Jippe C Balt, Norbert M van Hemel, Hein J J Wellens, Willem G de Voogt

  Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 09/2010; 12(12):1739-44.

  The right ventricular outflow tract (RVOT) is used as an alternative pacing site, but its superiority to the RV apex remains to be established. This lack of proof may in part be explained byThe right ventricular outflow tract (RVOT) is used as an alternative pacing site, but its superiority to the RV apex remains to be established. This lack of proof may in part be explained by heterogeneity within the RVOT-paced group, due to poor definitions of the RVOT. The aim of the present study is to characterize the RVOT in terms of fluoroscopic and electrocardiographic parameters. One hundred and forty-three patients who underwent pacemaker implantation with a ventricular lead in the RVOT were included. Lead position was determined by fluoroscopy. The RVOT was divided into three areas: anterior, septal, and free wall (FW). On a 12-lead electrocardiogram (ECG) during forced ventricular pacing, QRS duration, configuration, and amplitude was determined. Lead position was judged to be anterior in 52 (36%), septal in 43 (30%), and FW in 48 (34%) patients, respectively. QRS duration is not significantly different between groups. QRS axis differs significantly between pacing sites (septal 79 ± 31°, anterior 60 ± 46°, FW 47 ± 38°, P < 0.05). QRS vector in lead I and QRS morphology and vector in lead aVL differ significantly between pacing sites. Precordial transition is earlier (towards V1) in septal pacing. This study demonstrates heterogeneity of pacing site and depolarization pattern within a cohort of patients paced form the RVOT. However, due to considerable overlap, we could not define clear cut-off point or devise flow-charts to match ECG and pacing site.

• Myocardial perfusion SPECT identifies patients with left bundle branch block patterns at high risk for future coronary events.

  Authors: Tim J F ten Cate, Johannes C Kelder, Herbert W M Plokker, J Fred Verzijlbergen, Norbert M van Hemel

  Journal of nuclear cardiology : official publication of the American Society of Nuclear Cardiology. 04/2010; 17(2):216-24.

  The value of myocardial perfusion SPECT (MPS) for patients with left bundle branch block (LBBB) or right ventricular apical (RVA) pacing seems reduced. The prognosis of patients with only abnormalThe value of myocardial perfusion SPECT (MPS) for patients with left bundle branch block (LBBB) or right ventricular apical (RVA) pacing seems reduced. The prognosis of patients with only abnormal activation related perfusion defects (AARD) due to LBBB or RVA-pacing is similar to those with a normal MPS. We assessed the prognostic value of MPS in patients with LBBB or RVA pacing. Patients with LBBB or RVA pacing referred for vasodilator stress MPS between April 2002 and January 2006 were analyzed. Group 1 are patients with normal MPS and MPS with AARD. Group 2 are patients with an MPS with a perfusion defect extending outside the AARD area. Events were cardiac death, acute myocardial infarction and coronary revascularization. In Group 1 (101 patients) 12 events and in Group 2 (96 patients) 45 events occurred during a mean follow-up of 2.6 +/- 1.5 years. The prognosis of Group 2 was significantly worse (49%) compared with Group 1 (91%). The annual cardiac death rate was 0.7%/year in Group 1 and 6.4%/year in Group 2 (P < .001). The prognosis of patients with LBBB was not different from those with RVA pacing. Group 2 had a significantly worse cardiac prognosis compared to Group 1. The annual cardiac death rate of <1% in Group 1 warrants a watchful waiting strategy, whereas the cardiac death rate in Group 2 warrants aggressive invasive coronary strategies.

• Left Atrial Pressure Reduction for Mitral Stenosis Reverses Left Atrial Direction Dependent Conduction Abnormalities.

  Authors: Ruben Coronel, Jorina Langerveld, Lucas V A Boersma, Eric F D Wever, Laurens Bon, Pascal F H M van Dessel, André C Linnenbank, Wiek H van Gilst, Sjef M P G Ernst, Tobias Opthof, Norbert M van Hemel

  Cardiovascular research. 11/2009;

  AIMS: Left atrial (LA) stretch-associated electrophysiological in patients with mitral stenosis (MS) predispose to atrial fibrillation. We hypothesized that the normalization of the pressure gradientAIMS: Left atrial (LA) stretch-associated electrophysiological in patients with mitral stenosis (MS) predispose to atrial fibrillation. We hypothesized that the normalization of the pressure gradient by percutaneous transvenous mitral balloon valvotomy (PTMV) affects LA but not right atrial (RA) conduction dependent on the site of stimulation. Because direction dependent (asymmetric) changes of conduction may contribute to arrhythmogenesis we assessed conduction symmetry in MS patients and tested whether it is restored by PTMV. METHODS: In 9 patients with MS, atrial effective refractory period and local activation times (AT) were determined during stimulation before and after PTMV, with up to 4 decapolar catheters (LA and RA). Eight patients with ventricular preexcitation served as controls. RESULTS: ATs at basic cycle length were similar before and after PTMV. With stimulation from either atrium they were about 45 ms in the ipsilateral atrium and about 115 ms in the contralateral atrium. With premature stimulation ATs increased dramatically. The shortest ATs were found in the RA with RA-stimulation (78+/-9 and 80+/-6, before and after PTMV, ns). PTMV caused a shortening in LA-ATs (following LA stimulation) from 118+/-14 ms to 82+/-5 ms (before and after; p<0.05). Asymmetry in conduction properties was therefore normalized by PTMV. PTMV led to a decrease in RA-ATs (following LA stimulation) from 196+/-11 ms to 174+/-13 ms (p<0.02). In addition, following RA-stimulation, the dispersion in ATs in the LA decreased significantly by PTMV (from 66+/-10 ms to 34+/-7 ms; p<0.02). CONCLUSION: MS is associated with LA conduction delay, increased LA dispersion of conduction, and conduction asymmetry. These changes are immediately reversible by PTMV.

• Long-term clinical response of cardiac resynchronization after chronic right ventricular pacing.

  Authors: Peter Paul H M Delnoy, Jan Paul Ottervanger, Henk Oude Luttikhuis, Arif Elvan, Anand R Ramdat Misier, Willem P Beukema, Norbert M van Hemel

  The American journal of cardiology. 08/2009; 104(1):116-21.

  Chronic right ventricular (RV) pacing might elicit unpredictably deleterious effects on left ventricular (LV) function similar to that of native left bundle branch block (LBBB). The objective of theChronic right ventricular (RV) pacing might elicit unpredictably deleterious effects on left ventricular (LV) function similar to that of native left bundle branch block (LBBB). The objective of the present study was to evaluate the clinical and echocardiographic response to cardiac resynchronization therapy after years of chronic RV pacing. In this prospective observational study of 284 consecutive patients, cardiac resynchronization therapy was performed in 194 patients (68%) with a native LBBB and in 90 patients (32%) with a pacing-induced LBBB after chronic RV pacing (upgraded group). Echocardiographic and clinical parameters were evaluated in both groups at baseline and during 2 years of follow-up. The clinical response was defined as survival with improvement of > or =1 in the New York Heart Association class without heart failure hospitalization. Reverse LV remodeling was defined as LV end-systolic volume reduction of > or =15%. At baseline, the New York Heart Association class, quality of life, and exercise capacity were comparable but the LV ejection fraction was significant greater and the LV volumes were significant smaller in the upgraded group. Changes with time in the clinical parameters, echocardiographic parameters, and clinical response were not significantly different between the 2 groups. Reverse LV remodeling was observed in 86% in the upgraded group versus 78% of the native LBBB group after 1 year (p = 0.39). Survival was not significantly different between the 2 groups. In conclusion, comparable clinical and echocardiographic improvement was seen when resynchronization therapy was applied in patients with preceding chronic RV pacing compared with patients with a native LBBB.

• Anticoagulation management during cardiac device surgery: Many tastes tolerated?

  Authors: Norbert M van Hemel

  Heart rhythm : the official journal of the Heart Rhythm Society. 07/2009;

• The prognostic significance of typical perfusion defects on vasodilator stress myocardial perfusion SPECT in patients with left bundle branch block or right ventricular apical pacing.

  Authors: Tim J F Ten Cate, Johannes C Kelder, Margot D Bogaard, Norbert M van Hemel, Johan Fred Verzijlbergen

  Nuclear medicine communications. 04/2009; 30(3):232-9.

  PURPOSE: Left bundle branch block (LBBB) and ventricular pacing may induce typical artefacts that appear as perfusion defects in myocardial perfusion single photon emission computed tomography (MPS).PURPOSE: Left bundle branch block (LBBB) and ventricular pacing may induce typical artefacts that appear as perfusion defects in myocardial perfusion single photon emission computed tomography (MPS). We assessed the prognosis of patients with LBBB or right ventricular apical (RVA) pacing who had chest pain and an MPS with only abnormal activation-related defects (AARD). METHODS: All patients with LBBB or ventricular pacing referred for vasodilator stress MPS between April 2002 and January 2006 were analyzed. AARD were defined as small, nontransmural, fixed defects and small reversible defects in well-defined regions always accompanied with concomitant wall motion abnormalities. RESULTS: Ninety-seven patients were included, with a mean follow-up period of 3+/-1.3 years. MPS showed AARD in 57 and it was completely normal in 40 patients. No significant difference in cumulative cardiac event-free follow-up was observed between patients with AARD (93%) and normal MPS (85%). The average annual cardiac event rate was not significantly different between the groups (1.7 and 4.3% per year, respectively). No difference was found between patients with LBBB and RVA pacing. CONCLUSION: Patients with chest pain and LBBB or RVA pacing who show AARD on MPS have a comparable prognosis as patients with abnormal activation and a normal MPS. This justifies MPS for risk stratification of patients with chest pain and LBBB or RVA pacing.

• Pressure-volume loop analysis during implantation of biventricular pacemaker/cardiac resynchronization therapy device to optimize right and left ventricular pacing sites.

  Authors: Peter Paul H M Delnoy, Jan Paul Ottervanger, Henk Oude Luttikhuis, Dick H S Vos, Arif Elvan, Anand R Ramdat Misier, Willem P Beukema, Paul Steendijk, Norbert M van Hemel

  European heart journal. 02/2009;

  Aims To evaluate the clinical utility of pressure-volume loop analyses during pacemaker/implantable cardioverter defibrillator (ICD) implantations to assess the optimal right ventricular (RV) and/orAims To evaluate the clinical utility of pressure-volume loop analyses during pacemaker/implantable cardioverter defibrillator (ICD) implantations to assess the optimal right ventricular (RV) and/or left ventricular (LV) lead position. Methods and results 29 patients with heart failure and chronic RV apical pacing were studied. Stroke work (SW), LV ejection fraction (LVEF), cardiac output (CO), and LV dP/dt(max) were assessed using a conductance catheter in the LV during RV apical, RV outflow tract, single-site LV, and biventricular pacing at different left-sided pacing locations. Left ventricular ejection fraction was 34.3 +/- 9.8%. Compared with baseline, RV outflow tract pacing showed a small increase of 4.0 +/- 6.4% in LV dP/dt(max) and no improvement in SW, LVEF, or CO. In the optimal biventricular configuration, SW increased 39 +/- 41%, LVEF increased 22 +/- 13%, CO increased 16 +/- 16%, and LV dP/dt(max) increased 10 +/- 11% (all P < 0.05). In 45% of the patients, the optimal LV lead position was found at a different location as the 'first choice' postero-lateral or lateral target vein. Conclusion Pressure-volume loop analysis during pacemaker/ICD implantations facilitates to determine the optimal LV pacing site. Patients with chronic RV pacing showed a significant acute improvement in LV function when LV pacing or biventricular pacing is applied.

• Predictors of improved quality of life 1 year after pacemaker implantation.

  Authors: J W Martijn van Eck, Norbert M van Hemel, Arjan van den Bos, William Taks, Diederick E Grobbee, Karel G M Moons

  American heart journal. 10/2008; 156(3):491-7.

  BACKGROUND: Patient's health-related quality of life (HRQoL) of pacemaker (PM) patients has increasingly become an important issue of health care evaluation. Currently, knowledge of pacingBACKGROUND: Patient's health-related quality of life (HRQoL) of pacemaker (PM) patients has increasingly become an important issue of health care evaluation. Currently, knowledge of pacing performance and technology is more or less outlined. However, determinants of poor or good HRQoL of paced patients require further elucidation. OBJECTIVES: The purpose of this study is to determine the HRQoL 1 year after PM implantation and predictors of differences in HRQoL between pre- and post-PM implantation. METHODS: We quantified the mean differences between HRQoL before implantation (baseline) and 1 year later, assessed with the generic Medical Outcomes Survey 36-Item Short-Form Survey and EuroQol (EQ5D), and the PM patient-specific AQUAREL (Assessment of QUality of life And RElated events) questionnaires, in 501 consecutively included patients in the Dutch multicenter longitudinal FOLLOWPACE cohort study. Multivariable linear regression modeling was then performed to determine predictive factors of the HRQoL 1 year after implantation. RESULTS: The HRQoL of the patients increased markedly in the first year after implantation. Seventy percent of the patients considered their health improved, whereas 11% experienced a complete recovery in HRQoL. The most important predictors for improved HRQoL after 1 year were HRQoL at baseline, age, presence of cardiac comorbidities, and atrial fibrillation with slow ventricular response as indication for chronic pacing. CONCLUSION: In most patients receiving a PM, HRQoL increased in the first year after PM implantation. Knowledge of the predictors of this increase may aid physicians to timely differentiate between patients who most likely will benefit most from PM implantation in terms of HRQoL.

• Routine follow-up after pacemaker implantation: frequency, pacemaker programming and professionals in charge.

  Authors: Jacob W M van Eck, Norbert M van Hemel, Willem G de Voogt, Joan G Meeder, Hans A Spierenburg, Har Crommentuyn, Rens Keijzer, Diederick E Grobbee, Karel G M Moons

  Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 07/2008; 10(7):832-7.

  AIMS: To describe current evidence of the frequency, contents, and involved professionals of the routine follow-up visits in patients who have received a pacemaker (PM). METHODS AND RESULTS: TheAIMS: To describe current evidence of the frequency, contents, and involved professionals of the routine follow-up visits in patients who have received a pacemaker (PM). METHODS AND RESULTS: The multicentre FOLLOWPACE study prospectively collected data during implantation and follow-up of 1526 patients who received a PM for the first time. A total of 4914 follow-up visits were studied. Mean follow-up was 394 days with a mean of 3.2 visits per patient. At all follow-up visits, the battery condition was tested in >93%, the stimulation threshold in >91%, and sensing in >87%. The pacemaker parameters as stimulation and sensing thresholds, lead impedances, and percentages of pacing remained stable over time, but these values did depend on the lead location, lead fixation, and pulse duration. The majority of PM (re-)programming was performed during implantation and/or shortly before hospital discharge (50%). PM re-programming during follow-up was most frequently performed by the PM technician alone (95%). CONCLUSION: Crucial PM parameters are regularly checked. Re-programming of PM parameters declined during the first year after PM implantation. The majority of PM checks were carried out by the PM technician, indicating the major influence of the allied professional on the quality and safety of the pacing therapy.

• The influence of myocardial scar and dyssynchrony on reverse remodeling in cardiac resynchronization therapy.

  Authors: Annemieke H M Jansen, Frank Bracke, Jan Melle van Dantzig, Kathinka H Peels, Johannes C Post, Harrie C M van den Bosch, Berry van Gelder, Albert Meijer, Hendrikus H M Korsten, Jolanda De Vries, Norbert M van Hemel

  European journal of echocardiography : the journal of the Working Group on Echocardiography of the European Society of Cardiology. 07/2008; 9(4):483-8.

  AIM: The influence of location and extent of transmural scar and its relation with dyssynchrony in cardiac resynchronization therapy (CRT) was investigated as posterolateral scar tissue has beenAIM: The influence of location and extent of transmural scar and its relation with dyssynchrony in cardiac resynchronization therapy (CRT) was investigated as posterolateral scar tissue has been invoked as a cause of non-response to CRT. METHODS AND RESULTS: Fifty-seven patients eligible for CRT were assessed for transmural scar with gadolinium-enhanced MRI and for left ventricular (LV) dyssynchrony with tissue Doppler. After implant, both atrioventricular and interventricular pacing intervals were optimized. LV reverse remodeling was defined as >/=10% decrease in LV end-systolic volume after 3 months. Sixteen patients had transmural scar in the posterolateral (PL) area (LV lead location), 14 at a remote site (non-PL) and 27 patients had no scar. LV reverse remodeling was observed in respectively 25%, 64% and 89% (P = 0.0001). Univariate analyses showed a relation with LV dyssynchrony (P = 0.004) and with absence of PL scar (P = 0.04) but not with QRS duration and the extent of LV scar tissue. In multivariate analysis, only LV dyssynchrony (OR: 19.62; 95% CI: 2.5-151.9; P = 0.004) independently predicted LV reverse remodeling. CONCLUSION: In this study LV dyssynchrony remains the most important determinant of response to CRT, even in the presence of posterolateral scar provided atrioventricular and interventricular pacing intervals are optimized.

• Medium-term outcome of different surgical methods to cure atrial fibrillation: is less worse?

  Authors: Guillaume S C Geuzebroek, Philippe K E W Ballaux, Norbert M van Hemel, Johannes C Kelder, Jo J A M T Defauw

  Interactive cardiovascular and thoracic surgery. 05/2008; 7(2):201-6.

  Different lesion sets and ablation techniques have been performed. We compared these outcomes in search of the best method. We performed a retrospective analysis of patients who have undergone AFDifferent lesion sets and ablation techniques have been performed. We compared these outcomes in search of the best method. We performed a retrospective analysis of patients who have undergone AF surgery different from the maze III. The surgical lesion sets were pulmonary vein isolation (PVI) alone, left atrial maze (LAM) and bi-atrial maze (BAM) and were made with different ablation techniques. During surgery one patient died due to bleeding of a pulmonary vein. The number of patients in the PVI-, LAM-, BAM-groups was 12, 28 and 26, respectively, with freedom from AF at latest follow-up [22.0+/-15.6 (3.1-81.2) months] of 33%, 59% and 60%, respectively. Atrial flutter occurred less in the BAM-group (4%) than in the left-sided procedures (15.4%) (P=0.231). Multivariate analysis demonstrated a higher recurrence of AF for PVI alone (OR 4.42, CL 0.95-20.6, P=0.0583) and a lower recurrence for the 'cut-and-sew' technique (OR 0.13, CL 0.030-0.60, P=0.0084). Left- and bi-atrial maze procedures are equally effective in the suppression of AF, whereas omission of right-sided lesions results in a higher prevalence of atrial flutter. The 'cut-and-sew' technique is superior in terms of freedom from AF compared to bipolar and unipolar radiofrequency.

• Poor health-related quality of life of patients with indication for chronic cardiac pacemaker therapy.

  Authors: J W Martijn van Eck, Norbert M van Hemel, Johannes C Kelder, Arjan A van den Bos, William Taks, Diederick E Grobbee, Karel G M Moons

  Pacing and clinical electrophysiology : PACE. 05/2008; 31(4):480-6.

  BACKGROUND: Studies on health-related quality of life (HRQoL) of patients awaiting pacemaker (PM) implantation are scarce, or executed in specific patient subgroups (regarding age or specific cardiacBACKGROUND: Studies on health-related quality of life (HRQoL) of patients awaiting pacemaker (PM) implantation are scarce, or executed in specific patient subgroups (regarding age or specific cardiac rhythm disorders). The purpose of this study was to systematically assess the HRQoL in a large unselected cohort of patients with a conventional indication for PM therapy. METHODS: Pre-PM implantation HRQoL (measured with the SF-36 questionnaire, completed at hospital admission) of 818 consecutive Dutch patients included in the FOLLOWPACE study was compared with the HRQoL in a sample of the general Dutch population, and with several cohorts of patients with other conditions. Linear regression analysis was performed to analyze determinants of this HRQoL. RESULTS: Almost all SF-36 subscale scores were substantially and significantly lower in the PM patients compared to the general population, with P-values < 0.001 in all SF-36 subscales except for "pain" and "general health perception." In the PM patients, presence of comorbidities, gender, and age were significantly associated with the overall physical component summary score (mean 38.8 +/- 27 standard deviation) whereas the overall mental component summary score (46.8 +/- 27.0) was associated with gender and age. CONCLUSION: The HRQoL of patients before first PM implantation is significantly lower than that of a general population and also various other patient populations. Physicians should be aware of this unfavorable condition and keep the time interval between the diagnosis of a cardiac rhythm disorder requiring PM implantation and the implantation procedure as short as possible.

• Clinical response of cardiac resynchronization therapy in the elderly.

  Authors: Peter Paul H M Delnoy, Jan Paul Ottervanger, Henk Oude Luttikhuis, Arif Elvan, Anand R Ramdat Misier, Willem P Beukema, Norbert M van Hemel

  American heart journal. 04/2008; 155(4):746-51.

  BACKGROUND: Although prevalence of heart failure increases with age, in most clinical trials of cardiac resynchronization therapy (CRT), older patients are not included. Observational studies ofBACKGROUND: Although prevalence of heart failure increases with age, in most clinical trials of cardiac resynchronization therapy (CRT), older patients are not included. Observational studies of effects of CRT in older patients had a small sample size. In the present study, the clinical and echocardiographic response to CRT in a larger group of elderly (age > 75 years) patients was evaluated. METHODS: In this prospective observational study of 266 consecutive patients, CRT was performed in 107 elderly patients (40%) and 159 (60%) younger patients (age < or = 75 years). Echocardiographic and clinical parameters were evaluated at baseline and at 3, 12, and 24 months. RESULTS: In the elderly group, mean age was 79 years compared with 67 years in patients aged < or = 75 years. Clinical baseline characteristics between the 2 groups were comparable. During follow-up, there was a comparable and sustained improvement in both groups according to New York Heart Association (NYHA) class, quality of life score, and left ventricular (LV) ejection fraction. Clinical response, defined as survival with improvement (> or = 1 score) of NYHA class without hospital admittance for heart failure, was seen in 67% and 69% (group aged < or = 75 years) versus 65% and 60% (group aged > 75 years) after 3 months and 1 year, respectively. Reverse LV remodeling defined as LV end-systolic volume reduction > or = 10% was seen in 79% and 87% (group aged < or = 75 years) versus 71% and 79% (group aged > 75 years) after 3 months and 1 year, respectively. Hospitalization for heart failure decreased significantly in both groups in the year after CRT. A subgroup analysis of 39 octogenarians (> 80 years) also showed a significant improvement in NYHA class and LV ejection fraction in this subgroup. Also, LV reverse remodeling occurred in a similar extent (75% and 84%) after 3 months and 1 year, respectively. CONCLUSIONS: This study shows a clinical and echocardiographic improvement of CRT in patients aged > 75 years and even so in octogenarians.

• Right ventricular outflow and apical pacing comparably worsen the echocardioghraphic normal left ventricle.

  Authors: Tim J F Ten Cate, Mike G Scheffer, George R Sutherland, J Fred Verzijlbergen, Norbert M van Hemel

  European journal of echocardiography : the journal of the Working Group on Echocardiography of the European Society of Cardiology. 04/2008;

  AIMS: A depressed left ventricular function (LVF) is sometimes observed during right ventricular apical (RVA) pacing, but any prediction of this adverse effect cannot be done. Right ventricularAIMS: A depressed left ventricular function (LVF) is sometimes observed during right ventricular apical (RVA) pacing, but any prediction of this adverse effect cannot be done. Right ventricular outflow tract (RVOT) pacing is thought to deteriorate LVF less frequently because of a more normal LV activation pattern. This study aims to assess the acute effects of RVA and RVOT pacing on LVF in order to determine the contribution of echocardiography for the selection of the optimum pacing site during pacemaker (PM) implantation. METHODS AND RESULTS: Fourteen patients with a DDD-pacemaker (7 RVA, 7 RVOT) and normal LVF without other cardiac abnormalities were studied. PM dependency, because of sick sinus syndrome with normal atrioventricular and intraventricular conduction, was absent in all, allowing acute programming changes. Wall motion score (WMS), longitudinal LV strain, and tissue Doppler imaging for electromechanical delay were assessed with echocardiography during AAI pacing constituting baseline and DDD pacing. The WMS was normal at baseline (AAI pacing) in all patients and LV dyssynchrony was absent. Acute RVA and RVOT pacing deteriorated WMS, electromechanical delay, and longitudinal LV strain, but no difference of the deterioration between both pacing sites was present and dyssynchrony did not emerge. CONCLUSION: Both acute RVA and RVOT pacing negatively affect WMS, longitudinal LV strain, and mechanical activation times, without clear differences between both pacing sites. Thus echocardiographic techniques do not facilitate the selection between RVOT and RVA pacing to exclude adverse effects on LVF during PM implantation in patients with a normal LVF.

• Comparison of usefulness of cardiac resynchronization therapy in patients with atrial fibrillation and heart failure versus patients with sinus rhythm and heart failure.

  Authors: Peter Paul H M Delnoy, Jan Paul Ottervanger, Henk Oude Luttikhuis, Arif Elvan, Anand R Ramdat Misier, Willem P Beukema, Norbert M van Hemel

  The American journal of cardiology. 06/2007; 99(9):1252-7.

  The prevalence of atrial fibrillation (AF) in patients with heart failure is high, but data about the effects of cardiac resynchronization therapy (CRT) in patients with chronic AF are scarce. InThe prevalence of atrial fibrillation (AF) in patients with heart failure is high, but data about the effects of cardiac resynchronization therapy (CRT) in patients with chronic AF are scarce. In this prospective observational study of 263 consecutive patients, CRT was performed in 96 patients (37%) with chronic AF and 167 patients (63%) with sinus rhythm (SR). Echocardiographic and clinical parameters were evaluated at baseline and 3 and 12 months. Reverse left ventricular (LV) remodeling is defined as LV end-systolic volume decrease > or =10%. Hospitalization rates for heart failure in the year before and after implantation were compared. Baseline characteristics between patients with and without AF were similar, but the AF group had smaller LV end-systolic and end-diastolic volumes and larger left atrial dimensions. New York Heart Association class, 6-minute walking distance, quality-of-life score, LV ejection fraction, and mitral regurgitation improved significantly at 3 and 12 months in both groups, and the changes were similar. Reverse LV remodeling after 3 and 12 months was 74% and 82% (AF group) versus 77% and 83%, respectively (SR group, p = 0.79). After 1 year, cardioversion had occurred in 25% of patients with AF. In the year after implantation, significant decreases in hospitalizations for heart failure in both groups (84% and 90%) were documented. Long-term mortality was almost equal in both groups. In conclusion, this large-scale study shows that the benefit of CRT in patients with chronic AF and heart failure is similar to that in patients with SR. Patients with chronic AF and heart failure should be considered candidates for CRT.

• Improvement in diastolic function and left ventricular filling pressure induced by cardiac resynchronization therapy.

  Authors: Annemieke H M Jansen, Jan Melle van Dantzig, Frank Bracke, Kathinka H Peels, Jacques J Koolen, Albert Meijer, Jolanda De Vries, Hendrikus Korsten, Norbert M van Hemel

  American heart journal. 05/2007; 153(5):843-9.

  BACKGROUND: Variable results of cardiac resynchronization therapy (CRT) on diastolic function have been described. We investigated 3 and 12 months' effect of CRT on diastolic function and leftBACKGROUND: Variable results of cardiac resynchronization therapy (CRT) on diastolic function have been described. We investigated 3 and 12 months' effect of CRT on diastolic function and left ventricular (LV) filling pressures and their relation to LV reverse remodeling. METHODS: Fifty-two patients' (36 male, 69 +/- 8 years, QRS duration 170 +/- 29 milliseconds) echo-Doppler was performed before and 3 and 12 months after CRT. Tissue Doppler early diastolic annular (Em) and color M-mode-derived flow propagation (Vp) velocities were used to estimate LV filling pressures by E/Em and E/Vp ratios. RESULTS: After 12 months, LV reverse remodeling (end-systolic volume decrease >15%) was observed in 58%. Despite a significantly more compromised baseline diastolic function of patients without LV reverse remodeling, multivariate analysis revealed that only LV dyssynchrony could predict LV reverse remodeling. Grades 2 and 3 diastolic function improved only in LV reverse remodeling patients (from 34% to 13% to 10%), whereas a nonsignificant increase from 59% to 67% to 72% was observed in patients without reverse remodeling. Irrespective of LV volume response, short-term symptomatic benefit was related to decreased filling pressure. However, after 12 months, E/Em and E/Vp only significantly decreased in patients with LV reverse remodeling (from 16.0 +/- 6 to 10.4 +/- 4 and 2.2 +/- 0.6 to 1.5 +/- 0.4, respectively). CONCLUSIONS: Left ventricular reverse remodeling induced by CRT is accompanied by improvement in diastolic function and estimated LV filling pressure. Short-term symptomatic benefit was related to decreased filling pressure. However, for longer-term symptomatic improvement and decreased filling pressures, LV reverse remodeling appeared mandatory.