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J Thorac Cardiovasc Surg 2008;136:915-921
© 2008 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

The role of temporary biventricular pacing in the cardiac surgical patient with severely reduced left ventricular systolic function

William Beaumont Hospital, Royal Oak, Michigan

Received for publication May 16, 2007; revisions received November 16, 2007; accepted for publication November 26, 2007.

^_* Address for reprints: David E. Haines, MD, William Beaumont Hospital, 3601 West 13 Mile Rd, Royal Oak, MI 48073. (Email: DHaines{at}beaumont.edu).

Objective: The objective was to evaluate the effects of atrial synchronous biventricular pacing in postoperative patients with severe cardiomyopathy.

Methods: Atrial synchronous biventricular pacing epicardial leads were placed during cardiac surgery in patients with an ejection fraction of 30% or less. Patients were randomized to usual care pacing, the mode determined by the surgeon (excluding atrial synchronous biventricular pacing) with a preference for no pacing or atrial pacing (atrial inhibited pacing); atrial synchronous right ventricular pacing; or atrial synchronous biventricular pacing. Pacing was continued until cessation of hemodynamic support. At 12 hours postoperatively, patients were randomly tested in each mode (atrial inhibited, atrial synchronous right ventricular, and atrial synchronous biventricular pacing), and thermodilution outputs were measured.

Results: Forty subjects were randomized. Groups were similar in age (66 ± 11 years), gender (85% were male), ejection fraction (23% ± 6%), QRS duration (111 ± 30 ms), and surgical indication. There was no difference in stroke index or cardiac index at 12 hours, duration of inotropic or intra-aortic balloon pump support, intensive care unit, or hospital length of stay. On comparative crossover testing, stroke volume was similar with atrial inhibited pacing and atrial synchronous biventricular pacing (59.3 ± 13.4 vs 57 ± 12.1, respectively, P = not significant); however, atrial synchronous right ventricular pacing was inferior (56 ± 12.9, P < .05 for comparison with atrial inhibited pacing). When compared with atrial inhibited pacing, atrial synchronous biventricular pacing showed a positive response in 17% of subjects (increase in stroke volume 5%), whereas 41% had a 5% or greater decrease in stroke volume.

Conclusion: Pacing mode affects stroke volume in patients with severe cardiomyopathy. Atrial synchronous biventricular pacing was helpful in a minority, but in 41% it compromised stroke volume.

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