Articles

Table of Contents Circulation. 1997; 96:3273-3277

(Circulation. 1997; 96:3273-3277.) 1997 American Heart Association, Inc.

Articles

Evaluation of Different Ventricular Pacing Sites in Patients with Severe Heart Failure
Results of an Acute Hemodynamic Study Jean-Jacques Blanc, MD; Yves Etienne, MD; Martine Gilard, MD; Jacques Mansourati, MD; Stphane Munier, MD; Jacques Boschat, MD; David G. Benditt, MD; ; Keith G. Lurie, MD From the Department of Cardiology, Brest (France) University Hospital (J.-J.B., Y.E., M.G., J.M., S.M., J.B.) and the Cardiac Arrhythmia Center, University of Minnesota, Minneapolis (D.G.B., K.G.L.). Correspondence to Jean-Jacques Blanc, MD, Department of Cardiology, University Hospital, Blvd Tanguy Prigent, 29609 Brest Cdex, France.
Background Multisite ventricular pacing has recently been proposed as an additional treatment for patients with severe congestive heart failure. To further assess the potential value of this technique, we compared the acute hemodynamic changes associated with pacing the right ventricular apex (RVA) or outflow tract (RVOT) alone, the left ventricle (LV) alone, or biventricular (BIV) pacing of the RVA and LV together. Methods and Results Acute hemodynamic findings were measured in 27 patients with severe heart failure despite optimal therapy and either first-degree AV block and/or an intraventricular conduction defect. In the 23 patients with a high pulmonary capillary wedge pressure (PCWP) (>15 mm Hg), data were collected after transvenous pacing at different ventricular sites in either the VDD mode (AV delay=100 ms) or the VVI mode in patients with atrial fibrillation (n=6). The mean baseline cardiac index was 1.82 L min-1 m-2. MeanSD baseline systolic blood pressure (SBP) (118.515.2 mm Hg), PCWP (26.46.6 mm Hg), and V-wave amplitude (39.114.6 mm Hg) were similar before and after either RVA or RVOT pacing. In contrast, LV-based pacing (either LV alone or BIV pacing) resulted in

higher SBP (P<.03) and lower PCWP (P<.01) and V-wave amplitude (P<.001) than either baseline or RV pacing measurements. With LV pacing alone, SBP, PCWP, and V waves were 126.515.1, 20.75.9, and 25.58.1 mm Hg, respectively. The results with LV pacing alone were similar to those obtained with BIV pacing. Conclusions In patients with severe congestive heart failure, both LV pacing alone and BIV pacing resulted in a similar and significant acute improvement in SBP, PCWP, and V-wave amplitude compared with baseline measurements and RV pacing alone. These results provide a strong basis for initiating long-term studies examining the chronic effects of LV-based pacing in patients with medically refractory congestive heart failure. Key Words: heart failure pacing hemodynamics

Warfarin and Aspirin in Patients with Heart Failure and Sinus Rhythm Shunichi Homma, M.D., John L.P. Thompson, Ph.D., Patrick M. Pullicino, M.D., Bruce Levin, Ph.D., Ronald S. Freudenberger, M.D., John R. Teerlink, M.D., Susan E. Ammon, N.P., Susan Graham, M.D., Ralph L. Sacco, M.D., Douglas L. Mann, M.D., J.P. Mohr, M.D., Barry M. Massie, M.D., Arthur J. Labovitz, M.D., Stefan D. Anker, M.D., Ph.D., Dirk J. Lok, M.D., Piotr Ponikowski, M.D., Ph.D., Conrado J. Estol, M.D., Ph.D., Gregory Y.H. Lip, M.D., Marco R. Di Tullio, M.D., Alexandra R. Sanford, M.S., Vilma Mejia, B.S., Andre P. Gabriel, M.D., Mirna L. del Valle, B.S., and Richard Buchsbaum for the WARCEF Investigators May 2, 2012 (10.1056/NEJMoa1202299) Comments open through May 23, 2012 Abstract Article References Comments BACKGROUND It is unknown whether warfarin or aspirin therapy is superior for patients with heart failure who are in sinus rhythm. Full Text of Background... METHODS We designed this trial to determine whether warfarin (with a target international normalized ratio of 2.0 to 3.5) or aspirin (at a dose of 325 mg per day) is a better treatment for patients in sinus rhythm who have a reduced left ventricular ejection fraction (LVEF). We followed 2305 patients for up to 6 years (mean [SD], 3.51.8). The primary outcome was the time to the first event in a composite end point of ischemic stroke, intracerebral hemorrhage, or death from any cause. Full Text of Methods... RESULTS

The rates of the primary outcome were 7.47 events per 100 patient-years in the warfarin group and 7.93 in the aspirin group (hazard ratio with warfarin, 0.93; 95% confidence interval [CI], 0.79 to 1.10; P=0.40). Thus, there was no significant overall difference between the two treatments. In a timevarying analysis, the hazard ratio changed over time, slightly favoring warfarin over aspirin by the fourth year of follow-up, but this finding was only marginally significant (P=0.046). Warfarin, as compared with aspirin, was associated with a significant reduction in the rate of ischemic stroke throughout the follow-up period (0.72 events per 100 patient-years vs. 1.36 per 100 patient-years; hazard ratio, 0.52; 95% CI, 0.33 to 0.82; P=0.005). The rate of major hemorrhage was 1.78 events per 100 patient-years in the warfarin group as compared with 0.87 in the aspirin group (P<0.001). The rates of intracerebral and intracranial hemorrhage did not differ significantly between the two treatment groups (0.27 events per 100 patient-years with warfarin and 0.22 with aspirin, P=0.82). Full Text of Results... CONCLUSIONS Among patients with reduced LVEF who were in sinus rhythm, there was no significant overall difference in the primary outcome between treatment with warfarin and treatment with aspirin. A reduced risk of ischemic stroke with warfarin was offset by an increased risk of major hemorrhage. The choice between warfarin and aspirin should be individualized. (Funded by the National Institute of Neurological Disorders and Stroke; WARCEF ClinicalTrials.gov number,NCT00041938.)