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Nguyên UC, Prinzen FW, Vernooy K. Left ventricular lead placement in cardiac resynchronization therapy: Current data and potential explanations for the lack of benefit. Heart Rhythm 2024; 21:197-205. [PMID: 37806647 DOI: 10.1016/j.hrthm.2023.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/22/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Abstract
The present article reviews the literature on image-guided cardiac resynchronization therapy (CRT) studies. Improved outcome to CRT has been associated with the placement of a left ventricular (LV) lead in the latest activated segment free from scar. The majority of randomized controlled trials investigating guided LV lead implantation did not show superiority over conventional implantation approaches. Several factors may contribute to this paradoxical observation, including inclusion criteria favoring patients with left bundle branch block who already respond well to conventional anatomical LV lead implantation, differences in activation wavefronts during simultaneous right ventricular and LV pacing, incorrect definition of target regions, and limitations in coronary venous anatomy that prevent access to target regions that are detected by imaging. It is imperative that exclusion of patients lacking access to target regions from these studies would lead to larger benefit of image-guided CRT.
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Affiliation(s)
- Uyên Châu Nguyên
- Department of Physiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands; Department of Cardiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.
| | - Frits W Prinzen
- Department of Physiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
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Hara H, Igarashi T, Kaida T, Murakami M, Ito H, Niwano S, Ako J. Estimation of left ventricular activation sequence in patients with heart failure using two-dimensional speckle tracking echocardiography. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:1251-1262. [PMID: 36971867 DOI: 10.1007/s10554-023-02834-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 03/10/2023] [Indexed: 06/09/2023]
Abstract
Evaluation of longitudinal strain (LS) from two-dimensional echocardiography is useful for global and regional left ventricular (LV) dysfunction assessment. We determined whether the LS reflects contraction process in patients with asynchronous LV activation. We studied 144 patients with an ejection fraction ≤ 35%, who had left bundle branch block (LBBB, n = 42), right ventricular apical (RVA) pacing (n = 34), LV basal- or mid-lateral pacing (n = 23), and no conduction block (Narrow-QRS, n = 45). LS distribution maps were constructed using 3 standard apical views. The times from the QRS onset-to-early systolic positive peak (Q-EPpeak) and late systolic negative peak (Q-LNpeak) were measured to determine the beginning and end of contractions in each segment. Negative strain in LBBB initially appeared in the septum and basal-lateral contracted late. In RVA and LV pacing, the contracted area enlarged centrifugally from the pacing site. Narrow-QRS showed few regional differences in strain during the systolic period. The Q-EPpeak and Q-LNpeak exhibited similar sequences characterized by septum to basal-lateral via the apical regions in LBBB, apical to basal regions in RVA pacing, and lateral to a relatively large delayed contracted area between the apical- and basal-septum in LV pacing. Differences in Q-LNpeaks between the apical and basal segments in delayed contracted wall were 107 ± 30 ms in LBBB, 133 ± 46 ms in RVA pacing, and 37 ± 20 ms in LV pacing (p < 0.05, between QRS groups). Specific LV contraction processes were demonstrated by evaluating the LS distribution and time-to-peak strain. These evaluations may have potential to estimate the activation sequence in patients with asynchronous LV activation.
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Affiliation(s)
- Hideyuki Hara
- Division of Cardiology, Numazu City Hospital, Aza-Harunoki 550, Higashi-Shiiji, Numazu City, Shizuoka Prefecture, 410-0302, Japan.
| | - Tazuru Igarashi
- Division of Cardiology, Numazu City Hospital, Aza-Harunoki 550, Higashi-Shiiji, Numazu City, Shizuoka Prefecture, 410-0302, Japan
| | - Toyoji Kaida
- Division of Cardiology, Numazu City Hospital, Aza-Harunoki 550, Higashi-Shiiji, Numazu City, Shizuoka Prefecture, 410-0302, Japan
| | - Masami Murakami
- Division of Cardiology, Numazu City Hospital, Aza-Harunoki 550, Higashi-Shiiji, Numazu City, Shizuoka Prefecture, 410-0302, Japan
| | - Hiroshi Ito
- Division of Cardiology, Numazu City Hospital, Aza-Harunoki 550, Higashi-Shiiji, Numazu City, Shizuoka Prefecture, 410-0302, Japan
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
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Wilczek J, Jadczyk T, Wojakowski W, Gołba KS. Time-related factors predicting a positive response to cardiac resynchronisation therapy in patients with heart failure. Sci Rep 2023; 13:8524. [PMID: 37237039 PMCID: PMC10219980 DOI: 10.1038/s41598-023-35174-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/14/2023] [Indexed: 05/28/2023] Open
Abstract
This study aimed to identify time parameters predicting favourable CRT response. A total of 38 patients with ischemic cardiomyopathy, qualified for CRT implantation, were enrolled in the study. A 15% reduction in indexed end-systolic volume after 6 months was a criterion for a positive response to CRT. We evaluated QRS duration, measured from a standard ECG before and after CRT implantation and obtained from mapping with NOGA XP system (AEMM); and the delay, measured with the implanted device algorithm (DCD) and its change after 6 months (ΔDCD); and selected delay parameters between the left and right ventricles based on AEMM data. A total of 24 patients presented with a positive response to CRT versus 9 non-responders. After CRT implantation, we observed differences between responders and non-responders group in the reduction of QRS duration (31 ms vs. 16 ms), duration of paced QRS (123 ms vs. 142 ms), and the change of ΔDCDMaximum (4.9 ms vs. 0.44 ms) and ΔDCDMean (7.7 ms vs. 0.9 ms). The difference in selected parameters obtained during AEMM in both groups was related to interventricular delay (40.3 ms vs. 18.6 ms). Concerning local activation time and left ventricular activation time, we analysed the delays in individual left ventricular segments. Predominant activation delay of the posterior wall middle segment was associated with a better response to CRT. Some AEMM parameters, paced QRS time of less than 120 ms and reduction of QRS duration greater than 20 ms predict the response to CRT. ΔDCD is associated with favourable electrical and structural remodelling.Clinical trial registration: SUM No. KNW/0022/KB1/17/15.
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Affiliation(s)
- Jacek Wilczek
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland.
- Electrocardiology Department, Upper Silesian Medical Center, Katowice, Poland.
| | - Tomasz Jadczyk
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
- Third Department of Cardiology, Upper Silesian Medical Center, Katowice, Poland
- Interventional Cardiac Electrophysiology Group, International Clinical Research Center, St. Anne's University Hospital in Brno, Brno, Czech Republic
| | - Wojciech Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
- Third Department of Cardiology, Upper Silesian Medical Center, Katowice, Poland
| | - Krzysztof S Gołba
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
- Electrocardiology Department, Upper Silesian Medical Center, Katowice, Poland
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Gowani ZS, Tomashitis B, Vo CN, Field ME, Gold MR. Role of Electrical Delay in Cardiac Resynchronization Therapy Response. Card Electrophysiol Clin 2022; 14:233-241. [PMID: 35715081 DOI: 10.1016/j.ccep.2021.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Traditionally, left ventricular (LV) lead position was guided by anatomic criteria of pacing from the lateral wall of the LV. However, large trials showed little effect of LV lead position on outcomes, other than noting worse outcomes with apical positions. Given the poor correlation of cardiac resynchronization therapy (CRT) outcomes with anatomically guided LV lead placement, focus shifted toward more physiologic predictors such as targeting the areas of delayed mechanical and electrical activation. Measures of left ventricular delay and interventricular delay are strong predictors of CRT response.
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Affiliation(s)
- Zain S Gowani
- Department of Medicine, Medical University of South Carolina, 25 Courtenay Drive, MS-492, Charleston, SC 29425, USA
| | - Brett Tomashitis
- Department of Medicine, Medical University of South Carolina, 25 Courtenay Drive, MS-492, Charleston, SC 29425, USA
| | - Chau N Vo
- Department of Medicine, Medical University of South Carolina, 25 Courtenay Drive, MS-492, Charleston, SC 29425, USA
| | - Michael E Field
- Department of Medicine, Medical University of South Carolina, 25 Courtenay Drive, MS-492, Charleston, SC 29425, USA
| | - Michael R Gold
- Department of Medicine, Medical University of South Carolina, 25 Courtenay Drive, MS-492, Charleston, SC 29425, USA.
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2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Translation of the document prepared by the Czech Society of Cardiology. COR ET VASA 2022. [DOI: 10.33678/cor.2022.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJ, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM. Grupo de trabajo sobre estimulación cardiaca y terapia de resincronización cardiaca de la Sociedad Europea de Cardiología (ESC). Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM, Leyva F, Linde C, Abdelhamid M, Aboyans V, Arbelo E, Asteggiano R, Barón-Esquivias G, Bauersachs J, Biffi M, Birgersdotter-Green U, Bongiorni MG, Borger MA, Čelutkienė J, Cikes M, Daubert JC, Drossart I, Ellenbogen K, Elliott PM, Fabritz L, Falk V, Fauchier L, Fernández-Avilés F, Foldager D, Gadler F, De Vinuesa PGG, Gorenek B, Guerra JM, Hermann Haugaa K, Hendriks J, Kahan T, Katus HA, Konradi A, Koskinas KC, Law H, Lewis BS, Linker NJ, Løchen ML, Lumens J, Mascherbauer J, Mullens W, Nagy KV, Prescott E, Raatikainen P, Rakisheva A, Reichlin T, Ricci RP, Shlyakhto E, Sitges M, Sousa-Uva M, Sutton R, Suwalski P, Svendsen JH, Touyz RM, Van Gelder IC, Vernooy K, Waltenberger J, Whinnett Z, Witte KK. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Europace 2022; 24:71-164. [PMID: 34455427 DOI: 10.1093/europace/euab232] [Citation(s) in RCA: 124] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J 2021; 42:3427-3520. [PMID: 34455430 DOI: 10.1093/eurheartj/ehab364] [Citation(s) in RCA: 814] [Impact Index Per Article: 271.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Wang J, Wang Y, Yang M, Shao S, Tian Y, Shao X, Fan S, Zhang F, Yang W, Xin W, Tang H, Xu M, Yang L, Wang X, Zhou W. Mechanical contraction to guide CRT left-ventricular lead placement instead of electrical activation in myocardial infarction with left ventricular dysfunction: An experimental study based on non-invasive gated myocardial perfusion imaging and invasive electroanatomic mapping. J Nucl Cardiol 2020; 27:419-430. [PMID: 30972718 PMCID: PMC10961107 DOI: 10.1007/s12350-019-01710-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 03/29/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Whether the region of the latest electrical activation (LEA) corresponds with the segment of the latest mechanical contraction (LMC) in ischemic cardiomyopathy (ICM) is uncertain. We aimed to investigate the relationship between the left-ventricular (LV) viable segments with LEA and with LMC after myocardial infarction (MI) and analyze the acute hemodynamic responses (dP/dtmax) after cardiac resynchronization therapy (CRT) pacing at different LV sites. METHODS AND RESULTS Bama suckling pigs (n = 6) were subjected to create MI models. Both gated myocardial perfusion imaging (GMPI) and electroanatomic mapping (EAM) were performed successfully before MI and 4 weeks after MI. LMC was assessed by phase analysis of GMPI, while LEA was evaluated by EAM. The dP/dtmax was measured before CRT and when the CRT LV electrode was implanted in viable segments of LMC, viable segments of lateral wall and scar, respectively. The viable segments of LEA were consistent with the sites of LMC for five in six cases. The dP/dtmax increased significantly compared with that before CRT when the CRT LV electrode was implanted in viable segments of LMC (1103.33 ± 195.76 vs 717.83 ± 80.74 mmHg·s-1, P = .001), which was also significantly higher than in viable segments of lateral wall (751.17 ± 105.62 mmHg·s-1, P = .000) and scar (679.50 ± 60.87 mmHg·s-1, P = .001). CONCLUSIONS Non-invasive GMPI may be a better option than invasive EAM for guiding LV electrode implantation for CRT in ICM.
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Affiliation(s)
- Jianfeng Wang
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Yuetao Wang
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China.
| | - Minfu Yang
- Department of Nuclear Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100000, China
| | - Shan Shao
- Department of Cardiology, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Yi Tian
- Department of Nuclear Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Xiaoliang Shao
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Shengdeng Fan
- Department of Anesthesiology, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Feifei Zhang
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Wei Yang
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Wenchong Xin
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Haipeng Tang
- School of Computing, University of Southern Mississippi, Long Beach, MS, 39560, USA
| | - Min Xu
- Department of Echocardiogram, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Ling Yang
- Department of Cardiology, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Xiaosong Wang
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Weihua Zhou
- School of Computing, University of Southern Mississippi, Long Beach, MS, 39560, USA
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Maffessanti F, Jadczyk T, Kurzelowski R, Regoli F, Caputo ML, Conte G, Gołba KS, Biernat J, Wilczek J, Dąbrowska M, Pezzuto S, Moccetti T, Krause R, Wojakowski W, Prinzen FW, Auricchio A. The influence of scar on the spatio-temporal relationship between electrical and mechanical activation in heart failure patients. Europace 2020; 22:777-786. [DOI: 10.1093/europace/euz346] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 12/05/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
The aim of this study was to determine the relationship between electrical and mechanical activation in heart failure (HF) patients and whether electromechanical coupling is affected by scar.
Methods and results
Seventy HF patients referred for cardiac resynchronization therapy or biological therapy underwent endocardial anatomo-electromechanical mapping (AEMM) and delayed-enhancement magnetic resonance (CMR) scans. Area strain and activation times were derived from AEMM data, allowing to correlate mechanical and electrical activation in time and space with unprecedented accuracy. Special attention was paid to the effect of presence of CMR-evidenced scar. Patients were divided into a scar (n = 43) and a non-scar group (n–27). Correlation between time of electrical and mechanical activation was stronger in the non-scar compared to the scar group [R = 0.84 (0.72–0.89) vs. 0.74 (0.52–0.88), respectively; P = 0.01]. The overlap between latest electrical and mechanical activation areas was larger in the absence than in presence of scar [72% (54–81) vs. 56% (36–73), respectively; P = 0.02], with smaller distance between the centroids of the two regions [10.7 (4.9–17.4) vs. 20.3 (6.9–29.4) % of left ventricular radius, P = 0.02].
Conclusion
Scar decreases the association between electrical and mechanical activation, even when scar is remote from late activated regions.
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Affiliation(s)
- Francesco Maffessanti
- Center for Computational Medicine in Cardiology, Università della Svizzera italiana, Via G. Buffi 13, CH-6900 Lugano, Switzerland
| | - Tomasz Jadczyk
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
- Interventional Cardiac Electrophysiology Group, International Clinical Research Center, St. Anne’s University Hospital Brno, Czech Republic
| | - Radosław Kurzelowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - François Regoli
- Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Maria Luce Caputo
- Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Giulio Conte
- Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Krzysztof S Gołba
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
| | - Jolanta Biernat
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
| | - Jacek Wilczek
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
| | - Magdalena Dąbrowska
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
| | - Simone Pezzuto
- Center for Computational Medicine in Cardiology, Università della Svizzera italiana, Via G. Buffi 13, CH-6900 Lugano, Switzerland
| | - Tiziano Moccetti
- Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Rolf Krause
- Center for Computational Medicine in Cardiology, Università della Svizzera italiana, Via G. Buffi 13, CH-6900 Lugano, Switzerland
| | - Wojciech Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Frits W Prinzen
- Department of Physiology, CARIM, Maastricht University, Maastricht, The Netherlands
| | - Angelo Auricchio
- Center for Computational Medicine in Cardiology, Università della Svizzera italiana, Via G. Buffi 13, CH-6900 Lugano, Switzerland
- Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
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Nguyên UC, Verzaal NJ, van Nieuwenhoven FA, Vernooy K, Prinzen FW. Pathobiology of cardiac dyssynchrony and resynchronization therapy. Europace 2018; 20:1898-1909. [DOI: 10.1093/europace/euy035] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 02/16/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Uyên Châu Nguyên
- Department of Physiology, Cardiovascular Research Institute Maastricht, Universiteitssingel 50, ER Maastricht, The Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Universiteitssingel 50, ER Maastricht, The Netherlands
| | - Nienke J Verzaal
- Department of Physiology, Cardiovascular Research Institute Maastricht, Universiteitssingel 50, ER Maastricht, The Netherlands
| | - Frans A van Nieuwenhoven
- Department of Physiology, Cardiovascular Research Institute Maastricht, Universiteitssingel 50, ER Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Universiteitssingel 50, ER Maastricht, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht, Universiteitssingel 50, ER Maastricht, The Netherlands
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Varma N, O'Donnell D, Bassiouny M, Ritter P, Pappone C, Mangual J, Cantillon D, Badie N, Thibault B, Wisnoskey B. Programming Cardiac Resynchronization Therapy for Electrical Synchrony: Reaching Beyond Left Bundle Branch Block and Left Ventricular Activation Delay. J Am Heart Assoc 2018; 7:e007489. [PMID: 29432133 PMCID: PMC5850248 DOI: 10.1161/jaha.117.007489] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 11/30/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND QRS narrowing following cardiac resynchronization therapy with biventricular (BiV) or left ventricular (LV) pacing is likely affected by patient-specific conduction characteristics (PR, qLV, LV-paced propagation interval), making a universal programming strategy likely ineffective. We tested these factors using a novel, device-based algorithm (SyncAV) that automatically adjusts paced atrioventricular delay (default or programmable offset) according to intrinsic atrioventricular conduction. METHODS AND RESULTS Seventy-five patients undergoing cardiac resynchronization therapy (age 66±11 years; 65% male; 32% with ischemic cardiomyopathy; LV ejection fraction 28±8%; QRS duration 162±16 ms) with intact atrioventricular conduction (PR interval 194±34, range 128-300 ms), left bundle branch block, and optimized LV lead position were studied at implant. QRS duration (QRSd) reduction was compared for the following pacing configurations: nominal simultaneous BiV (Mode I: paced/sensed atrioventricular delay=140/110 ms), BiV+SyncAV with 50 ms offset (Mode II), BiV+SyncAV with offset that minimized QRSd (Mode III), or LV-only pacing+SyncAV with 50 ms offset (Mode IV). The intrinsic QRSd (162±16 ms) was reduced to 142±17 ms (-11.8%) by Mode I, 136±14 ms (-15.6%) by Mode IV, and 132±13 ms (-17.8%) by Mode II. Mode III yielded the shortest overall QRSd (123±12 ms, -23.9% [P<0.001 versus all modes]) and was the only configuration without QRSd prolongation in any patient. QRS narrowing occurred regardless of QRSd, PR, or LV-paced intervals, or underlying ischemic disease. CONCLUSIONS Post-implant electrical optimization in already well-selected patients with left bundle branch block and optimized LV lead position is facilitated by patient-tailored BiV pacing adjusted to intrinsic atrioventricular timing using an automatic device-based algorithm.
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Affiliation(s)
| | | | | | | | - Carlo Pappone
- Department of Electrophysiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | | | | | | | - Bernard Thibault
- Electrophysiology Service, Montreal Heart Institute, Montreal, Canada
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