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Comparison of Depolarization and Repolarization Parameters in Left vs. Right Ventricular Septal Pacing—An Intraprocedural Electrocardiographic Study. J Cardiovasc Dev Dis 2023; 10:jcdd10030108. [PMID: 36975872 PMCID: PMC10054600 DOI: 10.3390/jcdd10030108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 02/26/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
Compared with conventional right ventricular septal pacing (RVSP), several studies have shown a net clinical benefit of left bundle branch area pacing (LBBAP) in terms of ejection fraction preservation and reduced hospitalizations for heart failure. The purpose of this study was to compare acute depolarization and repolarization electrocardiographic parameters between LBBAP and RVSP in the same patients during the LBBAP implant procedure. We prospectively included 74 consecutive patients subjected to LBBAP from 1 January to 31 December 2021 at our institution in the study. After the lead was placed deep into the ventricular septum, unipolar pacing was performed and 12-lead ECGs were recorded from the distal (LBBAP) and proximal (RVSP) electrodes. QRS duration (QRSd), left ventricular activation time (LVAT), right ventricular activation time (RVAT), QT and JT intervals, QT dispersion (QTd), T-wave peak-to-end interval (Tpe), and Tpe/QT were measured for both instances. The final LBBAP threshold was a 0.7 ± 0.31 V at 0.4 ms duration with a sensing threshold of 10.7 ± 4.1 mV. RVSP produced a significantly larger QRS complex than the baseline QRS (194.88 ± 17.29 ms vs. 141.89 ± 35.41 ms, p < 0.001), while LBBAP did not significantly change the mean QRSd (148.10 ± 11.52 ms vs. 141.89 ± 35.41 ms, p = 0.135). LVAT (67.63 ± 8.79 ms vs. 95.89 ± 12.02 ms, p < 0.001) and RVAT (80.54 ± 10.94 ms vs. 98.99 ± 13.80 ms, p < 0.001) were significantly shorter with LBBAP than with RVSP. Moreover, all the repolarization parameters studied were significantly shorter in LBBAP than in RVSP (QT—425.95 ± 47.54 vs. 487.30 ± 52.32; JT—281.85 ± 53.66 vs. 297.69 ± 59.02; QTd—41.62 ± 20.07 vs. 58.38 ± 24.44; Tpe—67.03 ± 11.19 vs. 80.27 ± 10.72; and Tpe/QT—0.158 ± 0.028 vs. 0.165 ± 0.021, p < 0.05 for all), irrespective of the baseline QRS morphology. LBBAP was associated with significantly better acute depolarization and repolarization electrocardiographic parameters compared with RVSP.
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Odland HH, Holm T, Cornelussen R, Kongsgård E. Determinants of the time-to-peak left ventricular dP/dt (Td) and QRS duration with different fusion strategies in cardiac resynchronization therapy. Front Cardiovasc Med 2022; 9:979581. [PMID: 36186985 PMCID: PMC9520326 DOI: 10.3389/fcvm.2022.979581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/23/2022] [Indexed: 12/03/2022] Open
Abstract
Background Cardiac resynchronization therapy (CRT) is helpful in selected patients; however, responder rates rarely exceed 70%. Optimization of CRT may therefore benefit a large number of patients. Time-to-peak dP/dt (Td) is a novel marker of myocardial synergy that reflects the degree of myocardial dyssynchrony with the potential to guide and optimize treatment with CRT. Optimal electrical activation is a prerequisite for CRT to be effective. Electrical activation can be altered by changing the electrical wave-front fusion resulting from pacing to optimize resynchronization. We designed this study to understand the acute effects of different electrical wave-front fusion strategies and LV pre-/postexcitation on Td and QRS duration (QRSd). A better understanding of measuring and optimizing resynchronization can help improve the benefits of CRT. Methods Td and QRSd were measured in 19 patients undergoing a CRT implantation. Two biventricular pacing groups were compared: pacing the left ventricle (LV) with fusion with intrinsic right ventricular activation (FUSION group) and pacing the LV and right ventricle (RV) at short atrioventricular delay (STANDARD group) to avoid fusion with intrinsic RV activation. A quadripolar LV lead enabled pacing from widely separated electrodes; distal (DIST), proximal (PROX) and both electrodes combined (multipoint pacing, MPP). The LV was stimulated relative in time to RV activation (either RV pace-onset or QRS-onset), with the LV stimulated prior to (PRE), simultaneous with (SIM) or after (POST) RV activation. In addition, we analyzed the interactions of the two groups (FUSION/STANDARD) with three different electrode configurations (DIST, PROX, MPP), each paced with three different degrees of LV pre-/postexcitation (PRE, SIM, POST) in a statistical model. Results We found that FUSION provided shorter Td and QRSd than STANDARD, MPP provided shorter Td and QRSd than DIST and PROX, and SIM provided both the shortest QRSd and Td compared to PRE and POST. The interaction analysis revealed that pacing MPP with fusion with intrinsic RV activation simultaneous with the onset of the QRS complex (MPP*FUSION*SIM) shortened QRSd and Td the most compared to all other modes and configurations. The difference in QRSd and Td from their respective references were significantly correlated (β = 1, R = 0.9, p < 0.01). Conclusion Pacing modes and electrode configurations designed to optimize electrical wave-front fusion (intrinsic RV activation, LV multipoint pacing and simultaneous RV and LV activation) shorten QRSd and Td the most. As demonstrated in this study, electrical and mechanical measures of resynchronization are highly correlated. Therefore, Td can potentially serve as a marker for CRT optimization.
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Affiliation(s)
- Hans Henrik Odland
- Department of Cardiology and Pediatric Cardiology, Section for Arrhythmias, Oslo University Hospital, Oslo, Norway
- *Correspondence: Hans Henrik Odland
| | - Torbjørn Holm
- Department of Cardiology, Section for Arrhythmias, Oslo University Hospital, Oslo, Norway
| | | | - Erik Kongsgård
- Department of Cardiology, Section for Arrhythmias, Oslo University Hospital, Oslo, Norway
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Programming Algorithms for Cardiac Resynchronization Therapy. Card Electrophysiol Clin 2022; 14:243-252. [PMID: 35715082 DOI: 10.1016/j.ccep.2021.12.018] [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: 11/21/2022]
Abstract
Current cardiac resynchronization therapy (CRT) implant guidelines emphasize the presence of electrical dyssynchrony (left bundle branch block (LBBB) and QRS > 150 ms) yet have modest predictive value for response and have not reduced the 30% nonresponse rate. Optimized programming to optimize CRT delivery has promised much but to date has largely been ineffective. What is missing is the understanding of LV paced effects (which are unpredictable) and optimal paced AV interval (that can be conserved during physiologic variations) that then can be incorporated into an individualized programming prescription. Automatic device-based algorithms that deliver electrical optimization and maintain this during ambulatory fluctuations in AV interval are discussed.
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Borgquist R, Barrington WR, Bakos Z, Werther-Evaldsson A, Saba S. Targeting the latest site of left ventricular mechanical activation is associated with improved long-term outcomes for recipients of Cardiac Resynchronization Therapy. Heart Rhythm O2 2022; 3:377-384. [PMID: 36097466 PMCID: PMC9463689 DOI: 10.1016/j.hroo.2022.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Previous studies have suggested that targeting the site of latest mechanical activation of the left ventricle (LV) results in improved cardiac resynchronization therapy (CRT) outcomes. It is not known whether these benefits are sustained over medium-term follow-up. Objective To assess the clinical outcome of imaging-guided LV lead position. Methods We sought to assess the medium-term clinical outcome by performing a patient-level meta-analysis of 2 previously published randomized controlled trials (the “STARTER” trial and the “CRT Clinic” trial). These 2 trials compared imaging-guided LV lead placement in the latest activated scar-free segment (intervention group) to standard of care (control). Mortality and heart failure hospitalization outcomes over extended follow-up were gathered from the medical records and merged. Results were stratified for native electrocardiogram (ECG) morphology. Results A total of 289 patients were followed for a median of 6.3 years. Seven years post implant, 47 (28%) in the intervention group had died, vs 47 (38%) in the control group (P = .13); 49 (30%) vs 53 (42%) had been hospitalized for heart failure (P = .035); and 47% vs 59% (P = .057) had reached the combined endpoint. In Kaplan-Meier analysis, patients in the intervention group had better survival free of heart failure hospitalization (P = .045) and lower risk of heart failure hospitalization (P = .019). Conclusion Targeting the latest mechanically activated segment in CRT results in better medium-term clinical outcome, mainly driven by a reduced risk of hospitalization for heart failure. The effect was seen regardless of native ECG morphology.
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Affiliation(s)
- Rasmus Borgquist
- Arrhythmia Section, Department of Cardiology, Lund University, Skane University Hospital, Lund, Sweden
- Address reprint requests and correspondence: Dr Rasmus Borgquist, Arrhythmia Section, Skane University Hospital, 221 85, Lund, Sweden.
| | - William R. Barrington
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Zoltan Bakos
- Department of Cardiology, Kristianstad Hospital, Kristianstad, Sweden
| | - Anna Werther-Evaldsson
- Heart Failure and Transplant Section, Department of Cardiology, Lund University, Skane University Hospital, Lund, Sweden
| | - Samir Saba
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Wouters PC, Vernooy K, Cramer MJ, Prinzen FW, Meine M. Optimizing lead placement for pacing in dyssynchronous heart failure: The patient in the lead. Heart Rhythm 2021; 18:1024-1032. [PMID: 33601035 DOI: 10.1016/j.hrthm.2021.02.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 10/22/2022]
Abstract
Cardiac resynchronization therapy (CRT) greatly reduces morbidity and mortality in patients with dyssynchronous heart failure. However, despite tremendous efforts, response has been variable and can be further improved. Although optimizing left ventricular lead placement (LVLP) is arguably the cornerstone of CRT, the procedure of LVLP using the transvenous approach has remained largely unchanged for more than 2 decades. Improvements have been developed using scar location and electrical and/or mechanical mapping, and interest in conduction system pacing as an alternative to biventricular pacing has emerged recently. Conduction system pacing is promising but may not be suitable for all patients with dyssynchronous heart failure. This review underscores the importance of a patient-tailored approach and discusses the potential applications of both conduction system pacing and targeted biventricular CRT.
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Affiliation(s)
- Philippe C Wouters
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maarten J Cramer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, The Netherlands
| | - Mathias Meine
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
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Corbisiero R, Mathew A, Bickert C, Muller D. Multipoint Pacing with Fusion-optimized Cardiac Resynchronization Therapy: Using It All to Narrow QRS Duration. J Innov Card Rhythm Manag 2021; 12:4355-4362. [PMID: 33520350 PMCID: PMC7834044 DOI: 10.19102/icrm.2021.120102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 08/18/2020] [Indexed: 11/25/2022] Open
Abstract
Adaptive atrioventricular (AV)-shortening algorithms have achieved QRS duration (QRSd) narrowing in traditional cardiac resynchronization therapy (CRT) patients. Multipoint pacing (MPP) has also demonstrated benefit in this population. An additional site of activation via intrinsic conduction of the septum may further contribute to CRT; however, the incorporation of all strategies together has yet to be explored. We therefore developed and tested a method combining MPP-CRT and controlled septal contribution to create a multifuse pacing (MFP) technique, establishing four ventricular activation sites for CRT patients using measurements from intracardiac electrograms (EGMs) and incorporating an AV-delay shortening algorithm (SyncAV™; Abbott Laboratories, Chicago, IL, USA) to narrow the QRSd. Patients in sinus rhythm with an AV conduction time of less than 350 ms were included in this analysis and were further stratified by strictly defined left bundle branch block (sLBBB) or nonspecific intraventricular conduction delay (IVCD). EGM-based measurements to determine the QRS septal onset to right ventricular (RV) time (SRAT) and the left ventricular (LV) to RV pacing conduction time were collected and applied to a formula to facilitate MFP. QRSd was compared between before and after programming. A total of 22 patients (19 men and three women) with similar baseline characteristics were compared (all values in mean ± standard deviation). The overall baseline QRSd of 153.31 ± 24.60 ms was decreased to 115.31 ± 16.31 ms after MFP programming (p < 0.0001). The measured SRAT was 59.40 ± 28.49 ms, resulting in a negative AV offset of −20.0 ± 24.97 ms. Patients in the sLBBB group (n = 7) were aged 67.8 ± 13.3 years and had a QRSd of 168.85 ± 27.29 ms that decreased to 113 ± 16.69 ms for a reduction of 55.42 ± 19.3 ms or 32.1% (p = 0.0003). In the IVCD group (n = 15), the baseline QRSd of 146.06 ± 20.29 ms was decreased to 116 ± 16.66 ms for a reduction of 30.07 ± 16.41 ms or 20.62% (p = 0.0001). When comparing the sLBBB and IVCD groups, the sLBBB group was favored by a reduction of 25.35 ms (p = 0.00046). Ultimately, MFP achieved statistically significant reductions in QRSd in all patients tested in this analysis. The benefit was also significantly better in the sLBBB group as compared with in the IVCD group.
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Ferchaud V, Garcia R, Bidegain N, Degand B, Milliez P, Pezel T, Moubarak G. Non-invasive hemodynamic determination of patient-specific optimal pacing mode in cardiac resynchronization therapy. J Interv Card Electrophysiol 2020; 62:347-356. [PMID: 33128179 DOI: 10.1007/s10840-020-00908-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 10/26/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Cardiac resynchronization therapy (CRT) devices have multiple programmable pacing parameters. The purpose of this study was to determine the best pacing mode, i.e., associated with the greatest acute hemodynamic response, in each patient. METHODS Patients in sinus rhythm and intact atrioventricular conduction were included within 3 months of implantation of devices featuring SyncAV and multipoint pacing (MPP) algorithms. The effect of nominal biventricular pacing using the latest activated electrode (BiV-Late), optimized atrioventricular delay (AVD), nominal and optimized SyncAV, and anatomical MPP was determined by non-invasive measurement of systolic blood pressure (SBP). CRT response was defined as SBP increase > 10% relative to baseline. RESULTS Thirty patients with left bundle branch block (LBBB) were included. BiV-Late increased SBP compared to intrinsic rhythm (128 ± 21 mmHg vs. 121 ± 22 mmHg, p = 0.0002). The best pacing mode further increased SBP to 140 ± 19 mmHg (p < 0.0001 vs. BiV-Late). The proportion of CRT responders increased from 40% with BiV-Late to 80% with the best pacing mode (p = 0.0005). Compared to BiV-Late, optimized AVD and optimized SyncAV increased SBP (to 134 ± 21 mmHg, p = 0.004, and 133 ± 20 mmHg, p = 0.0003, respectively), but nominal SyncAV and MPP did not. The best pacing mode was variable between patients and was different from nominal BiV-Late in 28 (93%) patients. Optimized AVD was the most frequent best mode, in 14 (47%) patients. CONCLUSION In patients with LBBB, the best pacing mode was patient-specific and doubled the magnitude of acute hemodynamic response and the proportion of acute CRT responders compared to nominal BiV-Late pacing. TRIAL REGISTRATION ClinicalTrials.gov : NCT03779802.
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Affiliation(s)
- Virginie Ferchaud
- Department of Electrophysiology and Pacing, Centre Médico-Chirurgical Ambroise Paré, 27 Boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France
- Department of Cardiology, Centre Hospitalier Universitaire de Caen Normandie, Caen, France
| | - Rodrigue Garcia
- Department of Cardiology, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Nicolas Bidegain
- Department of Cardiology, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Bruno Degand
- Department of Cardiology, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Paul Milliez
- Department of Cardiology, Centre Hospitalier Universitaire de Caen Normandie, Caen, France
| | - Théo Pezel
- Department of Cardiology, Centre Hospitalier Universitaire Lariboisière, Paris, France
| | - Ghassan Moubarak
- Department of Electrophysiology and Pacing, Centre Médico-Chirurgical Ambroise Paré, 27 Boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France.
- Department of Cardiology, Centre Hospitalier Universitaire Lariboisière, Paris, France.
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Pereira H, Niederer S, Rinaldi CA. Electrocardiographic imaging for cardiac arrhythmias and resynchronization therapy. Europace 2020; 22:euaa165. [PMID: 32754737 PMCID: PMC7544539 DOI: 10.1093/europace/euaa165] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 05/25/2020] [Indexed: 12/12/2022] Open
Abstract
Use of the 12-lead electrocardiogram (ECG) is fundamental for the assessment of heart disease, including arrhythmias, but cannot always reveal the underlying mechanism or the location of the arrhythmia origin. Electrocardiographic imaging (ECGi) is a non-invasive multi-lead ECG-type imaging tool that enhances conventional 12-lead ECG. Although it is an established technology, its continuous development has been shown to assist in arrhythmic activation mapping and provide insights into the mechanism of cardiac resynchronization therapy (CRT). This review addresses the validity, reliability, and overall feasibility of ECGi for use in a diverse range of arrhythmias. A systematic search limited to full-text human studies published in peer-reviewed journals was performed through Medline via PubMed, using various combinations of three key concepts: ECGi, arrhythmia, and CRT. A total of 456 studies were screened through titles and abstracts. Ultimately, 42 studies were included for literature review. Evidence to date suggests that ECGi can be used to provide diagnostic insights regarding the mechanistic basis of arrhythmias and the location of arrhythmia origin. Furthermore, ECGi can yield valuable information to guide therapeutic decision-making, including during CRT. Several studies have used ECGi as a diagnostic tool for atrial and ventricular arrhythmias. More recently, studies have tested the value of this technique in predicting outcomes of CRT. As a non-invasive method for assessing cardiovascular disease, particularly arrhythmias, ECGi represents a significant advancement over standard procedures in contemporary cardiology. Its full potential has yet to be fully explored.
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Affiliation(s)
- Helder Pereira
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, 4th Floor, Lambeth Wing, St. Thomas’ Hospital, Westminster Bridge Rd, London SE1 7EH, UK
- Cardiac Physiology Services—Clinical Investigation Centre, Bupa Cromwell Hospital, London, UK
| | - Steven Niederer
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, 4th Floor, Lambeth Wing, St. Thomas’ Hospital, Westminster Bridge Rd, London SE1 7EH, UK
| | - Christopher A Rinaldi
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, 4th Floor, Lambeth Wing, St. Thomas’ Hospital, Westminster Bridge Rd, London SE1 7EH, UK
- Cardiovascular Department, Guys and St Thomas NHS Foundation Trust, London, UK
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Deshmukh A, Sattur S, Bechtol T, Heckman LIB, Prinzen FW, Deshmukh P. Sequential His bundle and left ventricular pacing for cardiac resynchronization. J Cardiovasc Electrophysiol 2020; 31:2448-2454. [DOI: 10.1111/jce.14674] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 06/23/2020] [Accepted: 07/10/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Amrish Deshmukh
- Department of Internal Medicine, Division of Cardiovascular Medicine, Samuel and Jean Frankel Cardiovascular Center University of Michigan Ann Arbor Michigan USA
| | - Sudhakar Sattur
- Department of Internal Medicine, Division of Cardiology, Arrhythmia Center Robert Packer Hospital Sayre Pennsylvania USA
| | - Tim Bechtol
- Department of Field CRM Abbott Williamsport Pennsylvania USA
| | | | - Frits W. Prinzen
- Cardiovascular Research Institute Maastricht Maastricht The Netherlands
| | - Pramod Deshmukh
- Department of Internal Medicine, Division of Cardiology, Arrhythmia Center Robert Packer Hospital Sayre Pennsylvania USA
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Moubarak G, Sebag FA, Socie P, Villejoubert O, Louembe J, Ferchaud V. Interrelationships between interventricular electrical delays in cardiac resynchronization therapy. J Cardiovasc Electrophysiol 2020; 31:2405-2414. [PMID: 32562444 DOI: 10.1111/jce.14629] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/07/2020] [Accepted: 06/14/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION In cardiac resynchronization therapy, pacing the left ventricle (LV) at sites of prolonged electrical delay is associated with better outcomes. We sought to characterize the interrelationships between intrinsic, right-ventricular (RV)-paced, and LV-paced interventricular delays. METHODS AND RESULTS The following electrical timings were measured at implantation for all electrodes of the LV quadripolar leads: QLV, interventricular delay in intrinsic rhythm (RVs-LVs), in RV-paced rhythm (RVp-LVs), and in LV-paced rhythm (LVp-RVs). We included 32 patients (78% men, age 72 years, LV ejection fraction 29%, left bundle branch block 84%). QLV and RVs-LVs were correlated (R2 = .72, p < .0001), as were RVs-LVs and RVp-LVs (R2 = .27, p = .002) and RVp-LVs and LVp-RVs (R2 = .60, p < .001). Direction of activation along the four LV lead electrodes was concordant between RVs-LVs and RVp-LVs in only 17 (53%) patients. The latest-activated electrodes in RVs-LVs and RVp-LVs were concordant in 26 (81%) patients, adjacent in 3 (9%) patients, and remote in 3 (9%) patients. Biventricular-paced QRS duration varied by more than 10 ms between the two electrodes in half of the patients with dissimilar latest electrodes. Among the seven echocardiographic nonresponders at 6 months, the programmed electrode was remote from the latest electrode in RVs-LVs in five patients and in RVp-LVs in three patients. CONCLUSION Intrinsic and RV-paced interventricular electrical delays are correlated, but there is substantial heterogeneity between patients. The latest-activated electrode may be different between RVs-LVs and RVp-LVs, and this might have important implications in selecting the optimal LV vector.
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Affiliation(s)
- Ghassan Moubarak
- Department of Electrophysiology and Pacing, Centre Médico-Chirurgical Ambroise Paré, Neuilly-sur-Seine, France
| | - Frédéric A Sebag
- Département de Cardiologie Médicale, Institut Mutualiste Montsouris, Paris, France
| | - Pierre Socie
- Department of Cardiology, Centre Hospitalier de Chartres, Chartres, France
| | - Olivier Villejoubert
- Département de Cardiologie Médicale, Institut Mutualiste Montsouris, Paris, France
| | - Jules Louembe
- Department of Cardiology, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Virginie Ferchaud
- Department of Electrophysiology and Pacing, Centre Médico-Chirurgical Ambroise Paré, Neuilly-sur-Seine, France.,Department of Cardiology, Centre Hospitalier Universitaire de Caen Normandie, Caen, France
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11
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Wisnoskey BJ, Varma N. Left ventricular paced activation in cardiac resynchronization therapy patients with left bundle branch block and relationship to its electrical substrate. Heart Rhythm O2 2020; 1:85-95. [PMID: 34113862 PMCID: PMC8183968 DOI: 10.1016/j.hroo.2020.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Cardiac resynchronization therapy (CRT) uses left ventricular (LV) pacing to restore rapid synchronized LV activation when it is delayed in patients with myocardial disease. Objective Although intrinsic LV activation delays are understood, little is known about reactions to LV stimulation and whether they are affected by QRS duration (QRSd), morphology, LV substrate, or choice of electrode pair. The purpose of this study was to test these interactions. Methods In 120 heart failure patients with left bundle branch block (LBBB) and QRS >120 ms receiving CRT with quadripolar LV leads, device-based measurements of intrinsic activation delay (qLV) and paced inter- (and intra-) LV conduction times were evaluated at the proximal and distal LV bipoles. Results During intrinsic conduction, qLV varied little between the proximal and distal pairs in patients with LBBB (n = 120; age 68 ± 11 years; 63% male; ejection fraction 25% ± 7%; 33% ischemic cardiomyopathy; QRSd 162 ± 19 ms). A minority (30%) had conduction barriers (ie, gradients) (ΔqLV 29 ± 8 ms vs 9 ± 5 ms in patients without gradients; P <.01), which occurred equally in ischemic and nonischemic patients. A majority were functional (and not scar-mediated), as they resolved with pacing in most patients (75%). Importantly, LV-paced conduction times were unrelated to baseline QRS morphology (LBBB 166 ± 30 ms vs RBBB control 172 ± 30 ms; P = NS), longer than intrinsic conduction (166 ± 30 ms vs 129 ± 28 ms; P <.01), and varied significantly by electrode pair (ie, small distances) and etiology. Correlation between intrinsic activation delay (qLV) and LV-paced conduction time was poor (R2 = 0.278; P <.05). Conclusion LV-paced effect, which is core to CRT, is unpredictable based on conventionally used measures and should be considered during CRT optimization.
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Affiliation(s)
| | - Niraj Varma
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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12
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Abstract
Left bundle branch block may be due to conduction system degeneration or a reflection of myocardial pathology. Left bundle branch block may also develop following aortic valve disease or cardiac procedures. Patients with heart failure with reduced ejection fraction and left bundle branch block may respond positively to cardiac resynchronization therapy. Lead placement via the coronary sinus is the mainstay approach of cardiac resynchronization therapy. However, other options, including physiological pacing, are being explored. In this review, we summarize the salient pathophysiologic and clinical aspects of left bundle branch block, as well as current and future strategies for management.
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Affiliation(s)
- Nicholas Y Tan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Chance M Witt
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Yong-Mei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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13
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Kaye G. The desire for physiological pacing: Are we there yet? J Cardiovasc Electrophysiol 2019; 30:3025-3038. [DOI: 10.1111/jce.14248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/11/2019] [Accepted: 10/16/2019] [Indexed: 01/23/2023]
Affiliation(s)
- Gerry Kaye
- University of Queensland Medical School, Herston Brisbane Queensland Australia
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Jackson T, Claridge S, Behar J, Sieniewicz B, Gould J, Porter B, Sidhu B, Yao C, Lee A, Niederer S, Rinaldi CA. Differential effect with septal and apical RV pacing on ventricular activation in patients with left bundle branch block assessed by non-invasive electrical imaging and in silico modelling. J Interv Card Electrophysiol 2019; 57:115-123. [PMID: 31201592 PMCID: PMC7036078 DOI: 10.1007/s10840-019-00567-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 05/19/2019] [Indexed: 11/24/2022]
Abstract
Purpose It is uncertain whether right ventricular (RV) lead position in cardiac resynchronization therapy impacts response. There has been little detailed analysis of the activation patterns in RV septal pacing (RVSP), especially in the CRT population. We compare left bundle branch block (LBBB) activation patterns with RV pacing (RVP) within the same patients with further comparison between RV apical pacing (RVAP) and RVSP. Methods Body surface mapping was undertaken in 14 LBBB patients after CRT implantation. Nine patients had RVAP, 5 patients had RVSP. Activation parameters included left ventricular total activation time (LVtat), biventricular total activation time (VVtat), interventricular electrical synchronicity (VVsync), and dispersion of left ventricular activation times (LVdisp). The direction of activation wave front was also compared in each patient (wave front angle (WFA)). In silico computer modelling was applied to assess the effect of RVAP and RVSP in order to validate the clinical results. Results Patients were aged 64.6 ± 12.2 years, 12 were male, 8 were ischemic. Baseline QRS durations were 157 ± 18 ms. There was no difference in VVtat between RVP and LBBB but a longer LVtat in RVP (102.8 ± 19.6 vs. 87.4 ± 21.1 ms, p = 0.046). VVsync was significantly greater in LBBB (45.1 ± 20.2 vs. 35.9 ± 17.1 ms, p = 0.01) but LVdisp was greater in RVP (33.4 ± 5.9 vs. 27.6 ± 6.9 ms, p = 0.025). WFA did rotate clockwise with RVP vs. LBBB (82.5 ± 25.2 vs. 62.1 ± 31.7 op = 0.026). None of the measurements were different to LBBB with RVSP; however, the differences were preserved with RVAP for VVsync, LVdisp, and WFA. In silico modelling corroborated these results. Conclusions RVAP activation differs from LBBB where RVSP appears similar. Trial registration (ClinicalTrials.gov identifier: NCT01831518) Electronic supplementary material The online version of this article (10.1007/s10840-019-00567-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- T Jackson
- Department of Imaging Sciences, St Thomas' Hospital, King's College London, London, SE1, UK.
- Department of Cardiology, Salisbury NHS Foundation Trust, Salisbury, Wiltshire, SP2 8BJ, UK.
| | - S Claridge
- Department of Imaging Sciences, St Thomas' Hospital, King's College London, London, SE1, UK
| | - J Behar
- Department of Imaging Sciences, St Thomas' Hospital, King's College London, London, SE1, UK
| | - B Sieniewicz
- Department of Imaging Sciences, St Thomas' Hospital, King's College London, London, SE1, UK
| | - J Gould
- Department of Imaging Sciences, St Thomas' Hospital, King's College London, London, SE1, UK
| | - B Porter
- Department of Imaging Sciences, St Thomas' Hospital, King's College London, London, SE1, UK
| | - B Sidhu
- Department of Imaging Sciences, St Thomas' Hospital, King's College London, London, SE1, UK
| | - C Yao
- Medtronic/CardioInsight, Cleveland, OH, USA
| | - A Lee
- Department of Imaging Sciences, St Thomas' Hospital, King's College London, London, SE1, UK
| | - S Niederer
- Department of Imaging Sciences, St Thomas' Hospital, King's College London, London, SE1, UK
| | - C A Rinaldi
- Department of Imaging Sciences, St Thomas' Hospital, King's College London, London, SE1, UK
- Guy's and St Thomas' NHS Trust, King's College London, London, SE1 9RT, UK
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15
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Khurwolah MR, Yao J, Kong XQ. Adverse Consequences of Right Ventricular Apical Pacing and Novel Strategies to Optimize Left Ventricular Systolic and Diastolic Function. Curr Cardiol Rev 2019; 15:145-155. [PMID: 30499419 PMCID: PMC6520581 DOI: 10.2174/1573403x15666181129161839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 11/20/2018] [Accepted: 11/22/2018] [Indexed: 11/25/2022] Open
Abstract
Several studies have focused on the deleterious consequences of Right Ventricular Apical (RVA) pacing on Left Ventricular (LV) function, mediated by pacing-induced ventricular dyssyn-chrony. Therapeutic strategies to reduce the detrimental consequences of RVA pacing have been pro-posed, that includes upgrading of RVA pacing to Cardiac Resynchronization Therapy (CRT), alterna-tive Right Ventricular (RV) pacing sites, minimal ventricular pacing strategies, as well as atrial-based pacing. In developing countries, single chamber RV pacing still constitutes a majority of cases of permanent pacing, and assessment of the optimal RV pacing site is of paramount importance. In chronically-paced patients, it is crucial to maintain as close and normal LV physiological function as possible, by minimizing ventricular dyssynchrony, reducing the chances for heart failure and other complications to develop. This review provides an analysis of the deleterious immediate and long-term consequences of RVA pacing, and the most recent available evidence regarding improvements in pacing options and strategies to optimize LV diastolic and systolic function. Furthermore, the place of advanced echocardiography in the identification of patients with pacing-induced LV dysfunction, the potential role of a new predictor of LV dysfunction in RV-paced subjects, and the long- term out-comes of patients with RV septal pacing will be explored
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Affiliation(s)
- Mohammad Reeaze Khurwolah
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Jing Yao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Xiang-Qing Kong
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
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16
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Kalinin A, Potyagaylo D, Kalinin V. Solving the Inverse Problem of Electrocardiography on the Endocardium Using a Single Layer Source. Front Physiol 2019; 10:58. [PMID: 30804802 PMCID: PMC6370732 DOI: 10.3389/fphys.2019.00058] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 01/18/2019] [Indexed: 12/04/2022] Open
Abstract
The inverse problem of electrocardiography consists in reconstructing cardiac electrical activity from given body surface electrocardiographic measurements. Despite tremendous progress in the field over the last decades, the solution of this problem in terms of electrical potentials on both epi- and the endocardial heart surfaces with acceptable accuracy remains challenging. This paper presents a novel numerical approach aimed at improving the solution quality on the endocardium. Our method exploits the solution representation in the form of electrical single layer densities on the myocardial surface. We demonstrate that this representation brings twofold benefits: first, the inverse problem can be solved for the physiologically meaningful single layer densities. Secondly, a conventional transfer matrix for electrical potentials can be split into two parts, one of which turned out to posess regularizing properties leading to improved endocardial reconstructions. The method was tested in-silico for ventricular pacings utilizing realistic CT-based heart and torso geometries. The proposed approach provided more accurate solution on the ventricular endocardium compared to the conventional potential-based solutions with Tikhonov regularization of the 0th, 1st, and 2nd orders. Furthermore, we show a uniform spatio-temporal behavior of the single layer densities over the heart surface, which could be conveniently employed in the regularization procedure.
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17
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Varma N, Ghanem R, Jia P. Pacing prescription for cardiac resynchronization therapy: When RV stimulation matters. J Cardiovasc Electrophysiol 2019; 30:769-770. [PMID: 30661268 DOI: 10.1111/jce.13850] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 01/03/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) aims to correct delayed left ventricle (LV) activation resulting from left bundle branch block (LBBB). The source of LV activation delay resides in the septum and/or anterior LV. LV pacing, timed with intrinsic right bundle branch (RBB) conduction, may restore "physiological" biventricular activation. This is not assured because LV paced wavefronts themselves propagate unpredictably. Less studied are effects of right ventricle (RV) pacing on LV activation in heart failure (HF) patients with LBBB. METHODS AND RESULTS In this case RV pacing pre-excited precisely the region left behind during LV pacing. Consequently, biventricular pacing produced confluent LV depolarization (the patient "responded" to this with reverse remodeling). CONCLUSION Successful electrical resynchronization requires best combination and timing of paced/intrinsic wavefront(s). This demands individualization. Sometimes, an RV paced wavefront may be valuable to resynchronization.
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Affiliation(s)
- Niraj Varma
- Cardiac Electrophysiology Section, Department of Cardiology, University Hospitals, Cleveland, Ohio
| | - Raja Ghanem
- Cardiac Bioelectricity Research and Training Center, Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio
| | - Ping Jia
- Cardiac Bioelectricity Research and Training Center, Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio
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18
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Wieslander B, Xia X, Jablonowski R, Axelsson J, Klem I, Nijveldt R, Maynard C, Schelbert EB, Sörensson P, Sigfridsson A, Chaudhry U, Platonov PG, Borgquist R, Engblom H, Couderc JP, Strauss DG, Atwater BD, Ugander M. The ability of the electrocardiogram in left bundle branch block to detect myocardial scar determined by cardiovascular magnetic resonance. J Electrocardiol 2018; 51:779-786. [PMID: 30177312 DOI: 10.1016/j.jelectrocard.2018.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/19/2018] [Accepted: 05/29/2018] [Indexed: 12/24/2022]
Abstract
AIMS We aimed to improve the electrocardiographic 2009 left bundle branch block (LBBB) Selvester QRS score (2009 LBSS) for scar assessment. METHODS We retrospectively identified 325 LBBB patients with available ECG and cardiovascular magnetic resonance imaging (CMR) with late gadolinium enhancement from four centers (142 [44%] with CMR scar). Forty-four semi-automatically measured ECG variables pre-selected based on the 2009 LBSS yielded one multivariable model for scar detection and another for scar quantification. RESULTS The 2009 LBSS achieved an area under the curve (AUC) of 0.60 (95% confidence interval 0.54-0.66) for scar detection, and R2 = 0.04, p < 0.001, for scar quantification. Multivariable modeling improved scar detection to AUC 0.72 (0.66-0.77) and scar quantification to R2 = 0.21, p < 0.001. CONCLUSIONS The 2009 LBSS detects and quantifies myocardial scar with poor accuracy. Improved models with extensive comparison of ECG and CMR had modest performance, indicating limited room for improvement of the 2009 LBSS.
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Affiliation(s)
- Björn Wieslander
- Department of Clinical Physiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Xiaojuan Xia
- Heart Research Follow-Up Program, University of Rochester, NY, USA
| | - Robert Jablonowski
- Department of Clinical Physiology and Nuclear Medicine, Skåne University Hospital, Lund University, Lund, Sweden
| | - Jimmy Axelsson
- Department of Clinical Physiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Igor Klem
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Robin Nijveldt
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Charles Maynard
- Department of Health Services, University of Washington, Seattle, WA, USA
| | | | - Peder Sörensson
- Department of Clinical Physiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Andreas Sigfridsson
- Department of Clinical Physiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Uzma Chaudhry
- Arrhythmia Clinic, Skane University Hospital, Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Pyotr G Platonov
- Arrhythmia Clinic, Skane University Hospital, Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Rasmus Borgquist
- Arrhythmia Clinic, Skane University Hospital, Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Henrik Engblom
- Department of Clinical Physiology and Nuclear Medicine, Skåne University Hospital, Lund University, Lund, Sweden
| | | | - David G Strauss
- Department of Clinical Physiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Brett D Atwater
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Martin Ugander
- Department of Clinical Physiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
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19
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Bear LR, Huntjens PR, Walton RD, Bernus O, Coronel R, Dubois R. Cardiac electrical dyssynchrony is accurately detected by noninvasive electrocardiographic imaging. Heart Rhythm 2018; 15:1058-1069. [PMID: 29477975 DOI: 10.1016/j.hrthm.2018.02.024] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Poor identification of electrical dyssynchrony is postulated to be a major factor contributing to the low success rate for cardiac resynchronization therapy. OBJECTIVE The purpose of this study was to evaluate the sensitivity of body surface mapping and electrocardiographic imaging (ECGi) to detect electrical dyssynchrony noninvasively. METHODS Langendorff-perfused pig hearts (n = 11) were suspended in a human torso-shaped tank, with left bundle branch block (LBBB) induced through ablation. Recordings were taken simultaneously from a 108-electrode epicardial sock and 128 electrodes embedded in the tank surface during sinus rhythm and ventricular pacing. Computed tomography provided electrode and heart positions in the tank. Epicardial unipolar electrograms were reconstructed from torso potentials using ECGi. Dyssynchrony markers from torso potentials (eg, QRS duration) or ECGi (total activation time, interventricular delay [D-LR], and intraventricular markers) were correlated with those recorded from the sock. RESULTS LBBB was induced (n = 8), and sock-derived activation maps demonstrated interventricular dyssynchrony (D-LR and total activation time) in all cases (P < .05) and intraventricular dyssynchrony for complete LBBB (P < .05) compared to normal sinus rhythm. Only D-LR returned to normal with biventricular pacing (P = .1). Torso markers increased with large degrees of dyssynchrony, and no reduction was seen during biventricular pacing (P > .05). Although ECGi-derived markers were significantly lower than recorded (P < .05), there was a significant strong linear relationship between ECGi and recorded values. ECGi correctly diagnosed electrical dyssynchrony and interventricular resynchronization in all cases. The latest site of activation was identified to 9.1 ± 0.6 mm by ECGi. CONCLUSION ECGi reliably and accurately detects electrical dyssynchrony, resynchronization by biventricular pacing, and the site of latest activation, providing more information than do body surface potentials.
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Affiliation(s)
- Laura R Bear
- Electrophysiology and Heart Modelling Institute (IHU-LIRYC), Fondation Bordeaux Université, Pessac, France; Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux U1045, France; Inserm, U1045, Centre de Recherche Cardio-Thoracique de Bordeaux, France.
| | - Peter R Huntjens
- Electrophysiology and Heart Modelling Institute (IHU-LIRYC), Fondation Bordeaux Université, Pessac, France; Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux U1045, France; Inserm, U1045, Centre de Recherche Cardio-Thoracique de Bordeaux, France; CARIM School for Cardiovascular Diseases, Maastricht University MedicalCentre, Maastricht, The Netherlands
| | - Richard D Walton
- Electrophysiology and Heart Modelling Institute (IHU-LIRYC), Fondation Bordeaux Université, Pessac, France; Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux U1045, France; Inserm, U1045, Centre de Recherche Cardio-Thoracique de Bordeaux, France
| | - Olivier Bernus
- Electrophysiology and Heart Modelling Institute (IHU-LIRYC), Fondation Bordeaux Université, Pessac, France; Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux U1045, France; Inserm, U1045, Centre de Recherche Cardio-Thoracique de Bordeaux, France
| | - Ruben Coronel
- Electrophysiology and Heart Modelling Institute (IHU-LIRYC), Fondation Bordeaux Université, Pessac, France; Department of Experimental Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Rémi Dubois
- Electrophysiology and Heart Modelling Institute (IHU-LIRYC), Fondation Bordeaux Université, Pessac, France; Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux U1045, France; Inserm, U1045, Centre de Recherche Cardio-Thoracique de Bordeaux, France
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20
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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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21
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Left ventricular-only pacing in heart failure patients with normal atrioventricular conduction improves global function and left ventricular regional mechanics compared with biventricular pacing: an adaptive cardiac resynchronization therapy sub-study. Eur J Heart Fail 2017; 19:1335-1343. [DOI: 10.1002/ejhf.906] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 05/09/2017] [Accepted: 05/15/2017] [Indexed: 11/07/2022] Open
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22
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ter Horst IA, Bogaard MD, Tuinenburg AE, Mast TP, de Boer TP, Doevendans PA, Meine M. The concept of triple wavefront fusion during biventricular pacing: Using the EGM to produce the best acute hemodynamic improvement in CRT. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:873-882. [DOI: 10.1111/pace.13118] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 04/02/2017] [Accepted: 05/02/2017] [Indexed: 02/02/2023]
Affiliation(s)
- Iris A.H. ter Horst
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Margot D. Bogaard
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Anton E. Tuinenburg
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Thomas P. Mast
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Teun P. de Boer
- Department of Medical Physiology; University Medical Center Utrecht; Utrecht The Netherlands
| | | | - Mathias Meine
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
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23
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Duchateau J, Potse M, Dubois R. Spatially Coherent Activation Maps for Electrocardiographic Imaging. IEEE Trans Biomed Eng 2016; 64:1149-1156. [PMID: 27448338 DOI: 10.1109/tbme.2016.2593003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Cardiac mapping is an important diagnostic step in cardiac electrophysiology. One of its purposes is to generate a map of the depolarization sequence. This map is constructed in clinical routine either by directly analyzing cardiac electrograms (EGMs) recorded invasively or an estimate of these EGMs obtained by a noninvasive technique. Activation maps based on noninvasively estimated EGMs often show artefactual jumps in activation times. To overcome this problem, we present a new method to construct the activation maps from reconstructed unipolar EGMs. METHODS On top of the standard estimation of local activation time from unipolar intrinsic deflections, we propose to mutually compare the EGMs in order to estimate the delays in activation for neighboring recording locations. We then describe a workflow to construct a spatially coherent activation map from local activation times and delay estimates in order to create more accurate maps. The method is optimized using simulated data and evaluated on clinical data from 12 different activation sequences. RESULTS We found that the standard methodology created lines of artificially strong activation time gradient. The proposed workflow enhanced these maps significantly. CONCLUSION Estimating delays between neighbors is an interesting option for activation map computation in electrocardiographic imaging.
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van Stipdonk A, Wijers S, Meine M, Vernooy K. ECG Patterns In Cardiac Resynchronization Therapy. J Atr Fibrillation 2015; 7:1214. [PMID: 27957163 DOI: 10.4022/jafib.1214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 04/08/2015] [Accepted: 04/13/2015] [Indexed: 11/10/2022]
Abstract
Cardiac resynchronization therapy is an established treatment modality in heart failure. Though non-response is a serious issue. To address this issue, a good understanding of the electrical activation during underlying intrinsic ventricular activation, biventricular as well as right- and left ventricular pacing is needed. By interpreting the 12-lead electrocardiogram, possible reasons for suboptimal treatment can be identified and addressed. This article reviews the literature on QRS morphology in cardiac resynchronization therapy and its role in optimization of therapy.
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Affiliation(s)
| | - Sofieke Wijers
- Department of Cardiology, University Medical Center Urecht
| | - Mathias Meine
- Department of Cardiology, University Medical Center Urecht
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center
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25
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Ovsyshcher IE. Common sense or evidence: an optimal place for right and left ventricular leads? J Interv Card Electrophysiol 2015; 43:1-3. [PMID: 25877679 DOI: 10.1007/s10840-015-9995-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 03/06/2015] [Indexed: 10/23/2022]
Affiliation(s)
- I Eli Ovsyshcher
- Cardiology, Faculty of Health Sciences, Ben-Gurion University, Beersheva, Israel,
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