Comparison of novel ventricular pacing strategies using an electro-mechanical simulation platform

Abstract

Aims Focus of pacemaker therapy is shifting from right ventricular (RV) apex pacing (RVAP) and biventricular pacing (BiVP) to conduction system pacing. Direct comparison between the different pacing modalities and their consequences to cardiac pump function is difficult, due to the practical implications and confounding variables. Computational modelling and simulation provide the opportunity to compare electrical, mechanical, and haemodynamic consequences in the same virtual heart. Methods and results Using the same single cardiac geometry, electrical activation maps following the different pacing strategies were calculated using an Eikonal model on a three-dimensional geometry, which were then used as input for a lumped mechanical and haemodynamic model (CircAdapt). We then compared simulated strain, regional myocardial work, and haemodynamic function for each pacing strategy. Selective His-bundle pacing (HBP) best replicated physiological electrical activation and led to the most homogeneous mechanical behaviour. Selective left bundle branch (LBB) pacing led to good left ventricular (LV) function but significantly increased RV load. RV activation times were reduced in non-selective LBB pacing (nsLBBP), reducing RV load but increasing heterogeneity in LV contraction. LV septal pacing led to a slower LV and more heterogeneous LV activation than nsLBBP, while RV activation was similar. BiVP led to a synchronous LV–RV, but resulted in a heterogeneous contraction. RVAP led to the slowest and most heterogeneous contraction. Haemodynamic differences were small compared to differences in local wall behaviour. Conclusion Using a computational modelling framework, we investigated the mechanical and haemodynamic outcome of the prevailing pacing strategies in hearts with normal electrical and mechanical function. For this class of patients, nsLBBP was the best compromise between LV and RV function if HBP is not possible.

Virtual pacing of a patient’s digital twin to predict left ventricular reverse remodelling after cardiac resynchronization therapy

“…This electrical characterization may especially be important in ischaemic patients that have abnormal conduction in scarred areas. 31 When also combining such a DT with models of electrical wave propagation to simulate different pacing conditions, 32 the interaction between the patient’s electrical and non-electrical tissue characteristics may be more closely investigated.…”

Arrhythmias in Patients with Pulmonary Hypertension and Right Ventricular Failure: Importance of Rhythm Control Strategies

“…Strategies for resynchronizing the right ventricle, through RV myocardial or conduction system pacing, are under investigation. Given the increasing use of conduction system pacing, it should be noted that selective left bundle branch pacing significantly increases the RV load, which may be problematic in patients with PH [31]. A strategy of device implantation and atrioventricular junction ablation should be undertaken only after careful consideration, as it does not restore atrial contraction or AV synchrony.…”

Advancing clinical translation of cardiac biomechanics models: a comprehensive review, applications and future pathways

“…The TriSeg model has been used in combination with echocardiography strain data to investigate different substrates in RV arrhythmogenesis cardiomyopathy, and was able to link RV deformation abnormalities to changes in RV contractility and compliance [ 157 , 158 ], to identify potential causes of abnormal septal motion in patients with pulmonary hypertension [ 159 ] and to link cellular contractile properties to CRT response [ 160 ]. The MultiPatch model has been used to investigate local work heterogeneity during different pacing modalities to compare various CRT delivery methods [ 161 ]. Depending on the application, CircAdapt and its extensions constitute a valuable tool for in silico investigations.…”