Impact of Pacing Site on QRS Duration and Its Relationship to Hemodynamic Response in Cardiac Resynchronization Therapy for Congestive Heart Failure

Derval, Nicolas; Bordachar, Pierre; Lim, H.; Sacher, Frédéric; Ploux, Sylvain; Laborderie, Julien; Steendijk, Paul; Deplagne, Antoine; Ritter, Philippe; Garrigue, Stéphane; Denis, Arnaud; Hocini, Mélèze; Haı̈ssaguerre, Michel; Clémenty, Jacques; Jaı̈s, Pierre

doi:10.1111/jce.12464

Cited by 26 publications

(24 citation statements)

References 33 publications

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“…Derval et al. (22) found that LVendo pacing was superior to posterolateral LVepi pacing in nonischemic patients with significant individual variation between the optimal LVendo pacing sites (22). Spragg et al.…”

Section: Discussionmentioning

confidence: 99%

Optimized Left Ventricular Endocardial Stimulation Is Superior to Optimized Epicardial Stimulation in Ischemic Patients With Poor Response to Cardiac Resynchronization Therapy

Behar

Jackson

Hyde

et al. 2016

JACC: Clinical Electrophysiology

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ObjectivesThe purpose of this study was to identify the optimal pacing site for the left ventricular (LV) lead in ischemic patients with poor response to cardiac resynchronization therapy (CRT).BackgroundLV endocardial pacing may offer benefit over conventional CRT in ischemic patients.MethodsWe performed cardiac magnetic resonance, invasive electroanatomic mapping (EAM), and measured the acute hemodynamic response (AHR) in patients with existing CRT systems.ResultsIn all, 135 epicardial and endocardial pacing sites were tested in 8 patients. Endocardial pacing was superior to epicardial pacing with respect to mean AHR (% change in dP/dtmax vs. baseline) (11.81 [-7.2 to 44.6] vs. 6.55 [-11.0 to 19.7]; p = 0.025). This was associated with a similar first ventricular depolarization (Q-LV) (75 ms [13 to 161 ms] vs. 75 ms [25 to 129 ms]; p = 0.354), shorter stimulation–QRS duration (15 ms [7 to 43 ms] vs. 19 ms [5 to 66 ms]; p = 0.010) and shorter paced QRS duration (149 ms [95 to 218 ms] vs. 171 ms [120 to 235 ms]; p < 0.001). The mean best achievable AHR was higher with endocardial pacing (25.64 ± 14.74% vs. 12.64 ± 6.76%; p = 0.044). Furthermore, AHR was significantly greater pacing the same site endocardially versus epicardially (15.2 ± 10.7% vs. 7.6 ± 6.3%; p = 0.014) with a shorter paced QRS duration (137 ± 22 ms vs. 166 ± 30 ms; p < 0.001) despite a similar Q-LV (70 ± 38 ms vs. 79 ± 34 ms; p = 0.512). Lack of capture due to areas of scar (corroborated by EAM and cardiac magnetic resonance) was associated with a poor AHR.ConclusionsIn ischemic patients with poor CRT response, biventricular endocardial pacing is superior to epicardial pacing. This may reflect accessibility to sites that cannot be reached via coronary sinus anatomy and/or by access to more rapidly conducting tissue. Furthermore, guidance to the optimal LV pacing site may be aided by modalities such as cardiac magnetic resonance to target delayed activating sites while avoiding scar.

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Section: Discussionmentioning

confidence: 99%

Optimized Left Ventricular Endocardial Stimulation Is Superior to Optimized Epicardial Stimulation in Ischemic Patients With Poor Response to Cardiac Resynchronization Therapy

Behar

Jackson

Hyde

et al. 2016

JACC: Clinical Electrophysiology

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“…6 Electric activation times (ATs) as measured by contact mapping were decreased with ENDO-CRT BV over EPI-CRT BV , consistent with concurrent improvements in systolic LV function and more synchronous electric activation compared with EPI-CRT BV . [8][9][10] Specifically, ENDO-CRT BV resulted in an average decrease in LV endocardial and BV epicardial latest ATs (LATs; measured as time from stimulus) of ≈16% and 11%, respectively, when compared with EPI-CRT BV at the equivalent transmural epicardial location. Similar improvements in electric synchrony have been reported for canines undergoing ENDO-CRT BV with LBBB and myocardial infarction, or LBBB with HF.…”

mentioning

confidence: 99%

Beneficial Effect on Cardiac Resynchronization From Left Ventricular Endocardial Pacing Is Mediated by Early Access to High Conduction Velocity Tissue

Hyde

Behar

Claridge

et al. 2015

Circ: Arrhythmia and Electrophysiology

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Dyssynchronous heart failure (HF) is routinely treated with cardiac resynchronization therapy (CRT). During conventional biventricular (BV) CRT, pacing is applied to the right ventricle (RV) endocardium and the left ventricle (LV) epicardium via the coronary sinus (EPI-CRT BV ). Current best practice results in 30% to 40% of CRT patients failing to display improved clinical response.1 Recent clinical 2-5 and experimental 6,7 evidence suggests that BV CRT with an endocardial pacing strategy for the LV lead (ENDO-CRT BV ) can provide an improvement in acute hemodynamic response and stroke work over EPI-CRT BV and offers a novel approach for increasing CRT response rates. However, the relative importance of cardiac physiology or better access to optimal pacing sites in causing this improved outcome remains controversial. Identifying and understanding physiological mechanisms behind improved ENDO-CRT BV response are crucial for optimizing clinical procedures and identifying patients who will receive the maximal benefit from this therapy.In acute left bundle branch block (LBBB) canine studies, ENDO-CRT BV improved the systolic LV function over conventional EPI-CRT BV .6 Electric activation times (ATs) as measured by contact mapping were decreased with ENDO-CRT BV © 2015 American Heart Association, Inc. Original Article Circ Arrhythm Electrophysiol Background-Cardiac resynchronization therapy (CRT) delivered via left ventricular (LV) endocardial pacing (ENDO-CRT) is associated with improved acute hemodynamic response compared with LV epicardial pacing (EPI-CRT).The role of cardiac anatomy and physiology in this improved response remains controversial. We used computational electrophysiological models to quantify the role of cardiac geometry, tissue anisotropy, and the presence of fast endocardial conduction on myocardial activation during ENDO-CRT and EPI-CRT. Methods and Results-Cardiac activation was simulated using the monodomain tissue excitation model in 2-dimensional (2D) canine and human and 3D canine biventricular models. The latest activation times (LATs) for LV endocardial and biventricular epicardial tissue were calculated (LVLAT and TLAT), as well the percentage decrease in LATs for endocardial (en) versus epicardial (ep) LV pacing (defined as %dLV=100×(LVLAT ep −LVLAT en )/LVLAT ep and %dT=100×(TLAT ep −TLAT en )/TLAT ep , respectively). Normal canine cardiac anatomy is responsible for %dLV and %dT values of 7.4% and 5.5%, respectively. Concentric and eccentric remodeled anatomies resulted in %dT values of 15.6% and 1.3%, respectively. The 3D biventricular-paced canine model resulted in %dLV and %dT values of −7.1% and 1.5%, in contrast to the experimental observations of 16% and 11%, respectively. Adding fast endocardial conduction to this model altered %dLV and %dT to 13.1% and 10.1%, respectively. Conclusions-Our results provide a physiological explanation for improved response to ENDO-CRT. We predict that patients with viable fast-conducting endocardial tissue or distal Purkinje network or both, as we...

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“…Additionally, although QRS intervals were similar at baseline, MG had a significantly shorter QRS interval than controls at the 6-month follow-up, which is comparable with better cardiac synchrony in MG. A longer Q-LV interval and a shorter QRS interval have been reported to be a better prognostic parameter of CRT response. [16][17][18][19][20] Thus, the Q-LV interval in MG versus CG represents a better prognosis of the former in this study. In the SMART-AV study, Gold et al found that patients with a Q-LV greater than the median 95 milliseconds had better outcomes.…”

Section: Discussionmentioning

confidence: 56%

Left Ventricular Lead Placement Targeted at the Latest Activated Site Guided by Electrophysiological Mapping in Coronary Sinus Branches Improves Response to Cardiac Resynchronization Therapy

Zhou

et al. 2015

Cardiovasc electrophysiol

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Impact of Pacing Site on QRS Duration and Its Relationship to Hemodynamic Response in Cardiac Resynchronization Therapy for Congestive Heart Failure

Cited by 26 publications

References 33 publications

Optimized Left Ventricular Endocardial Stimulation Is Superior to Optimized Epicardial Stimulation in Ischemic Patients With Poor Response to Cardiac Resynchronization Therapy

Optimized Left Ventricular Endocardial Stimulation Is Superior to Optimized Epicardial Stimulation in Ischemic Patients With Poor Response to Cardiac Resynchronization Therapy

Beneficial Effect on Cardiac Resynchronization From Left Ventricular Endocardial Pacing Is Mediated by Early Access to High Conduction Velocity Tissue

Left Ventricular Lead Placement Targeted at the Latest Activated Site Guided by Electrophysiological Mapping in Coronary Sinus Branches Improves Response to Cardiac Resynchronization Therapy

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