QRS morphology, left ventricular lead location, and clinical outcome in patients receiving cardiac resynchronization therapy

Kandala, Jagdesh; Upadhyay, Gaurav A.; Altman, Robert K.; Parks, Kimberly A.; Orencole, Mary; Mela, Theofanie; Heist, E. Kevin; Singh, Jagmeet P.

doi:10.1093/eurheartj/eht123

Cited by 72 publications

(59 citation statements)

References 23 publications

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“…Our data confirm the observation of Kandala et al 23 especially in non-LBBB patients. This underscores the importance of determining intrapatient Q-LV interval, because CRT is becoming increasingly controversial in non-LBBB patients.…”

Section: Discussionsupporting

confidence: 93%

“…Gold et al 17 reported a cut-off value of 95 ms in responders to CRT >6-month follow-up. Similarly, Kandala et al 23 found a correlation between LV electric delay and a composite clinical end-point of time to first HF hospitalization, and the composite outcome of all-cause mortality, HF hospitalization, LV assist device implantation, and cardiac transplantation at 3 years. Specifically, in 144 LBBB and non-LBBB patients, a long LV electric delay was associated with an improved outcome.…”

Section: Discussionmentioning

confidence: 85%

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Determination of the Longest Intrapatient Left Ventricular Electrical Delay May Predict Acute Hemodynamic Improvement in Patients After Cardiac Resynchronization Therapy

Zanon

Baracca

Pastore

et al. 2014

Circ: Arrhythmia and Electrophysiology

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Background-One of the reasons for patient nonresponse to cardiac resynchronization therapy is a suboptimal left ventricular (LV) pacing site. LV electric delay (Q-LV interval) has been indicated as a prognostic parameter of cardiac resynchronization therapy response. This study evaluates the LV delay for the optimization of the LV pacing site. Methods and Results-Thirty-two consecutive patients (23 men; mean age, 71±11 years; LV ejection fraction, 30±6%; 18 with ischemic cardiomyopathy; QRS, 181±25 ms; all mean±SD) underwent cardiac resynchronization therapy device implantation. All available tributary veins of the coronary sinus were tested, and the Q-LV interval was measured at each pacing site. The hemodynamic effects of pacing at different sites were evaluated by invasive measurement of LV dP/dt max at baseline and during pacing. Overall, 2.9±0.8 different veins and 6.4±2.3 pacing sites were tested. In 31 of 32 (96.8%) patients, the highest LV dP/dt max coincided with the maximum Q-LV interval. Q-LV interval correlated with the increase in LV dP/dt max in all patients at each site (AR1 ρ=0.98; P<0.001). A Q-LV value >95 ms corresponded to a >10% in LV dP/dt max . An inverse correlation between paced QRS duration and improvement in LV dP/dt max was seen in 24 patients (75%). Conclusions-Pacing the LV at the latest activated site is highly predictive of the maximum increase in contractility, expressed as LV dP/dt max . A positive correlation between Q-LV interval and hemodynamic improvement was found in all patients at every pacing site, a value of 95 ms corresponding to an increase in LV dP/dt max of ≥10%. (Circ Arrhythm Electrophysiol. 2014;7:377-383.)Key Words: cardiac resynchronization therapy ◼ cardiomyopathies ◼ heart failure ◼ hemodynamics Received July 11, 2013; accepted March 14, 2014. interval-the interval from the onset of the intrinsic QRS on the surface ECG to the first large peak of the LV electrogram) and hemodynamics was derived from single measurements in each patient and, therefore, cannot be extrapolated to the use of Q-LV interval within an individual patient. The aims of our study were to investigate acute hemodynamic improvement during LV pacing from all available sites within a patient, as well as to test the hypothesis that the region with the longest electric delay provides the best hemodynamic response. MethodsWe analyzed the relationship between LV dP/dt max increase and LV electric delay in a CRT population. The study was approved by the local ethics board, and all patients provided written informed consent.In accordance with our standard implantation procedure, the right ventricular and atrial leads were positioned in conventional sites in all patients. Specifically, the right ventricular leads were implanted in the midseptum. The coronary sinus was cannulated via a telescopic approach, as previously described 18 ; coronary sinus angiography was performed, and all suitable collateral veins were subcannulated and visualized selectively. For the purpose of the present article, we def...

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Section: Discussionsupporting

confidence: 93%

Section: Discussionmentioning

confidence: 85%

Determination of the Longest Intrapatient Left Ventricular Electrical Delay May Predict Acute Hemodynamic Improvement in Patients After Cardiac Resynchronization Therapy

Zanon

Baracca

Pastore

et al. 2014

Circ: Arrhythmia and Electrophysiology

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“…[7][8][9][10]12 Only the QLV ratio was used in clinical outcome studies. 7,12 There are several reasons why the use of the QLV ratio (instead of QLV) may be preferable. First, the QLV ratio represents a pure index of LV lead location.…”

Section: Discussionmentioning

confidence: 99%

“…9 Only 2 relatively small, single-center studies demonstrated that patients with poor LV lead position (QLV ratio <50%) presented with more HF hospitalizations and higher cardiac mortality as part of a combined clinical end point. 7,12 We hypothesized that a study with sufficient statistical power could confirm and expand the current evidence with respect to the independent association of LV lead electric location with hard end points, such as cardiac or total mortality. Therefore, this study aimed to investigate the long-term predictive value of QLV for HF hospitalization and total or cardiac mortality.…”

mentioning

confidence: 98%

Left Ventricular Lead Electrical Delay Is a Predictor of Mortality in Patients With Cardiac Resynchronization Therapy

Roubíček

Wichterle

Kučera

et al. 2015

Circ: Arrhythmia and Electrophysiology

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We retrospectively analyzed data from a prospective database of patients with an implanted biventricular pacemaker or defibrillator at the Regional Hospital Liberec, Czech Republic, between June 2005 and © 2015 American Heart Association, Inc. Original ArticleBackground-Electric left ventricular lead position, assessed by the electric delay from the beginning of the QRS complex to the local LV electrogram (QLV), was found in previous studies to be a strong predictor of short-term response to cardiac resynchronization therapy. We hypothesized that suboptimum electric position of the left ventricular lead is associated with an excess of heart failure events and mortality. Methods and Results-We analyzed the clinical outcome of patients with left bundle branch block or intraventricular conduction delay treated with cardiac resynchronization therapy at our institution during 9 years. Baseline clinical characteristics, QLV/ QRS duration (QLV ratio) at cardiac resynchronization therapy implant, and data about heart failure hospitalization and mode of death were collected in 329 patients who were followed for a period of 3.3±1.9 years. Of them, 83 were hospitalized for heart failure and 83 died. Event rates for all-cause mortality, cardiac mortality, noncardiac mortality, heart failure mortality, and sudden death were 25.2%, 14.9%, 10.3%, 12.2%, and 2.1%, respectively. Patients with a QLV ratio ≤0.70 had significantly worse event-free survival for all study end points-hazard ratio, 1.6; 95% confidence interval, 1.0 to 2.4; P=0.05 for heart failure hospitalization; hazard ratio, 2.9; 95% confidence interval, 1.6 to 5.5; P=0.001 for heart failure mortality; hazard ratio, 1.8; 95% confidence interval, 1.1 to 2.7; P=0.01 for cardiac mortality; and hazard ratio, 2.1; 95% confidence interval, 1.2 to 3.7; P=0.01 for all-cause mortality. In multivariable analysis, QLV ratio ≤0.70 remained associated with all study end points. Conclusions-Electric left ventricular lead position in cardiac resynchronization therapy patients was a significant predictor of heart failure hospitalization and mortality.

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“…53 Therefore, testing the effect of LV pacing at various sites might be warranted. Alternatively, the region of latest activation may be determined, based on measurement of the interval between Q-wave and LV electrograms depolarization (Q-LV time; Figure 7) 54,55 or of the latest contraction. 47 In patients in whom the initial CRT response was poor, adding another LV lead in combination with RV pacing (triventricular pacing) showed promising improvements.…”

Section: Improving Crt Deliverymentioning

confidence: 99%

Cardiac Resynchronization Therapy

Prinzen¹,

2013

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QRS morphology, left ventricular lead location, and clinical outcome in patients receiving cardiac resynchronization therapy

Abstract: Cardiac resynchronization therapy delivered from an LV pacing site characterized by the long LVLED was associated with the favourable outcome in LBBB and non-LBBB patients.

Cited by 72 publications

References 23 publications

Determination of the Longest Intrapatient Left Ventricular Electrical Delay May Predict Acute Hemodynamic Improvement in Patients After Cardiac Resynchronization Therapy

Determination of the Longest Intrapatient Left Ventricular Electrical Delay May Predict Acute Hemodynamic Improvement in Patients After Cardiac Resynchronization Therapy

Left Ventricular Lead Electrical Delay Is a Predictor of Mortality in Patients With Cardiac Resynchronization Therapy

Cardiac Resynchronization Therapy

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