The concept of triple wavefront fusion during biventricular pacing: Using the EGM to produce the best acute hemodynamic improvement in CRT

Horst, Iris A.; Bogaard, Margot D.; Tuinenburg, Anton E.; Mast, Thomas P.; Boer, Teun P. de; Doevendans, Pieter A.; Meine, Mathias

doi:10.1111/pace.13118

Cited by 25 publications

(25 citation statements)

References 39 publications

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“…As CRT aims to restore electrical synchrony in dyssynchronous ventricles with a prolonged QRS complex, programming to enhance this effect seems intuitive. Electrical mapping and hemodynamic techniques support this, but these are not applied readily outside investigational settings . The surface ECG, in contrast, is widely available, simple, inexpensive, and commonly used among implanters for adjudicating CRT programming.…”

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confidence: 99%

Programming Cardiac Resynchronization Therapy for Electrical Synchrony: Reaching Beyond Left Bundle Branch Block and Left Ventricular Activation Delay

Varma

O’Donnell

Bassiouny

et al. 2018

JAHA

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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 ResultsSeventy‐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.ConclusionsPost‐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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confidence: 99%

Programming Cardiac Resynchronization Therapy for Electrical Synchrony: Reaching Beyond Left Bundle Branch Block and Left Ventricular Activation Delay

Varma

O’Donnell

Bassiouny

et al. 2018

JAHA

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“…In default settings a CRT device is programmed to pace LV and RV simultaneously [10,11]. Studies of LV offset for CRT programming have been disappointing [12]. In this regard implication of LV-RV vs RV-LV conduction differences could lead to more consistent results.…”

Section: Discussionmentioning

confidence: 99%

Differences in right-to-left vs left-to-right interventricular conduction times in patients indicated to cardiac resynchronization therapy

et al. 2020

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Introduction Differences in conduction times from right ventricle to left ventricle and from left ventricle to right ventricle respectively were observed during biventricular devices implantation when changing pacing vector direction. In this article the phenomenon of interventricular conduction time differences is described and assessed in relationship to various clinical and electrophysiological parameters. Methods In 62 consecutive patients (9 females) interventricular conduction times between right and left ventricle in both directions were measured during cardiac resynchronization therapy device implantation procedure. Complex pacing protocol was performed. Results Investigated individuals was divided into 3 subgroups according to type of interventricular conduction pattern and statistically tested with various clinical data. Substantial differences in right-to-left vs left-to-right conduction times (> 5 ms, range 7-72 ms) were observed in 24 (39%) of all patients. They were more common in patients with dilated cardiomyopathy (20 of 38, 53%) compared to 4 (17%) of 24 patients with coronary artery disease (p = 0.011). The phenomenon occurred more often in hypertensive patients (p = 0.012). Other tested factors were nonsignificant. Conclusions There are almost no data on this topic. The occurrence of conduction difference phenomenon is quite common in dilated cardiomyopathy while it is rare in coronary artery disease.

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“…SyncAV algorithm paces RV at an optimal moment, when the intrinsic conduction starts to depolarize some part of the right ventricle and septum, with the preactivated LV pacing wavefront coming toward both the RV pacing wavefront and the intrinsic wavefront. Ter Horst et al pointed out that a triple wavefront fusion was associated with the best hemodynamic improvement by CRT in the vast majority of patients. In our center, the QuickOpt algorithm is the standard of care for those implanted with CRT device from the Abbott company.…”

Section: Discussionmentioning

confidence: 99%

“…Since 2017, another novel SyncAV algorithm has come into being, which provides a concept of triple wavefront fusion during BiV pacing . Similarly, SyncAV periodically measures intrinsic conduction and dynamically adjusts AV delays.…”

Section: Introductionmentioning

confidence: 99%

Patient‐tailored SyncAV algorithm: A novel strategy to improve synchrony and acute hemodynamic response in heart failure patients treated by cardiac resynchronization therapy

Wang

Liang

Chen

et al. 2019

Cardiovasc electrophysiol

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Introduction: Several automatic algorithms have developed to optimize the timing cycle setting in cardiac resynchronization therapy (CRT). The present study aims to investigate whether the novel device-based SyncAV algorithm could elicit better synchrony and acute hemodynamic response.Methods and Results: Thirty five patients undergoing CRT implantation were prospectively studied. The device was programmed to three biventricular (BiV) pacing modes sequentially after the procedure: QuickOpt algorithm (mode I), SyncAV algorithm with default 50 ms offset (mode II), and SyncAV algorithm with optimized offset minimizing QRS duration (QRSd) (mode III). After each setting, electrocardiographic and echocardiographic data were collected. As a result, QRSd was reduced from 172.8 ± 17.9 ms during intrinsic conduction to 153.1 ± 15.9 ms in mode I, further narrowed to 140.5 ± 16.7 ms in mode II, and reached shortest (134.8 ± 16.1 ms) in mode III (P < .01 for all). Besides, significantly shorter QT intervals were observed in mode I (453.2 ± 45.5 ms), mode II (443.9 ± 34.2 ms) and mode III (444.1 ± 28.7 ms), compared with native condition (472.5 ± 51.2 ms) (P < .01). All three BiV modes exhibited comparable T p T e interval and T p T e /QT ratio (P > .05). Mode I presented significantly higher aortic velocity time integral than intrinsic conduction (21.0 ± 6.4 cm vs 18.4 ± 5.5 cm; P < .01), which was even higher in mode II (22.0 ± 6.5 cm) and mode III (23.7 ± 6.5 cm). All three BiV modes significantly reduced standard deviation of time to peak contraction of 12-LV segments (Ts-SD) (Mode I: 55.2 ± 16.5 ms, Mode II: 50.2 ± 14.7 ms, Mode III: 45.4 ± 14.4 ms) compared with intrinsic conduction (66.3 ± 18.4 ms) (P < .01), with Mode III demonstrating the smallest (P < .01).

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The concept of triple wavefront fusion during biventricular pacing: Using the EGM to produce the best acute hemodynamic improvement in CRT

Abstract: Optimal hemodynamic BiVp facilitates triple wavefront fusion, by pacing the RV around the onset of intrinsic farfield signal on RV EGM, while preactivating the LV. Aiming at BiVp-fusion could be a target for noninvasive EGM-based CRT device setting optimization.

Cited by 25 publications

References 39 publications

Programming Cardiac Resynchronization Therapy for Electrical Synchrony: Reaching Beyond Left Bundle Branch Block and Left Ventricular Activation Delay

Programming Cardiac Resynchronization Therapy for Electrical Synchrony: Reaching Beyond Left Bundle Branch Block and Left Ventricular Activation Delay

Differences in right-to-left vs left-to-right interventricular conduction times in patients indicated to cardiac resynchronization therapy

Patient‐tailored SyncAV algorithm: A novel strategy to improve synchrony and acute hemodynamic response in heart failure patients treated by cardiac resynchronization therapy

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