Haemodynamic evaluation of alternative left ventricular endocardial pacing sites in clinical non-responders to cardiac resynchronisation therapy.

B.M Van Gelder,R Nathoe,F.A Bracke

doi:10.1007/s12471-015-0773-7

B.M Van Gelder, R Nathoe + Show 1 more

Open Access

https://doi.org/10.1007/s12471-015-0773-7

Copy DOI

Abstract

IntroductionNon response to cardiac resynchronisation therapy (CRT) may be related to the position of the coronary sinus lead.MethodsWe studied the acute haemodynamic response (AHR) from alternative left ventricular (LV) endocardial pacing sites in clinical non-responders to CRT. AHR and the interval from QRS onset to LV sensing (Q-LV interval) from four different endocardial pacing sites were evaluated in 24 clinical non-responders. A rise in LVdP/dtmax ≥ 15 % from baseline was considered a positive AHR. We also compared the AHR from endocardial with the corresponding epicardial lead position.ResultsThe implanted system showed an AHR ≥ 15 % in 5 patients. In 9 of the 19 remaining patients, AHR could be elevated to ≥ 15 % by endocardial LV pacing. The optimal endocardial pacing site was posterolateral. There was no significant difference in AHR between the epicardial and the corresponding endocardial position. The longest Q-LV interval corresponded with the best AHR in 12 out of the 14 patients with a positive AHR, with an average Q-LV/QRS width ratio of 90 %.ConclusionsAcute haemodynamic testing may indicate an alternative endocardial pacing site with a positive AHR in clinical non-responders. The Q-LV interval is a strongly correlated with the optimal endocardial pacing site. Endocardial pacing opposite epicardial sites does not result in a better AHR.

Highlights

Non response to cardiac resynchronisation therapy (CRT) may be related to the position of the coronary sinus lead
We studied the acute haemodynamic response (AHR) of the implanted system and alternative left ventricular endocardial pacing sites in patients clinically not responding to CRT [8]
In 3 out of these 5 patients with the coronary sinus lead in a posterolateral position, endocardial pacing did not increase the LVdP/dtmax substantially (AHR less than 3 % and even an adverse effect from left ventricular (LV) endocardial pacing was observed in one patient)

Summary

Introduction

Non response to cardiac resynchronisation therapy (CRT) may be related to the position of the coronary sinus lead. Methods We studied the acute haemodynamic response (AHR) from alternative left ventricular (LV) endocardial pacing sites in clinical non-responders to CRT. Conclusions Acute haemodynamic testing may indicate an alternative endocardial pacing site with a positive AHR in clinical non-responders. Even with growing experience and improved materials and tools, the optimal position cannot always be reached in one of the tributaries of the coronary sinus This can be due to the absence of suitable side branches in the posterolateral area, coronary vein stenosis, lead instability, high stimulation threshold, phrenic nerve stimulation, or a combination of the above [5,6,7]. We studied the acute haemodynamic response (AHR) of the implanted system and alternative left ventricular endocardial pacing sites in patients clinically not responding to CRT [8]

Methods

Results

Discussion

Conclusion