Hemodynamic comparison of different multisites and multipoint pacing strategies in cardiac resynchronization therapies

Francesco Zanon,Silvio Aggio,Sara Giatti,Lina Marcantoni,Gianluca Rigatelli,Gianni Pastore,Daniela Lanza,Frits W Prinzen,Domenico Pacetta,Giuseppina Giau,Enrico Baracca,Loris Roncon,Claudio Picariello,Marco Zuin,Franco Noventa

doi:10.1007/s10840-018-0362-y

Abstract

PurposeIn order to increase the responder rate to CRT, stimulation of the left ventricular (LV) from multiple sites has been suggested as a promising alternative to standard biventricular pacing (BIV). The aim of the study was to compare, in a group of candidates for CRT, the effects of different pacing configurations—BIV, triple ventricular (TRIV) by means of two LV leads, multipoint (MPP), and multipoint plus a second LV lead (MPP + TRIV) pacing—on both hemodynamics and QRS duration.MethodsFifteen patients (13 male) with permanent AF (mean age 76 ± 7 years; left ventricular ejection fraction 33 ± 7%; 7 with ischemic cardiomyopathy; mean QRS duration 178 ± 25 ms) were selected as candidates for CRT. Two LV leads were positioned in two different branches of the coronary sinus. Acute hemodynamic response was evaluated by means of a RADI pressure wire as the variation in LVdp/dtmax.ResultsPer patient, 2.7 ± 0.7 veins and 5.2 ± 1.9 pacing sites were evaluated. From baseline values of 998 ± 186 mmHg/s, BIV, TRIV, MPP, and MPP-TRIV pacing increased LVdp/dtmax to 1200 ± 281 mmHg/s, 1226 ± 284 mmHg/s, 1274 ± 303 mmHg, and 1289 ± 298 mmHg, respectively (p < 0.001). Bonferroni post-hoc analysis showed significantly higher values during all pacing configurations in comparison with the baseline; moreover, higher values were recorded during MPP and MPP + TRIV than at the baseline or during BIV and also during MPP + TRIV than during TRIV. Mean QRS width decreased from 178 ± 25 ms at the baseline to 171 ± 21, 167 ± 20, 168 ± 20, and 164 ± 15 ms, during BIV, TRIV, MPP, and MPP-TRIV, respectively (p < 0.001).ConclusionsIn patients with AF, the acute response to CRT improves as the size of the early activated LV region increases.

Highlights

A selected group of patients with systolic heart failure (HF) and prolonged QRS may benefit from Cardiac Resynchronization Therapy (CRT) [1, 2]
The implantation of two left ventricular (LV) leads was successfully performed in all patients
The present study showed a two-step increase in the acute hemodynamic effect of CRT, beyond that due to conventional biventricular pacing (BIV) pacing: a first increase yielded by triple ventricular (TRIV) or multipoint pacing (MPP) alone and a further increase yielded by combining the two approaches

Summary

Introduction

A selected group of patients with systolic heart failure (HF) and prolonged QRS may benefit from Cardiac Resynchronization Therapy (CRT) [1, 2]. One third of patients referred for this therapy do not show a favorable long-term outcome [3]. One of the reasons for the lack of response is the suboptimal position of the left ventricular (LV) pacing lead [4]. As described in our previous paper [5], we usually target the most electrically delayed site in order to achieve the optimal resynchronization. Multisite LV pacing can be carried out with several LV leads in separate coronary sinus (CS) veins [6, 7] or by means of a single multipolar lead capable of delivering multiple

Objectives

Methods

Conclusion