Abstract
BackgroundThe contribution of right ventricular (RV) stimulation to cardiac resynchronisation therapy (CRT) remains controversial. RV stimulation might be associated with adverse haemodynamic effects, dependent on intrinsic right bundle branch conduction, presence of scar, RV function and other factors which may partly explain non-response to CRT. This study investigates to what degree RV stimulation modulates response to biventricular (BiV) stimulation in CRT candidates and which baseline factors, assessed by cardiac magnetic resonance imaging, determine this modulation.Methods and resultsForty-one patients (24 (59 %) males, 67 ± 10 years, QRS 153 ± 22 ms, 21 (51 %) ischaemic cardiomyopathy, left ventricular (LV) ejection fraction 25 ± 7 %), who successfully underwent temporary stimulation with pacing leads in the RV apex (RVapex) and left ventricular posterolateral (PL) wall were included. Stroke work, assessed by a conductance catheter, was used to assess acute haemodynamic response during baseline conditions and RVapex, PL (LV) and PL+RVapex (BiV) stimulation.Compared with baseline, stroke work improved similarly during LV and BiV stimulation (∆+ 51 ± 42 % and ∆+ 48 ± 47 %, both p < 0.001), but individual response showed substantial differences between LV and BiV stimulation. Multivariate analysis revealed that RV ejection fraction (β = 1.01, p = 0.02) was an independent predictor for stroke work response during LV stimulation, but not for BiV stimulation. Other parameters, including atrioventricular delay and scar presence and localisation, did not predict stroke work response in CRT.ConclusionThe haemodynamic effect of addition of RVapex stimulation to LV stimulation differs widely among patients receiving CRT. Poor RV function is associated with poor response to LV but not BiV stimulation.Electronic supplementary materialThe online version of this article (doi:10.1007/s12471-015-0770-x) contains supplementary material, which is available to authorized users.
Highlights
Cardiac resynchronisation therapy (CRT) is an established therapy for drug-refractory symptomatic heart failure patients with reduced left ventricular ejection fraction (LVEF) and left bundle branch block (LBBB) [1]
This study shows that BiV and LV stimulation elicit comparable acute haemodynamic benefit, supporting the results
A significant positive correlation between baseline RV ejection fraction (RVEF) and LV stroke work response during LV stimulation was found, whereas no relation was found between baseline RVEF and BiV stimulation
Summary
Cardiac resynchronisation therapy (CRT) is an established therapy for drug-refractory symptomatic heart failure patients with reduced left ventricular ejection fraction (LVEF) and left bundle branch block (LBBB) [1]. The effect of LV-only stimulation has been studied intensively, whereas the influence of right ventricular (RV) stimulation in CRT has received less attention and remains controversial [5]. The contribution of right ventricular (RV) stimulation to cardiac resynchronisation therapy (CRT) remains controversial. RV stimulation might be associated with adverse haemodynamic effects, dependent on intrinsic right bundle branch conduction, presence of scar, RV function and other factors which may partly explain nonresponse to CRT. This study investigates to what degree RV stimulation modulates response to biventricular (BiV) stimulation in CRT candidates and which baseline factors, assessed by cardiac magnetic resonance imaging, determine this modulation. Stroke work improved during LV and BiV stimulation (∆+ 51 ± 42 % and ∆+ 48 ± 47 %, both p < 0.001), but individual response showed substantial differences between LV and BiV stimu-
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