Multipoint Left Ventricular Pacing Research Articles

JCS/JHRS 2019 guideline on non-pharmacotherapy of cardiac arrhythmias.

JCS/JHRS 2019 guideline on non-pharmacotherapy of cardiac arrhythmias.

Clinical and economic impact of multipoint left ventricular pacing: A comparative analysis from the Italian registry on multipoint pacing in cardiac resynchronization therapy (IRON-MPP).

Early evidence suggests that multipoint left ventricular pacing (MPP) may improve response to cardiac resynchronization therapy (CRT). It is unknown whether this benefit is sustained and cost-effective. We used real-world data to evaluate long-term impact of MPP-ON clinical status, heart failure hospitalizations (HFH) and costs. The Italian registry on multipoint left ventricular pacing is a prospective, multicenter registry of patients implanted with MPP-enabled CRT devices. For this analysis, clinical and echocardiographic data were collected through 24 months and compared between patients with (MPP-ON) or without (MPP-OFF) early MPP activation at implant. The total cost of each HFH was estimated with national Italian reimbursement rates. The study included 190 MPP-OFF and 128 MPP-ON patients with similar baseline characteristics. At 1 and 2 years, the MPP-ON group had lower rates of HFH vs MPP-OFF (1-year hazard ratio [HR]: 0.14, P = .0014; 2-year HR: 0.38, P = .009). The finding persisted in a subgroup of patients with consistent MPP activation through follow-up (1-year HR: 0.19; P = .0061; 2-year HR: 0.39, P = .022). Total HFH per-patient costs were lower in the MPP-ON vs the MPP-OFF group at 1 year (€101 ± 50 vs €698 ± 195, P < .001) and 2 years (€366 ± 149 vs €801 ± 203, P = .038). More MPP-ON patients had ≥5% improvement in ejection fraction (76.8% vs 65.4%, P = .025) and clinical composite score (66.7% vs 47.5%, P = .01). In this multicenter clinical study, early MPP activation was associated with a significant reduction in cumulative HFH and related costs after 1 and 2 years of follow-up.

Multisite, multipoint pacing

Cardiac resynchronization therapy in patients with heart failure, reduced ejection fraction and prolonged QRS duration has become standard of care. Unfortunately, despite improvements in delivery of this treatment still approximately 30% of patients are non-responders. Among causes of this phenomenon one can find an inability to deliver hemodynamically effective left ventricular pacing. There were proposed several solutions to solve the problem, including: multisite RV pacing, multisite LV pacing, multipoint LV pacing. Multisite RV pacing (two RV leads positioned in RV: apex and RVOT), although causes some hemodynamic improvement in LVEF or distance in 6MWT and reduction of LVESD or number of hospitalizations in comparison to no paced patients, but its efficacy is significantly worse than normal CRT. So it should not be considered as an alternative to CRT even to surgically placed LV lead. Multisite LV pacing (two leads iv cardiac veins) gives significant benefits over standard CRT, especially in patients with poor heart vein system, which preclude optimal LV lead placement. Clinical benefits of this mode of therapy were observed in non-responders to classical CRT, and were proved in: higher responder rates, improved EF, VO2, distance in 6MWT, reduction of NYHA class, LVESV, LVEDD and increase of dP/dt. Multipoint LV pacing (different pacing point located on the same LV lead) is encouraging way of CRT delivery and does not require any additional lead. Benefits of MP pacing over classical CRT were proved in numerous trails in acute tests by improvement in dP/dt, increase in maximal strain rate, shortening of total activation time, reduction in QRS duration and after mid- and long term follow-up in reduction of LVESV, increase in EF, reduction of asynchrony and higher percentage of responders. Multipoint left ventricular pacing should be a standard of CRT delivery in first implantations.

169-06: Reduction in Long-Term Premature Ventricular Contraction with Multipoint Left Ventricular Pacing in Cardiac Resynchronization Therapy Recipients

Introduction: High percentage of premature ventricular contractions (PVCs) reduces the effectiveness of cardiac resynchronization therapy (CRT) by lowering the percentage of biventricular (BiV) pacing. By pacing from two distinct locations in the left ventricle, multipoint left ventricular pacing (MultiPoint™ Pacing [MPP], St. Jude Medical) may alter the burden of PVCs relative to conventional CRT. Methods: Eighty-two patients receiving a quadripolar CRT implant (Quadra Assura MP™ CRT-D and Quartet™ LV lead, St. Jude Medical) were programmed to either conventional CRT (N = 22) or MPP (N = 60) and followed for 50 weeks post-implant. Weekly PVC burden recorded by the device was analyzed and compared between the groups. A cutoff of 5% was used to define patients with high PVC burden. Conclusions: These results suggest that CRT recipients with multipoint LV pacing may experience reduced long-term PVC burden relative to recipients of conventional CRT. Additional, larger studies are needed to further evaluate the relationship between multipoint LV pacing and PVC burden.

139-02: Comparison of the long-term efficacy of two different programming strategies for multipoint left ventricular pacing

Purpose: Cardiac resynchronization therapy (CRT) with multipoint left ventricular (LV) pacing (MultiPoint™ Pacing [MPP], St. Jude Medical) improves long-term LV reverse remodeling, though questions persist about how to program LV pacing vectors and delays. We evaluated if an empirical method of programming MPP improves CRT response similar to pressure-volume loop (PVL) optimization. Methods: Patients undergoing CRT implant (Quadra Assura MP™ CRT-D and Quartet™ LV lead, St. Jude Medical) received MPP with programmed settings optimized either by PVL measurements at implant (PVL-OPT group) or empirically determined by maximizing the spatial separation between the two cathodes and minimizing delays between the two pacing pulses (MAX-SEP group). CRT response was prospectively defined as a reduction in end-systolic volume (ESV) of ≥15% relative to baseline at 6 months as determined by a blinded observer. Conclusion: Both evaluated methods of MPP programming resulted in similar, high levels of CRT response. Empirical MPP programming by maximum spatial separation of LV cathodes may be an effective, simple, and non-invasive alternative to PVL optimization.

Characterization of ventricular activation pattern and acute hemodynamics during multipoint left ventricular pacing.

Multipoint left ventricular (LV) pacing (MultiPoint Pacing [MPP], St Jude Medical, Sylmar, CA) in a single coronary sinus branch has been introduced as a novel means of cardiac resynchronization therapy (CRT). It is speculated that MPP improves LV function by capturing a larger LV tissue area, resulting in uniform wavefront propagation throughout the ventricles, in comparison to conventional biventricular pacing (BIV). The purpose of this study was to evaluate MPP by means of contact mapping and hemodynamic measures to understand the underlying mechanisms and effects. Ten patients with non-ischemic cardiomyopathy (mean age 69 ± 9 years; 6 men (60%); New York Heart Association heart failure class II or III; QRS duration 173 ± 20 ms; LV ejection fraction 27% ± 5%) received a CRT-defibrillator capable of MPP. After the implantation procedure, an acute pacing protocol was implemented, including 2 BIV and up to 9 MPP interventions. In all pacing interventions, LV electrical activation patterns and hemodynamics (dP/dtmax) were evaluated, and for each patient, both the resulting measures were compared between MPP and BIV interventions. Compared with BIV, MPP resulted in an increase in LV dP/dtmax (30% ± 13% vs. 25% ± 11%; P = .041), a reduction in QRS duration (22% ± 11% vs. 11% ± 11%; P = .01), and a decrease in total endocardial activation time (25% ± 15% vs. 10% ± 20%; P = .01). MPP resulted in a larger capture of LV mass during the first 25 ms (35% ± 22% vs. 16% ± 8%; P = .005) and during the first 50 ms (78% ± 27% vs. 60% ± 23%; P = .03) of pacing, suggesting a quicker wavefront propagation throughout the left ventricle. In this acute study, MPP in CRT improved both endocardial and surface electrical parameters and hemodynamics in comparison with BIV.

Multipoint left ventricular pacing provides additional echocardiographic benefit to responders and non-responders to conventional cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) with multipoint left ventricular (LV) pacing [MultiPoint™ Pacing (MPP), St. Jude Medical, Sylmar, CA, USA] improves LV function and clinical response relative to conventional CRT in patients receiving a de novo device implant. We hypothesized that patients with a previously implanted conventional CRT device would receive additional benefit by switching to MPP. Patients receiving a CRT implant (Unify Quadra MP™ or Quadra Assura MP™ CRT-D and Quartet™ LV lead, St. Jude Medical) were programmed to conventional CRT (i.e. biventricular pacing with right ventricular and single LV sites) optimized by intraoperative haemodynamic measurements. After 12 months of conventional therapy, patients were reprogrammed to MPP and re-evaluated at 16 months post-implant. Response to CRT was prospectively defined as reduction in end-systolic volume (ESV) of ≥15% relative to baseline as determined by a blinded observer. Eight patients with an implanted CRT device [New York Heart Association III, ejection fraction (EF) 30 ± 5%, QRS 149 ± 18 ms] received 12 months of conventional CRT and were switched to MPP. After 12 months of conventional CRT, ESV reduction and EF increase relative to baseline were −18 ± 12 and +5 ± 4%, respectively, and six of eight (75%) patients were considered CRT responders. After 4 months of MPP, two of two (100%) patients classified as non-responders to conventional CRT became responders with additional reduction in ESV of −33 and −20% and improvement in EF of +15 and +4%. The remaining six patients classified as responders experienced additional reduction in ESV of −13 ± 21% and improvement in EF of +7 ± 7% after switching to MPP. Multipoint LV pacing may provide additional improvement to LV function in patients receiving conventional CRT.

Improving cardiac resynchronization therapy response with multipoint left ventricular pacing: Twelve-month follow-up study

Cardiac resynchronization therapy (CRT) with multipoint left ventricular (LV) pacing (MultiPoint™ Pacing [MPP], St. Jude Medical) improves acute LV function and LV reverse remodeling at 3 months. The purpose of this study was to test the hypothesis that MPP can also improve LV function at 12 months. Consecutive patients receiving a CRT implant (Unify Quadra MP™ or Quadra Assura MP™ CRT-D and Quartet™ LV lead, St. Jude Medical) were randomized to receive pressure-volume (PV) loop optimized biventricular pacing with either conventional cardiac resynchronization therapy (CONV) or MPP. CRT response was defined by a reduction in end-systolic volume (ESV) ≥15% relative to BASELINE as determined by a blinded observer and alive status. Forty-four patients (New York Heart Association class III, ejection fraction [EF] 29% ± 6%, QRS 152 ± 17 ms) were enrolled and randomized to either CONV (N = 22) or MPP (N = 22). During the observation period, 2 patients died of noncardiac causes and 2 patients were lost to follow-up. After 12 months, 12 of 21 patients (57%) in the CONV group and 16 of 21 patients (76%) in the MPP group were classified as CRT responders (P = .33). ESV reduction and EF increase relative to BASELINE were significantly greater with MPP than with CONV (ESV: median -25%, interquartile range [IQR] [-39% to -20%] vs median -18%, IQR [-25% to -2%], P = .03; EF: median +15%, IQR [8% to 20%] vs median +5%, IQR [-1% to 8%], P <.001). Sustaining the trend observed 3 months postimplant, PV loop-guided multipoint LV pacing resulted in greater LV reverse remodeling and increased LV function at 12 months compared to PV loop-guided conventional CRT.

O157 Multipoint left ventricular pacing provides similar acute hemodynamic improvement regardless of QRS duration or lead location in cardiac resynchronization therapy patients

R A L A B ST R A C T S Results: Groups were comparable with regards to baseline characteristics. The duration of QRS complex was significantly lower in III group (117 28 ms) compared to II group (154 46 ms, p<0.001) and I group (151 30 ms, p<0.001). Left bundle branch block was more frequently found in I group compared to III group (65% vs 36%, p1⁄40.004) and did not differ with II group (61%, p1⁄40.6). The rate of effective biventricular capture was significantly higher in III group compared to II group (97 6% vs 88 21%, p1⁄40.012) and had no difference with I group (95 15%, p1⁄40.3). The best survival rate calculated by Kaplan-Meier method was found in patients of III group. At the end of follow-up period the survival rate was 60% in I group, 58% in II, 97% in III group (p I-II1⁄40.46, p I-III1⁄40.00007, p IIIII1⁄40.0005). Multivariate Cox regression analysis revealed that AVJA was an independent predictor of lower mortality in patients with CRT (HR 0.035, CI 0.004-0.288, p1⁄40.002). Conclusion: In real clinical practice in patients with CHF and CRT survival was significantly better in subjects with AF who underwent AVJA compared to subjects with AF without AVJA probably because of the best rate of complete biventricular capture. Patients with AF and AVJA showed better survival even compared to patients with sinus rhythm. Disclosure of Interest: None Declared