scholarly journals A different cardiac resynchronization therapy technique might be needed in some patients with nonspecific intraventricular conduction disturbance pattern-final results

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Vereckei ◽  
G Katona ◽  
Z Szelenyi ◽  
B Kozman ◽  
G Szenasi
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Frontal Plane ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Electrode Position ◽  
Resynchronization Therapy ◽  
Conduction Disturbance ◽  
Intraventricular Conduction ◽  
St Segment ◽  
Surface Ecg

Abstract Background Current cardiac resynchronization therapy (CRT) works by pacing the latest activated left ventricular (LV) site. We hypothesized that the greater nonresponse rate of patients with nonspecific intraventricular conduction disturbance (NICD) than with left bundle branch block (LBBB) pattern to CRT might be due, besides less dyssynchrony, to the inability of the current CRT technique, devised to eliminate dyssynchrony caused by LBBB pattern, to eliminate dyssynchrony in some patients with NICD pattern, because their latest activated LV site is far away from that in LBBB. Methods We devised a novel surface ECG method to estimate the approximate location of the latest activated LV site based on the principle that the resultant ST vector of secondary ST segment alterations associated with wide QRS complexes is directed 180o away from the latest activated LV site. By measuring the amplitude and polarity of secondary ST segment alterations in two optional frontal and horizontal plane ECG leads and using a software, we determined the resultant 3D spatial secondary ST vector in 88 patients with LBBB and 57 patients with NICD patterns and heart failure. To validate the ECG method, we also estimated the latest activated LV region by echocardiography using 3D parametric imaging and 2D speckle tracking in 16 LBBB and 13 NICD patients. Patients with NICD pattern were subdivided according to their non-overlapping frontal plane resultant secondary ST vector ranges to NICD-1 (n=35) and NICD-2 (n=22) subgroups. Results The resultant 3D spatial secondary ST vector coordinates in the LBBB group were: (x axis: −0.228 mV, y axis: −0.062 mV, z axis: 0.63 mV); in the NICD-1 and NICD-2 subgroups: (x: 0.154 and 0.198 mV, y: −0.198 and 0.162 mV, z: 0.422 and 0.398 mV respectively). Consequently the latest activated LV sites were located leftward, posterosuperior in the LBBB group, right, posterosuperior in the NICD-1 and right, posteroinferior in the NICD-2 subgroups. The latest activated LV region determined by ECG and echocardiography matched in all patients, except 1. Conclusions The latest activated LV site was at the expected position in the LBBB group, while it was at an almost opposite site in the NICD-2 group [22/57 (39%)]. Thus, one potential reason for the unfavorable response to CRT, occurring in approx. 40% of patients with NICD pattern with a QRS duration of 120–149 ms in randomized studies, is that the current CRT technique using a left posterolateral LV electrode position may not be able to eliminate dyssynchrony in these patients. Funding Acknowledgement Type of funding source: None

scholarly journals Prognostic Implications of ‘Paced’ and ‘Native’ QRS Durations Following Cardiac Resynchronization Therapy

2016 ◽  
Vol 02 (01) ◽  
pp. 30
Author(s):  
Oguz Karaca ◽  
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Response To Therapy ◽  
Cardiac Resynchronization ◽  
Current Evidence ◽  
Conduction Time ◽  
Resynchronization Therapy ◽  
Intraventricular Conduction ◽  
Surface Ecg ◽  
Future Outcomes ◽  
Electrocardiographic Parameters

Current evidence strongly suggests that the extent of electrical dyssynchrony within the left ventricle is determined by the delayed intraventricular conduction time reflected by a prolonged QRS duration (QRSd) on the surface (ECG). However, in cardiac resynchronization therapy (CRT) follow-up algorithms, the QRSd on the post-operative ECG has been relatively less frequently addressed, although the baseline QRSd is accepted as an essential ‘pre-operative’ marker for patient selection and prediction of response to therapy. In this review, we discuss the clinical impact of post-implantation electrocardiographic parameters, such as the ‘paced’ QRSd and ‘native’ QRSd (assessed when the device is temporarily switched off) on the efficacy of therapy and on prediction of future outcomes after CRT.

Feasibility and efficacy of left bundle branch area pacing in patients indicated for cardiac resynchronization therapy

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_2) ◽  
pp. ii54-ii60
Author(s):  
Yuqiu Li ◽  
Lirong Yan ◽  
Yan Dai ◽  
Yu’an Zhou ◽  
Qi Sun ◽  
...  
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Left Ventricular Ejection ◽  
Resynchronization Therapy ◽  
Bundle Branch Block ◽  
Ventricular Ejection Fraction ◽  
Intraventricular Conduction ◽  
Lead Placement

Abstract Aims The present study was to evaluate the feasibility and clinical outcomes of left bundle branch area pacing (LBBAP) in cardiac resynchronization therapy (CRT)-indicated patients. Methods and results LBBAP was performed via transventricular septal approach in 25 patients as a rescue strategy in 5 patients with failed left ventricular (LV) lead placement and as a primary strategy in the remaining 20 patients. Pacing parameters, procedural characteristics, electrocardiographic, and echocardiographic data were assessed at implantation and follow-up. Of 25 enrolled CRT-indicated patients, 14 had left bundle branch block (LBBB, 56.0%), 3 right bundle branch block (RBBB, 12.0%), 4 intraventricular conduction delay (IVCD, 16.0%), and 4 ventricular pacing dependence (16.0%). The QRS duration (QRSd) was significantly shortened by LBBAP (intrinsic 163.6 ± 29.4 ms vs. LBBAP 123.0 ± 10.8 ms, P < 0.001). During the mean follow-up of 9.1 months, New York Heart Association functional class was improved to 1.4 ± 0.6 from baseline 2.6 ± 0.6 (P < 0.001), left ventricular ejection fraction (LVEF) increased to 46.9 ± 10.2% from baseline 35.2 ± 7.0% (P < 0.001), and LV end-diastolic dimensions (LVEDD) decreased to 56.8 ± 9.7 mm from baseline 64.1 ± 9.9 mm (P < 0.001). There was a significant improvement (34.1 ± 7.4% vs. 50.0 ± 12.2%, P < 0.001) in LVEF in patients with LBBB. Conclusion The present study demonstrates the clinical feasibility of LBBAP in CRT-indicated patients. Left bundle branch area pacing generated narrow QRSd and led to reversal remodelling of LV with improvement in cardiac function. LBBAP may be an alternative to CRT in patients with failure of LV lead placement and a first-line option in selected patients such as those with LBBB and heart failure.

scholarly journals Left cardiac atrioventricular delay and inter-ventricular delay in cardiac resynchronization therapy responder and non-responder

2016 ◽  
Vol 2 (1) ◽  
pp. 247-250 ◽  
Author(s):  
Matthias Heinke ◽  
Helmut Kühnert ◽  
Tobias Heinke ◽  
Jonas Tumampos ◽  
Gudrun Dannberg
Keyword(s):  
New York ◽  
Cardiac Resynchronization Therapy ◽  
Biventricular Pacing ◽  
Heart Association ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Atrioventricular Delay ◽  
Surface Ecg ◽  
New York Heart Association

AbstractCardiac resynchronization therapy is an established therapy for heart failure patients. The aim of the study was to evaluate electrical left cardiac atrioventricular delay and interventricular desynchronization in sinus rhythm cardiac resynchronization therapy responder and non-responder. Cardiac electrical desynchronization were measured by surface ECG and focused transesophageal bipolar left atrial and left ventricular ECG before implantation of cardiac resynchronization therapy defibrillators. Preoperative electrical cardiac desynchronization was 195.7 ± 46.7 ms left cardiac atrioventricular delay and 74.8 ± 24.5 ms interventricular delay in cardiac resynchronization therapy responder. Cardiac resynchronization therapy responder New York Heart Association class improved during long term biventricular pacing. Transesophageal left cardiac atrioventricular delay and interventricular delay may be additional useful parameters to improve patient selection for cardiac resynchronization therapy.

scholarly journals Electrode Model and Simulation of His- Bundle Pacing for Cardiac Resynchronization Therapy

2020 ◽  
Vol 6 (3) ◽  
pp. 555-558
Author(s):  
Domenic Pascual ◽  
Matthias Heinke ◽  
Reinhard Echle ◽  
Johannes Hörth
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Left Ventricular Ejection ◽  
Resynchronization Therapy ◽  
Electrical Field ◽  
His Bundle ◽  
His Bundle Pacing ◽  
Surface Ecg ◽  
Electrical Pacing

AbstractA disturbed synchronization of the ventricular contraction can cause a highly developed systolic heart failure in affected patients with reduction of the left ventricular ejection fraction, which can often be explained by a diseased left bundle branch block (LBBB). If medication remains unresponsive, the concerned patients will be treated with a cardiac resynchronization therapy (CRT) system. The aim of this study was to integrate His-bundle pacing into the Offenburg heart rhythm model in order to visualize the electrical pacing field generated by His-Bundle-Pacing. Modelling and electrical field simulation activities were performed with the software CST (Computer Simulation Technology) from Dessault Systèms. CRT with biventricular pacing is to be achieved by an apical right ventricular electrode and an additional left ventricular electrode, which is floated into the coronary vein sinus. The non-responder rate of the CRT therapy is about one third of the CRT patients. His- Bundle-Pacing represents a physiological alternative to conventional cardiac pacing and cardiac resynchronization. An electrode implanted in the His-bundle emits a stronger electrical pacing field than the electrical pacing field of conventional cardiac pacemakers. The pacing of the Hisbundle was performed by the Medtronic Select Secure 3830 electrode with pacing voltage amplitudes of 3 V, 2 V and 1,5 V in combination with a pacing pulse duration of 1 ms. Compared to conventional pacemaker pacing, His-bundle pacing is capable of bridging LBBB conduction disorders in the left ventricle. The His-bundle pacing electrical field is able to spread via the physiological pathway in the right and left ventricles for CRT with a narrow QRS-complex in the surface ECG.

scholarly journals Heart rhythm model for the simulation of electric fields in transesophageal atrial pacing and cardiac resynchronization therapy

2018 ◽  
Vol 4 (1) ◽  
pp. 443-445
Author(s):  
Kerem Göküs ◽  
Matthias Heinke ◽  
Johannes Hörth
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Heart Rhythm ◽  
Left Ventricular ◽  
Right Atrial ◽  
Cardiac Resynchronization ◽  
Electrode Position ◽  
Atrial Pacing ◽  
Far Field ◽  
Resynchronization Therapy ◽  
Rv Pacing

AbstractElectric field of biventricular (BV) pacing, left ventricular (LV) electrode position and electrical interventricular desynchronization are important parameters for successful cardiac resynchronization therapy (CRT) in patients with heart failure, sinus rhythm and reduced LV ejection fraction. The aim of the study was to evaluate electric pacing field of transesophageal left atrial (LA) pacing and BV pacing with 3D heart rhythm simulation. Bipolar right atrial (RA), right ventricular (RV), LV electrodes and multipolar hemispherical esophageal LA electrodes were modeled with CST (Computer Simulation Technology, Darmstadt). Electric pacing field were simulated with bipolar RA and RV pacing with Solid S (Biotronik) electrode, bipolar LV pacing with Attain 4194 (Medtronic) electrode and bipolar LA pacing with TO8 (Osypka) esophageal electrode. 3D heart rhythm model with esophagus allowed electric pacing field simulation of 4-chamber pacing with bipolar intracardiac RA, RV, LV pacing and bipolar transesophageal LA pacing. The pacing amplitudes were 3V RA pacing amplitude, 50V LA pacing amplitude, 1.5V RV pacing amplitude and 3V LV pacing amplitude with 0.5ms pacing pulse duration. The atrioventricular delay between RA pacing and BV pacing was 140ms atrioventricular pacing delay and simultaneous RV and LV pacing. Electric pacing fields were simulated during the different pacing modes AAI, VVI, DDD and DDD0V. The intracardiac far-field pacing potentials were evaluated with intracardiac electrodes and a distance of 1mm from the electrodes with RA electrode 1.104V, RV electrode 0.703V and LV electrode 1.32V. The transesophageal far-field pacing potential was evaluated with transesophageal electrode and a distance of 10mm from the elelctrode with LA electrode 6.076V. Heart rhythm model simulation with esophagus allows evaluation of electric pacing fields in AAI, VVI, DDD, DDD0V and DDD0D pacing modes. Electric pacing field of RA, RV and LV pacing in combination with LA pacing may additional useful pacing mode in CRT non-responders.

Clinical impact of left ventricular paced conduction disturbance in cardiac resynchronization therapy

Heart Rhythm ◽  
2020 ◽  
Vol 17 (11) ◽  
pp. 1870-1877
Author(s):  
Nobuhiko Ueda ◽  
Takashi Noda ◽  
Ikutaro Nakajima ◽  
Kohei Ishibashi ◽  
Kenzaburo Nakajima ◽  
...  
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Left Ventricular ◽  
Clinical Impact ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Conduction Disturbance

Technical and electrophysiological aspects of multisite cardiac stimulation through the access of the middle cardiac vein

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
A Rosa Filho ◽  
AAM Rosa ◽  
AW Rosa ◽  
JC Souza Neto ◽  
LB Cavalcanti ◽  
...  
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Guide Wire ◽  
Anatomical Variations ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Electrode Position ◽  
Resynchronization Therapy ◽  
Cardiac Stimulation ◽  
Funding Sources ◽  
Middle Cardiac Vein

Abstract Funding Acknowledgements Type of funding sources: None. Main funding source(s): Alfredo Aurélio Marinho Rosa and Alfredo Aurélio Marinho Rosa Filho Background Heart failure (HF) is a serious, progressive disease, caused by ventricular dysfunction, leading to a worsening in quality and a reduction in life expectancy. Cardiac resynchronization therapy through multisite stimulation has become an important tool in the treatment of advanced HF, however, due to anatomical variations and even the absence of appropriate veins for the insertion of the left ventricular electrode, the access of the middle cardiac vein can be an option for biventricular cardiac stimulation. Objective: To present the technique used to access the middle cardiac vein (MCV) for the implantation of the left ventricular electrode and the results of this multisite stimulation. Material and Method: Between March 2006 and May 2016, 388 patients (PT) underwent biventricular stimulation (BIV) at our service. 276 PT (71.1%), were associated with the cardioverter-defibrillator (ICD), 226 PT (58.2%) were male and their age ranged from 28 to 84 years with an average of 64 years. In this group, in 63 PT (16.2%) the left ventricular electrode was implanted through CMV. The technique initially consists of introducing a deflectable catheter for marking the coronary sinus (SC) via the femoral approach, then the SC approach is performed by puncturing the left subclavian vein, introducing an 8F sheath up to the proximal 1/3, where the VCM venogram is performed by introducing a 0.014 "guide wire and the 5 F bipolar or quadripolar electrode, then defining the best electrode position from the smallest stimulated QRS. Results: In this group of 63 PT, 52 PT (82.5%) responded to cardiac resynchronization therapy. The most frequent cardiopathies involved were ischemic (38%), chagasic (25%), hypertensive (12%) and others (25%). The thresholds varied from 3.5 to 0.5 V, impedance from 600 to 1200 ohms and sensitivity between 10 and 20 mV. There were no complications in the trans or post implant and in 5 PT (7.9%), there was phrenic stimulation. The procedure time varied from 50 to 180 minutes. Conclusion: Multisite stimulation through the access of the middle cardiac vein proved to be a possible alternative, easy to perform and with a high PT index responsive to cardiac resynchronization therapy.

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