scholarly journals His resynchronization therapy produces more physiological ventricular repolarisation compared with biventricular pacing

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
TC Cheng ◽  
ADA Arnold ◽  
JC Chow ◽  
MJS-S Shun-Shin ◽  
JPH Howard ◽  
...  
Keyword(s):  
Heart Failure ◽  
Action Potential ◽  
Action Potential Duration ◽  
Biventricular Pacing ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Activation Time ◽  
Ventricular Repolarisation ◽  
Non Invasive

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): British Heart Foundation BACKGROUND Biventricular pacing (BVP) is known to shorten activation time in patients with heart failure and left bundle branch block (LBBB) but its effects on repolarisation are not well studied. His bundle pacing (HBP) can correct LBBB to deliver cardiac resynchronization therapy (HBP-CRT), producing more physiological ventricular activation time and pattern than BVP. It is not known whether this translates to more physiological repolarisation, and if so whether the effect is mediated through its effects on activation. PURPOSE We measured the effects of HBP-CRT and BVP on left ventricular repolarisation using non-invasive epicardial mapping (ECGI). METHODS Patients were recruited in two groups. 1) Patients scheduled for clinically indicated BVP procedures for heart failure with LBBB, 2) Individuals with narrow QRS, normal ventricular function and intact conduction systems. Using non-invasive electrocardiographic imaging, we identified patients with LBBB in whom HBP shortened ECGI-derived left ventricular (LV) activation time by >10ms. We compared the effects of HBP and BVP on ECGI-derived dispersion of LV repolarisation times and activation-recovery intervals (a surrogate for action potential duration). RESULTS 21 patients in whom HBP shortened LV activation time by >10ms and an equal number of individuals with narrow intrinsic QRS were recruited. LV repolarisation dispersion was reduced by HBP-CRT (-42.0 ms, 95% confidence interval (CI): -52.3 to -31.7 ms, p <0.001) but not by BVP (11.9 ms, 95% CI: -6.24 to 30.1 ms, p = 0.182). The mean within-patient change in LV repolarisation dispersion from BVP to HBP-CRT was -56.5 ms (95% CI: -70.5 to -42.5 ms, p < 0.001). LV repolarisation dispersion with HBP-CRT was not different from individuals with narrow intrinsic QRS (2.75 ms, 95% CI: -16.2 to 21.7 ms, p = 0.981). The magnitude of reduction in LV repolarisation dispersion with HBP-CRT from intrinsic LBBB appeared similar to the magnitude of LV activation time shortening (-54.9 ms, 95% CI: -68.2 to -41.6 ms, p < 0.001). However, LV activation-recovery interval dispersion was also reduced by HBP-CRT (-44.3 ms, 95% CI: -69.2 to -19.3 ms, p < 0.001). Repolarisation mapping demonstrated normalisation of repolarisation pattern by HBP-CRT. CONCLUSIONS HBP-CRT can normalise repolarisation dispersion, producing more physiological repolarisation compared with BVP, which does not resolve the repolarisation abnormality of LBBB. HBP-CRT improves repolarisation through both activation resynchronization and modulation of action-potential duration. If these acute results translate to longer term outcomes, HBP-CRT may reduce the risk of ventricular arrhythmias in heart failure with LBBB to a greater extent than BVP. Abstract Figure. Epicardial Repolarisation Maps

scholarly journals The missing link- time to maximal rate of left ventricular pressure rise reflects resynchronization with biventricular pacing in patients with heart failure and left bundle branch block

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
H Odland ◽  
S Ross ◽  
LO Gammelsrud ◽  
R Cornelussen ◽  
E Kongsgard
Keyword(s):  
Heart Failure ◽  
Biventricular Pacing ◽  
Pressure Rise ◽  
Left Ventricular Pressure ◽  
Lateral Position ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Patient Specific ◽  
Resynchronization Therapy ◽  
Missing Link

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Norwegian South East Health Authorities Introduction Resynchronization therapy effectively restores myocardial function. No measures exist that specifically quantifies resynchronization. A parameter that quantifies resynchronization should be able to detect effective resynchronization and should not respond to changes in contractility caused by heterometric regulation.  Left ventricular pacing (LVP) is associated with dyssynchronous contraction patterns, while biventricular pacing (BIVP) promotes resynchronization dependent on the pacing position of the LV electrode. Purpose We compared the acute differences between BIVP and LVP with regards to the preload dependent maximum rate of the LV pressure rise (dP/dtmax), and time to peak dP/dt (Td) to determine which better reflect dyssynchrony and resynchronization. Methods Twenty nine patients in heart failure with LBBB underwent CRT implantation with continuous LV pressure registration. The LV lead was first placed in either apical or anterior position followed by a permanent placement in a lateral position. Sequential LVP and BIVP pacing were performed for one minute, at a rate 10% above intrinsic heart rate, before dP/dtmax measurements were recorded. For LVP, BIVP and RVP a patient specific AV delay was used to avoid fusion with intrinsic conduction. Td was defined as the time from pacemaker stimuli to peak dP/dt. Mixed linear models were used for statistics, numbers are estimated marginal means ± SEM and are only reported when with significance set at p < 0.05. Results We found no differences in dP/dtmax between BIVP (899 ± 37mmHg/s) and LVP (910 ± 37mmHg/s), while RVP (799 ± 37mmHg/s) was lower. Td was lower with BIVP (165 ± 4ms) than LVP (178 ± 4ms) and RVP (184 ± 4ms).  We found no differences in dP/dtmax between lateral (890 ± 35mmHg/s) and anterior (874 ± 38mmHg/s) while apical (824 ± 38mmHg/s) was lower. Td was lower in lateral (171 ± 4ms) than in anterior (179 ± 4ms) and apical (182 ± 4ms) positions. BIVP in lateral position (158 ± 4ms) was lower than any other pacingmode*position, with BIVP*anterior at 173 ± 4ms) and LVP*lateral at 170 ± 2ms. No difference was seen in dP/dtmax between  (BIVP + LVP)*(lateral + anterior) that was higher than all other pacingmode*positions. Conclusion Td shortens with BIVP and lateral position, and even more so with BIVP in lateral position and thus reflects resynchronization compared to all other combinations tested. DP/dtmax did not reflect resynchronization as BIVP/LVP and lateral/anterior performs equally good. There are no differences between dP/dtmax with any combination of pacing mode (BIVP + LVP) with position (anterior + lateral). This suggests that Td reflects resynchronization while dP/dtmax does not. Resynchronization with biventricular pacing in lateral position translates into a shorter Td and hence links electrical and mechanical events. Td could be the missing link between electrical and mechanical dyssynchrony and may serve as a biomarker for cardiac resynchronization therapy.

Optimization in cardiac resynchronization therapy with quadripolar leads offer improvement in cardiac energetics in heart failure patients compared with bipolar leads: HUMVEE Clinical Trial

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
K Antoniou ◽  
C Chrysohoou ◽  
P Dilaveris ◽  
K Konstantinou ◽  
P Manolakou ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Heart Failure ◽  
Cardiac Resynchronization Therapy ◽  
Ischemic Cardiomyopathy ◽  
Biventricular Pacing ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Cardiac Power

Abstract Background Cardiac resynchronization therapy (CRT) is a well-established technique for symptomatic heart failure (HF) patients, producing significant clinical benefits. Recent studies have revealed the potential role of multipoint pacing (MPP) in improving response and clinical outcomes. The aim of this work from the Heart failUre study of Multisite pacing effects on VEntriculoartErial coupling (HUMVEE) trial was to evaluate the association between MPP of the left ventricle vs those of optimized biventricular pacing (optBVP) on: a) ventriculoarterial coupling (VAC) and energy efficiency of the failing heart. Both BVP and MPP mode were optimized according to the optimal VTI value of left ventricular outflow track. Methods HUMVEE is a single-center, prospective (13 months) trial (clinicaltrials.gov identifier NCT03189368), of 80 NYHA III patients (68±10 years; 75% men; 53% ischemic cardiomyopathy), under optimal tolerated therapy, with standard BVP indication, having being implanted with a CRT system able to deliver both modes of pacing. Echocardiographic measurements, including VAC calculation, 6-min-walking-test and quality of life (MLHF questionnaire) were measured at baseline, 6 months post BVP optimization (right before MPP activation) and at the end of follow-up (6 months post MPP optimization). Cardiac power (CP) was calculated according the equation: CP=Cardiac Output x Mean Aortic Pressure/451. Results 23 patients (30%), due to inability to deliver MPP, remained in optBVP. Those in MPP had 45% ischemic cardiomyopathy vs. 65% in optBVP patients, (p=0.056); ejection fraction 26.5%, vs. 29.5%, p=0.05; while there was no significant difference in gender, age and baseline NYHA class. Both optBVP and MPP patients improved VAC (baseline: 1,26±0,3; CRT: 1.18±0.4; MPP: 1.07±0.06, p=0.07); but only MPP patients significant improved from baseline to 12-months (p=0.02); CP was improved in both groups (p=0.02 in optBVD and p=0.01 in MPP), with MPP patients showing improvement in CP by 30% vs 12% in optBVP (p=0.001); 6-min-walk test was improved in MPP patients by 42% from baseline (p=0.0001), compared to optBVP patients who showed improvement up to 30% (p=0.05) and during the first 6 months only. NtproBNP levels were decreased in all patients (p=0.05 for MPP and p=0.07 for optBVP). Only patients who achieved MPP showed improvement in the Quality of life score (baseline: 31.6±23; optBVD:20.1±17; MPP:15.8±12, p=0.002; while those remained in optBVP showed no significant improvement. Conclusions MPP is a new, promising biventricular pacing modality offering additive effects on myocardial energy balance, cardiac power, systolic and diastolic ventricular function and aortoventricular coupling. HUMVEE trial illustrates those clinical, imaging and biochemical divergences of MPP from even opt BVP that confer significant improvement in quality of life reflecting better myocardial energy handling in patients with advanced HF and cardiac dysychronization. Funding Acknowledgement Type of funding source: None

scholarly journals Improvement in pump function with endocardial biventricular pacing increases with activation time at the left ventricular pacing site in failing canine hearts

2011 ◽  
Vol 301 (4) ◽  
pp. H1447-H1455 ◽  
Author(s):  
Elliot J. Howard ◽  
James W. Covell ◽  
Lawrence J. Mulligan ◽  
Andrew D. McCulloch ◽  
Jeffrey H. Omens ◽  
...  
Keyword(s):  
Heart Failure ◽  
Biventricular Pacing ◽  
Pressure Change ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Activation Time ◽  
Lead Placement ◽  
Anterolateral Wall ◽  
The Right ◽  
Transmural Function

Recently, attention has been focused on comparing left ventricular (LV) endocardial (ENDO) with epicardial (EPI) pacing for cardiac resynchronization therapy. However, the effects of ENDO and EPI lead placement at multiple sites have not been studied in failing hearts. We hypothesized that differences in the improvement of ventricular function due to ENDO vs. EPI pacing in dyssynchronous (DYSS) heart failure may depend on the position of the LV lead in relation to the original activation pattern. In six nonfailing and six failing dogs, electrical DYSS was created by atrioventricular sequential pacing of the right ventricular apex. ENDO was compared with EPI biventricular pacing at five LV sites. In failing hearts, increases in the maximum rate of LV pressure change (dP/d t; r = 0.64), ejection fraction ( r = 0.49), and minimum dP/d t ( r = 0.51), relative to DYSS, were positively correlated ( P < 0.01) with activation time at the LV pacing site during ENDO but not EPI pacing. ENDO pacing at sites with longer activation delays led to greater improvements in hemodynamic parameters and was associated with an overall reduction in electrical DYSS compared with EPI pacing ( P < 0.05). These findings were qualitatively similar for nonfailing hearts. Improvement in hemodynamic function increased with activation time at the LV pacing site during ENDO but not EPI pacing. At the anterolateral wall, end-systolic transmural function was greater with local ENDO compared with EPI pacing. ENDO pacing and intrinsic activation delay may have important implications for management of DYSS heart failure.

scholarly journals Mechanical Synchrony and Myocardial Work in Heart Failure Patients With Left Bundle Branch Area Pacing and Comparison With Biventricular Pacing

2021 ◽  
Vol 8 ◽  
Author(s):  
Wen Liu ◽  
Chunqiang Hu ◽  
Yanan Wang ◽  
Yufei Cheng ◽  
Yingjie Zhao ◽  
...  
Keyword(s):  
Heart Failure ◽  
Cardiac Resynchronization Therapy ◽  
Biventricular Pacing ◽  
Mechanical Efficiency ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Peak Strain ◽  
Resynchronization Therapy ◽  
Promising Alternative ◽  
Reduced Ejection Fraction

Background: Little is known about the efficacy of permanent left bundle branch area pacing (LBBAP) in delivering cardiac resynchronization therapy (CRT). This study aimed to evaluate the effect of LBBAP on mechanical synchronization and myocardial work (MW) in heart failure (HF) patients and to compare LBBAP with biventricular pacing (BVP).Methods: This is a multicenter, prospective cohort study. From February 2018 to January 2021, 62 consecutive HF patients with reduced ejection fraction (LVEF ≤ 35%) and complete left bundle branch block (CLBBB) who underwent LBBAP or BVP were enrolled in this study. Echocardiograms and electrocardiograms and were conducted before and 3–6 months after implantation. Intra- and interventricular synchronization were assessed using two-dimensional speckle tracking imaging (2D-STI). The left ventricular pressure-strain loop was obtained by combining left ventricular strain with non-invasive blood pressure to evaluate mechanical efficiency.Results: The echocardiographic response rates were 68.6 and 88.9% in the BVP and LBBAP groups, respectively. Left bundle branch area pacing resulted in significant QRS narrowing (from 177.1 ± 16.7 to 113.0 ± 18.4 ms, P &lt; 0.001) and improvement in LVEF (from 29.9 ± 4.8 to 47.1 ± 8.3%, P &lt; 0.001). The global wasted work (GWW) (410.3 ± 166.6 vs. 283.0 ± 129.6 mmHg%, P = 0.001) and global work efficiency (GWE) (64.6 ± 7.8 vs. 80.5 ± 5.7%, P &lt; 0.001) were significantly improved along with shorter peak strain dispersion (PSD) (143.4 ± 45.2 vs. 92.6 ± 35.1 ms, P &lt; 0.001) and interventricular mechanical delay (IVMD) (56.4 ± 28.5 vs. 28.9 ± 19.0 ms, P &lt; 0.001), indicating its efficiency in improving mechanical synchronization. In comparison with BVP, LBBAP delivered greater improvement of QRS narrowing (−64.1 ± 18.9 vs. −32.5 ± 22.3 ms, P &lt; 0.001) and better mechanical synchronization and efficiency.Conclusions: Left bundle branch area pacing was effective in improving cardiac function, mechanical synchronization, and mechanical efficiency and may be a promising alternative cardiac resynchronization therapy.

scholarly journals Resynchronization in Heart Failure: What to choose?

2021 ◽  
Author(s):  
Mohammad El Baba ◽  
Moses Wananu ◽  
Marwan Refaat ◽  
Jayakumar Sahadevan
Keyword(s):  
Heart Failure ◽  
Biventricular Pacing ◽  
Nyha Class ◽  
Systolic Dysfunction ◽  
Severe Heart Failure ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Left Ventricular Ejection ◽  
Resynchronization Therapy ◽  
Ventricular Ejection Fraction

Achieving Cardiac resynchronization therapy (CRT) with Biventricular pacing(BiVP) pacing for patients with moderate-to-severe heart failure (HF), left ventricular (LV) systolic dysfunction and ventricular dyssynchrony is well established and is currently the standard of care. Multiple studies have demonstrated significant improvement in quality of life, functional status, and exercise capacity in patients with New York Heart Association (NYHA) class III and IV heart failure who underwent resynchronization therapy1,2. In addition, resynchronization therapy is associated with survival benefit3. However, one third of patients do not respond to BIVP. New modalities for resynchronization have emerged namely His bundle pacing (HBP) and left ventricular septal pacing (LVSP). In this paper, we will review the benefits and limitations of BiVP and also the role of new pacing modalities such as HBP and LVSP in patients with HF with reduced left ventricular ejection fraction (LVEF) and electrical dysynchrony.

scholarly journals Fusion Cardiac Resynchronization Therapy in an LVAD patient from two devices and crossing leads—a case report

2021 ◽  
Author(s):  
A D Egorova ◽  
L van Erven ◽  
S L M A Beeres ◽  
L F Tops
Keyword(s):  
Heart Failure ◽  
Cardiac Resynchronization Therapy ◽  
Biventricular Pacing ◽  
Severe Heart Failure ◽  
Venous Access ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Implantable Cardioverter Defibrillators ◽  
Resynchronization Therapy ◽  
Ventricular Assist

Abstract Background Cardiac implanted electronic devices (CIED) have significantly improved the survival and quality of life in heart failure patients. Although implantable cardioverter defibrillators (ICD) and cardiac resynchronization therapy (CRT) have a major role in patients with moderate to severe heart failure symptoms, the role of these devices in patients with a left ventricular assist device (LVAD) is not yet well defined. The burden of CIED-related procedures in patients with an LVAD is high. The price of lead malfunctions and pocket complications requires creative approaches to tackle CIED related issues in this patient population. Case summary Here we describe the clinical course of a 67-year-old ventricular pacing dependent LVAD patient with an ICD indication based on recurrent monomorphic VTs and a CRT indication due to previous deterioration of (right sided) heart failure in the absence of biventricular pacing. We were confronted with impending right ventricular (RV) lead failure and bilateral venous access problems due to chronic subclavian vein occlusion in a patient with a total of 5 transvenous leads, therapeutic anticoagulation and pronounced thoracic collaterals. We sought for a creative solution to be able to deliver effective biventricular fusion pacing with the existing leads from two contralateral pulse generators resulting in biventricular fusion pacing. This provided the solution to deliver effective CRT. Discussion This case illustrates the complexity of care and CIED related decision making in pacing dependent LVAD patients, in particularly those with an ICD and CRT indication.

Abstract 12717: Improvement of Longitudinal Function is Closely Related to Reverse Remodeling in Cardiac Resynchronization Therapy

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Nina E Hasselberg ◽  
Kristina H Haugaa ◽  
Anne Bernard-Brunet ◽  
Erik Kongsgård ◽  
Erwan Donal ◽  
...  
Keyword(s):  
Heart Failure ◽  
Cardiac Resynchronization Therapy ◽  
Biventricular Pacing ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Reverse Remodeling ◽  
Lv Function ◽  
Resynchronization Therapy ◽  
Heart Failure Patients ◽  
Longitudinal Function

Introduction: Response to cardiac resynchronization therapy (CRT) is often defined as reverse remodeling as a reduction in left ventricular (LV) end systolic volume (ESV). How myocardial mechanics are affected by biventricular pacing is not fully clarified. We tested the hypothesis that longitudinal and circumferential function are affected differently by biventricular pacing. Methods: Echocardiography (two dimensional) was performed before and 6 months after CRT implantation in heart failure patients with LV ejection fraction (EF) ≤ 35% and QRS ≥ 120 ms. LV function was assessed by EF and by global longitudinal (GLS) and global circumferential (GCS) strain from 16 LV segments by speckle tracking technique. CRT responders were defined as patients with reverse remodeling with a reduction in ESV ≥ 15% at 6 months. Results: We included 138 heart failure patients (65±10 years, 22% women, NYHA functional class 2.8±0.4, 48% ischemic cardiomyopathy). In the total population, GLS did not change (-8.5±3.9% to -8.9±4.7%, p=0.31) after 6 months with biventricular pacing, while GCS (-11.3±3.3% to -14.2±4.5%, p<0.001) and EF (27±9% to 36±12%, p<0.001) improved. Analyzing CRT responders (62%) and non-responders separately, GLS improved in responders (-8.4±3.8% to -9.5±3.8%, p=0.02) but not in non-responders (-8.7±4.1% to -7.9±4.5%, p=0.30) (Figure). GCS improved in both groups (-11.3±3.0% to -15.0±4.3%, p<0.001 and -11.4±3.8% to 13.0±4.7%, p=0.01). ΔGLS was a predictor of CRT response (OR 0.84 (0.75-0.95), p=0.009) and of ΔESV (1.62 (0.45-2.79), p=0.007) independently of ΔGCS. Conclusions: Biventricular pacing by CRT generally induced less changes in GLS than in GCS and EF. Importantly, GLS improved only in CRT responders with reverse remodeling. We suggest that reverse remodeling is more dependent on improved longitudinal function than circumferential function.

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