Comparison of adaptive and non-adaptive pacing modes on time-to-peak dP/dt in multipoint pacing or standard biventricular pacing with different degrees of intraventricular fusion

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Norwegian South-East Health Authorities Background We have investigated the timing of the peak left ventricular pressure rise, time to peak dP/dt (Td) as marker of resynchronization to be measured during implantation for detection of effective resynchronization. Td links the time domain (dyssynchrony) to the mechanical domain (pressure) as the dyssynergic muscular contractions resulting from electrical dyssynchrony delays pressure development and hence the timing of peak dP/dt, Td. Td shortens with resynchronization. Purpose In this study we investigated the acute changes in Td by comparing pacing the left ventricle (LV) with fusion of intrinsic right ventricular (RV) conduction (Adaptive, A) with pacing RV and LV (Non-Adaptive, NA), with and without multipoint pacing (MPP) and with different degrees of intraventricular pacing delays (RV-LV). Methods 19 patients with sinus rhythm and LBBB undergoing CRT implantation were studied. We measured pressures with an indwelling LV pressure catheter. Td was calculated as the time from onset of pacing to peak dP/dt, and averaged in 10 subsequent beats at each stage of pacing. We used quadripolar LV pacing leads positioned in what was considered an optimal mid/basal posterolateral/ lateral branch of the coronary sinus and sequential pacing (DDD) was performed; Adaptive and Non-Adaptive pacing was performed at LV distal [LVdist], proximal electrode [LVprox] and at both electrodes as multipoint pacing [MPP]. VV-timing: LV pacing was performed relative to QRS onset (either as a result of intrinsic activation or RV pace, mean ± SD): 1. LV only -76 ± 21ms before QRS activation with minimal fusion with RV activation (LVonly); 2. -28 ± 14ms before QRS activation (Pre); 3. 12 ± 15ms after (Post) QRS activation. Linear mixed models were used for statistics of the pooled data. Results are estimated marginal means ±SEM, and only significant P < 0.05 changes are reported. Results Average Td (data pooled) with RVP was 173 ± 2ms, MPP 144 ± 0.4ms and BIVP 150 ± 0.4ms. When analyzing the interaction between pacingmode (A,NA), VV-timing (LVonly,Pre,Post) and electrode(LVdist,LVprox,MPP) in all interventions we found that Td was shorter (p < 0.01) with A(Post) for all electrode combinations [LVdist] 143 ± 4ms, [LVprox] 140 ± 4ms and [MPP] 134 ± 4ms, while Td with A(Pre) was shorter with [MPP] 139 ± 4ms only. A(post)[MPP] provided shorter Td than the other adaptive modes (p < 0.01). NA(Post)[MPP] at 145 ± 4ms and NA(Post)[LVdist] at 146 ± 4ms provided the shortest Td (p < 0.01) of the NA pacing modes, and Td with NA(Post)[MPP] was shorter (p < 0.01) than all NA pacing modes. Conclusion Td shortens the most with LV MPP timed to near simultaneous intrinsic RV activation, indicating a beneficial mechanical effect from Adaptive MPP compared to standard biventricular pacing.

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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 ◽

10.1093/europace/euab116.455 ◽

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.

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B-PO03-193 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

Heart Rhythm ◽

10.1016/j.hrthm.2021.06.666 ◽

2021 ◽

Vol 18 (8) ◽

pp. S267-S268

Author(s):

Hans Henrik Odland ◽

Stian Ross ◽

Richard N. Cornelussen ◽

Erik Kongsgard

Keyword(s):

Heart Failure ◽

Left Bundle Branch Block ◽

Biventricular Pacing ◽

Pressure Rise ◽

Left Ventricular Pressure ◽

Left Ventricular ◽

Ventricular Pressure ◽

Maximal Rate ◽

Bundle Branch Block ◽

Patients With Heart Failure

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Shortening of time‐to‐peak left ventricular pressure rise (Td) in cardiac resynchronization therapy

ESC Heart Failure ◽

10.1002/ehf2.13601 ◽

2021 ◽

Author(s):

Hans Henrik Odland ◽

Manuel Villegas‐Martinez ◽

Stian Ross ◽

Torbjørn Holm ◽

Richard Cornelussen ◽

...

Keyword(s):

Cardiac Resynchronization Therapy ◽

Pressure Rise ◽

Left Ventricular Pressure ◽

Left Ventricular ◽

Ventricular Pressure ◽

Cardiac Resynchronization ◽

Resynchronization Therapy ◽

Time To Peak

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B-PO03-190 COMPARISON OF ADAPTIVE AND NON-ADAPTIVE PACING MODES WITH BIVENTRICULAR STIMULATION ON TIME-TO-PEAK DERIVATIVE OF LEFT VENTRICULAR PRESSURE

Heart Rhythm ◽

10.1016/j.hrthm.2021.06.663 ◽

2021 ◽

Vol 18 (8) ◽

pp. S266-S267

Author(s):

Hans Henrik Odland ◽

Richard N. Cornelussen ◽

Erik Kongsgard

Keyword(s):

Left Ventricular Pressure ◽

Left Ventricular ◽

Ventricular Pressure ◽

Time To Peak ◽

Biventricular Stimulation

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Time delay to peak left ventricular pressure rise identifies the substrate for dyssynchronous heart failure and detects disease modification with resynchronization- an observational clinical study

EP Europace ◽

10.1093/europace/euab116.456 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

H Odland ◽

T Holm ◽

S Ross ◽

LO Gammelsrud ◽

R Cornelussen ◽

...

Keyword(s):

Heart Failure ◽

Nyha Class ◽

Pressure Rise ◽

Left Ventricular Pressure ◽

Left Ventricular ◽

Ventricular Pressure ◽

Cardiac Resynchronization ◽

Disease Modification ◽

Volumetric Response

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Norwegian South East Health Authorities Introduction Identification of disease modification prior to implantation of Cardiac Resynchronization Therapy may help select the right patients, increase responder-rates and promote the utilization of CRT. We tested the hypothesis that shortening of time-to-peak left ventricular pressure rise (Td) with CRT is useful to predict long-term volumetric response (End-systolic volume (ESV) decrease >15%) to CRT. Methods Forty-five heart failure patients admitted for CRT implantation with a class I/IIa indication according to current ESC/AHA guidelines were included in the study. Td was measured from onset QRS at baseline and from onset of pacing with CRT. Results Baseline characteristics were mean age 63 ± 10 years , 71% males, NYHA class 2.5, 87% LBBB, QRS duration 173 ± 15ms, EF biplane 31 ± 1%, ESV 144 ± 12mL and end-diastolic volume 2044 ± 14mL. At 6-months follow-up six patients increased ESV by 5 ± 8%, while 37 responders (85%) had a mean ESV decrease of 40 ± 2%. Responders presented with a higher Td at baseline compared to non-responders (163 ± 4ms vs 119 ± 9ms, p < 0.01). Td decreased to 156 ± 4ms (p = 0.02) with CRT in responders, while in non-responders Td increased to 147 ± 10ms (p < 0.01) with CRT. A decrease in Td of less than +3.5ms from baseline accurately identified responders to therapy (AUC 0.98, p < 0.01, sensitivity 97%, specificity 100%). AUC was 0.92 for baseline Td and a cut-off at 120ms yielded a sensitivity of 100% and specificity of 80% to identify volumetric responders. A linear relationship between the change in Td from baseline and ESV decrease on long term was found (β=-61, R = 0.58, P < 0.01). Conclusions Td at baseline and the shortening of Td with CRT accurately identifies responders to CRT, with incremental value on top of current guidelines, in a population with already high response rates. Td carries the potential to become the marker for prediction of long-term volumetric response in CRT candidates. Abstract Figure.

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Abstract 4344: Biventricular Pacemaker Therapy Corrects Dyssynchrony in Non-Obstructive Hypertrophic Cardiomyopathy

Circulation ◽

10.1161/circ.118.suppl_18.s_869 ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Ibrar Ahmed ◽

Khalid Abozguia ◽

Ganesh Nallur-Shivu ◽

Thanh T Phan ◽

Abdul Maher ◽

...

Keyword(s):

Hypertrophic Cardiomyopathy ◽

Biventricular Pacing ◽

Cardiac Resynchronisation Therapy ◽

Tissue Doppler ◽

Left Ventricular ◽

Control Group ◽

Pacemaker Therapy ◽

Time To Peak ◽

Obstructive Hypertrophic Cardiomyopathy ◽

Peak Longitudinal Strain

Background. Previous studies have reported dyssynchrony using Tissue Doppler in patients with hypertrophic cardiomyopathy (HCM). In this study we assessed dyssynchrony using speckle tracking echocardiography (STE) in patients with non-obstructive hypertrophic cardiomyopathy vs a healthy control group and in a subgroup of highly symptomatic patients evaluated the acute effects of biventricular pacing on STE and Tissue Doppler (TDI) derived measures of dyssynchrony. Methods. We studied 48 healthy controls (age 48 ±18yrs, 22 males, LVEF 63 ±5%, QRS 86 ±7ms) and 57 patients with HCM (age 54 ±11yrs, 38 males, LVEF 61 ±7%, QRS 110 ±36ms). A subgroup of 15 symptomatic patients with HCM (Peak VO2<60% predicted) underwent biventricular pacing (age 53 ±12yrs, 12 males, LVEF 61 ±7%, QRS 110 ±32ms). Echocardiography was performed with the pacemaker off (VVi30) and on (DDDR, AV delay 90ms, LV-RV delay 0 – 4ms). Using STE, the standard deviation (SD) in time to peak longitudinal strain (Tϵ-SD), the time to peak longitudinal systolic velocity (Ts) for each of 18 left ventricular segments and the SD of this timing (Ts-SD) was derived. Using TDI dyssynchrony was assessed from the SD of Ts for the basal six segments and the maximum difference in Ts between any two basal segments (Ts-peak[basal]). Results. Using STE, Tϵ-SD (54.99 ±33.61ms vs 24.55 ±21.18ms p<0.001), Ts-SD (71.06 ±32.32ms vs 46.17 ±21.50ms p<0.001) and Ts (155.74 ±23.14ms vs 123.71 ±11.25ms p<0.001) were greater in HCM than in controls. Using STE we demonstrated that biventricular pacing significantly reduced Tϵ-SD and Ts-SD to values similar to those observed in controls (Ts-SD p=0.13). Using TDI we demonstrated that biventricular pacing significantly reduced Ts, Ts-SD, and Ts-peak[basal]. See Table . (All values expressed as mean ±SD) Conclusion. Cardiac resynchronisation therapy significantly reduced dyssynchrony in symptomatic patients with non-obstructive HCM as demonstrated using STE and TDI. Table

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862Syncav with multipoint pacing improves acute left ventricular hemodynamics

EP Europace ◽

10.1093/europace/euaa162.197 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

A Chow ◽

P Waddingham ◽

T Betts ◽

J Mangual ◽

N Badie ◽

...

Keyword(s):

Biventricular Pacing ◽

Pressure Change ◽

Left Ventricular ◽

Maximum Pressure ◽

Conduction Time ◽

Multipoint Pacing ◽

Surface Ecg ◽

Intrinsic Conduction ◽

Qrs Duration ◽

Incremental Improvement

Abstract Funding Acknowledgements Abbott Introduction SyncAV has been shown to improve electrical synchronization by automatically adjusting atrioventricular delay (AVD) according to the intrinsic atrioventricular conduction time. Additional incremental electrical synchronization may be gained by the addition of second left ventricular (LV) pulse with MultiPoint Pacing (MPP). While the electrical synchronization benefits of SyncAV have been previously explored, there has been no assessment of the acute hemodynamic impact of SyncAV with or without MPP. Objective Evaluate the acute LV hemodynamic impact of SyncAV with and without MPP. Methods Heart failure patients with LBBB and QRS duration (QRSd) > 140 ms undergoing CRT-P/D implant with a quadripolar LV lead were enrolled in this prospective study. A guidewire or catheter with pressure transducer was placed in the LV chamber and the maximum pressure change (dP/dtmax) was recorded during the following pacing modes: intrinsic conduction, conventional biventricular pacing with SyncAV (BiV + SyncAV), and MPP with SyncAV (MPP + SyncAV). Twelve-lead surface ECG was used to determine the patient-tailored SyncAV offset that minimized QRSd. Results Twenty-seven patients (67% male, 44% ischemic, 30 ± 7% ejection fraction) completed the acute recordings. Relative to the intrinsic QRSd of 163 ms, BiV + SyncAV reduced QRSd by 21.5% to 124 ms (p < 0.001 vs. intrinsic) and MPP + SyncAV reduced QRSd by 26.6% to 120 ms (p < 0.05 vs. BiV + SyncAV). Beyond electrical synchronization, SyncAV significantly improved acute hemodynamics. Relative to the intrinsic dP/dtmax of 842 mmHg/s, BiV + SyncAV elevated dP/dtmax by 6.3% to 900 mmHg/s (p < 0.001 vs. intrinsic) and MPP + SyncAV elevated dP/dtmax by 8.8% to 926 mmHg/s (p < 0.005 vs. BiV + SyncAV). Despite both QRSd and dP/dtmax improvement with SyncAV and MPP, correlation between electrical and hemodynamic measurements was poor (R2 = 0.0 for BiV + SyncAV, R2 = 0.1 for MPP + SyncAV). Conclusion SyncAV may significantly improve acute LV hemodynamics in addition to electrical synchrony in LBBB patients. Further incremental improvement was achieved by combining SyncAV with MPP. Abstract Figure.

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