Pressure-Volume Loop Analysis of Multipoint Pacing With a Quadripolar Left Ventricular Lead in Cardiac Resynchronization Therapy

doi:10.1016/j.jacep.2018.02.005

JACC: Clinical Electrophysiology

Volume 4, Issue 7, July 2018, Pages 881-889

https://doi.org/10.1016/j.jacep.2018.02.005 Get rights and content

Under an Elsevier user license

open archive

Abstract

Objectives

This study aimed to compare multipoint pacing (MPP) to optimal biventricular pacing with a quadripolar left ventricular (LV) lead and find factors associated with hemodynamic response to MPP.

Background

MPP with a quadripolar LV lead may increase response to cardiac resynchronization therapy.

Methods

Heart failure patients with a left bundle branch block underwent cardiac resynchronization therapy implantation. Q to LV sensing interval divided by the intrinsic QRS duration was measured. Invasive pressure-volume loops were assessed during 4 biventricular pacing settings and 3 MPP settings, using 4 atrioventricular delays. Hemodynamic response was defined as change in stroke work (Δ%SW) compared with baseline measurements during intrinsic conduction. Δ%SW of MPP was compared with conventional biventricular pacing using the distal electrode and the electrode with highest Δ%SW (BIV-OPT).

Results

Forty-three patients were analyzed (age 66 ± 10 years, 63% men, 30% ischemic cardiomyopathy, LV ejection fraction 29 ± 8%, and QRS duration 175 ± 13 ms). Q to local LV sensing interval corrected for QRS duration was 84 ± 8%, and variation between LV electrodes was 9 ± 5%. Compared with conventional biventricular pacing using the distal electrode, MPP showed a significant higher increase of SW (Δ%SW +15 ± 35%; p < 0.05) with a large interindividual variation. There was no significant difference in Δ%SW with MPP compared with BIV-OPT (−5 ± 24%; p = 0.19). Male sex and low LV ejection fraction were associated with increase in Δ%SW due to MPP versus BIV-OPT in multivariate analysis, while ischemic cardiomyopathy was only associated in univariate analysis.

Conclusions

Optimization of the pacing site of a quadripolar LV lead is more important than to program MPP. However, specific subgroups (i.e., especially men) may benefit substantially from MPP.

Graphical abstract

Key Words

acute hemodynamic response

cardiac resynchronization therapy

multipoint pacing

pressure-volume loops

quadripolar lead

Abbreviations and Acronyms

Δ%SW

change in stroke work

atrioventricular

BIV-CONV

biventricular pacing with the distal electrode of a quadripolar lead

BIV-OPT

biventricular pacing with the electrode with highest increase in stroke work, of a quadripolar lead

DCM

dilated cardiomyopathy

ECG

electrocardiographic/electrocardiography

electrophysiological

ICM

ischemic cardiomyopathy

LBBB

left bundle branch block

MPP

multipoint pacing

QLV/QRSd

Q to left ventricular sensing interval divided by the intrinsic QRS duration

pressure-volume

right atrial

right ventricular

Cited by (0)

: This study was conducted with an unrestricted research grant from St. Jude Medical (St. Paul, Minnesota). Dr. Prinzen has received research grant support from Medtronic, Boston Scientific, St. Jude Medical, Abbott, LivaNova, Biosense Webster, Merck Sharp & Dohme, Biotronik, and EBR Systems; and has served as an advisor for Medtronic Inc. Dr. Vernooy has received speaker fees and research grants from St. Jude Medical. Dr. Meine has received research grant support from Boston Scientific and St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

: All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.