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

Abstract

Cardiac resynchronization therapy (CRT) with multipoint left ventricular (LV) pacing [MultiPoint TM 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 TM or Quadra Assura MP TM CRT-D and Quartet TM 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 reevaluated at 16 months post-implant. Response to CRTwas 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 CRTand were switched to MPP. After 12 months of conventional CRT, ESV reduction and EF increase relative to baseline were 218 + 12 and +5 + 4%, respectively, and six of eight (75%) patients were considered CRTresponders. 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 233 and 220% and improvement in EF of +15 and +4%. The remaining six patients classified as responders experienced additional reduction in ESVof 213 + 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.

Optimisation Of Cardiac Resynchronisation Therapy With MultiPoint™ Pacing

“…27 Recently, Pappone published 12-month follow-up data from this study. 28,38 The trend observed at 3 months was sustained;…”

“…The MultiPoint pacing group showed a lower rate of negative responders (10 versus 25 %) and a higher rate of super responders (33 versus 14 %) compared with the CONV group (see Figure 4). 38…”

Optimisation of Cardiac Resynchronisation Therapy with MultiPoint™ Pacing

“…27 Recently, Pappone published 12-month follow-up data from this study. 28,38 The trend observed at 3 months was sustained; LVESV and EF were significantly improved in the MultiPoint pacing group relative to the CONV group. A clinical benefit was also seen: improvement of more than two NYHA classes was Figure 4).…”

“…A clinical benefit was also seen: improvement of more than two NYHA classes was Figure 4). 38 An example of acute haemodynamic measurements and echo measurements were given in a super responder: these included a decrease in EDV from 310 ml at baseline to 235 ml at 3 months and 211 ml at 12 months. The decrease in EF was 35 % at baseline and 41 % at both 3 and 12 months.…”

The effect of left ventricular pacing on transmural activation delay in myopathic human hearts

“…Although results from multisite pacing (MSP) in CRT recipients have been conflicting, there are some features that define patients who may respond better to MSP: (i) patients with wider separation of the two LV pacing sites, 17 (ii) patients with scar, 18 (iii) non-LBBB patients, (iv) larger 'bulk' endocardial LV activation is a better marker of response than total activation delay of the LV, and (v) responders do not show a decrease in the total LV endocardial activation delay but they do have a shorter delay between the 10th and 90th percentiles of activation, suggesting that the rate of endocardial activation is of higher importance. 19 Findings of MSP correlate with our data on LVEpiP: Although the transmural activation sequence is variable, the overall transmural activation time is shorter.…”