Non-invasive three-dimensional electrical activation mapping to predict cardiac resynchronization therapy response: site of latest left ventricular activation relative to pacing site

Abstract

Aims Pacing remote from the latest electrically activated site (LEAS) in the left ventricle (LV) may diminish response to cardiac resynchronization therapy (CRT). We tested whether proximity of LV pacing site (LVPS) to LEAS, determined by non-invasive three-dimensional electrical activation mapping [electrocardiographic Imaging (ECGI)], increased likelihood of CRT response. Methods and results Consecutive CRT patients underwent ECGI and chest/heart computed tomography 6–24 months of post-implant. Latest electrically activated site and the distance to LVPS (dp) were assessed. Left ventricular end-systolic volume (LVESV) reduction of ≥15% at clinical follow-up defined response. Logistic regression probabilistically modelled non-response; variables included demographics, heart failure classification, left bundle branch block (LBBB), ischaemic heart disease (IHD), atrial fibrillation, QRS duration, baseline ejection fraction (EF) and LVESV, comorbidities, use of CRT optimization algorithm, angiotensin-converting enzyme inhibitor(ACE)/angiotensin-receptor blocker (ARB), beta-blocker, diuretics, and dp. Of 111 studied patients [64 ± 11 years, EF 28 ± 6%, implant duration 12 ± 5 months (mean ± SD), 98% had LBBB, 38% IHD], 67% responded at 10 ± 3 months post CRT-implant. Latest electrically activated sites were outside the mid-to-basal lateral segments in 35% of the patients. dp was 42 ± 23 mm [31 ± 14 mm for responders vs. 63 ± 24 mm non-responders (P < 0.001)]. Longer dp and the lack of use of CRT optimization algorithm were the only independent predictors of non-response [area under the curve (AUC) 0.906]. dp of 47 mm delineated responders and non-responders (AUC 0.931). Conclusion The distance between LV pacing site and latest electrical activation is a strong independent predictor for CRT response. Non-invasive electrical evaluation to characterize intrinsic activation and guide LV lead deployment may improve CRT efficacy.

Targeted left ventricular lead positioning to the site of latest activation in cardiac resynchronization therapy: a systematic review and meta-analysis

“…recently showed that non-invasive three-dimensional electrical activation mapping to assess the QLV was a strong predictor for CRT response. 34 In the substudy of ImagingCRT however, QLV was not able to discriminate between CRT responders and non-responders. 35 Instead, a longer inter-electrical delay of ≥100 ms was found to be independently associated with more pronounced LV reverse remodelling after 6 months of follow-up, 35 and was associated with reduced all-cause death and HF hospitalization during long-term follow-up.…”

Prognostic implications of invasive hemodynamics during cardiac resynchronization therapy: Stroke work outperforms dP/dtmax

“…Alternative approaches to determine the optimal LV lead position have been proposed, using either electrical or image-based guidance. 18 , 19 While less invasive, these methods rely on indirect mechanisms to provide feedback, rather than evaluate actual changes in LV performance. Therefore, such methods may be less suitable to evaluate device programming or perioperatively compare the effects of different pacing modalities, as is the case when comparing BVP and conduction system pacing.…”

2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure

“…Quadripolar leads allow for more choices regarding pacing sites regardless of positioning, including ability to pace from nonapical sites despite apical lead placement 9 Compared to anatomic locations, placement of LV leads in areas of electrical delay can confer a greater benefit 262 . In a post hoc analysis of a large multicenter RCT, 252 HF clinical composite outcomes were assessed relative to interventricular electrical delay (short delay being <67 ms and long delay being ≥67 ms) in patients who underwent CRT placement.…”

“…9 Compared to anatomic locations, placement of LV leads in areas of electrical delay can confer a greater benefit. 262 In a post hoc analysis of a large multicenter RCT, 252 HF clinical composite outcomes were assessed relative to interventricular electrical delay (short delay being <67 ms and long delay being ≥67 ms) in patients who underwent CRT placement. The long interventricular electrical delay group had more clinical improvement, less clinical deterioration, and higher freedom from HFH or mortality.…”