Optimization of CRT programming using non‐invasive electrocardiographic imaging to assess the acute electrical effects of multipoint pacing

Abstract

Aim Quadripolar lead technology and multi‐point pacing ( MPP ) are important clinical adjuncts in cardiac resynchronization therapy ( CRT ) pacing aimed at reducing the rate of non‐response to therapy. Mixed results have been achieved using MPP and it is critical to identify which patients require this approach and how to configure their MPP stimulation, in order to achieve optimal electrical resynchronization. Methods & Results We sought to investigate whether electrocardiographic imaging ( ECG i), using the CARDIOINSIGHT ™ inverse ECG mapping system, could identify alterations in electrical resynchronization during different methods of device optimization. In no patient did a single form of programming optimization provide the best electrical response. The effects of utilizing MPP were idiosyncratic and highly patient specific. ECG i activation maps were clearly able to discern changes in bulk LV activation during differing MPP programming. In two of the five subjects, MPP resulted in more rapid activation of the left ventricle compared to standard CRT ; however, in the remaining three patients, the use of MPP did not appear to acutely improve electrical resynchronization. Crucially, this cohort showed evidence of extensive LV scarring which was well visualized using both CMR and ECG i voltage mapping. Conclusions Our work suggests a potential role for ECG i in the optimization of non‐responders to CRT , as it allows the fusion of activation maps and scar analysis above and beyond interrogation of the 12 lead ECG .

Clinical Utility of Body Surface Potential Mapping in CRT Patients

“…[ 19 ] The potential of ECGI activation maps for detection of the best configuration of multi-polar pacing was demonstrated in a pilot study with five patients. [ 26 ]…”

Improvement of electrical synchrony in cardiac resynchronization therapy using dynamic atrioventricular delay programming and multipoint pacing

“…For delivering MPP from a single quadripolar LV lead, multiple studies showed immediate improvement of electrical synchrony and hemodynamic response compared to BiV. 9,22 Pacing from two electrodes with large anatomical spacing resulted in greatest benefits compared to other MPP pacing configurations during a long-term follow-up. 10,23,24 Our results are in line with this data as QRSd was significantly shortened by MPP compared to BiV alone.…”

“…SyncAV Recent studies report an improvement of acute electrical synchrony and improved reverse remodeling during follow-up compared to conventional biventricular pacing. 9,10 Whether combination of SyncAV and MPP leads to a greater improvement of electrical synchrony remains unknown. In the present work, we assessed whether using the novel technologies improves electrical synchrony in both newly and previously implanted CRT devices.…”

Multi-polar stimulation of the left ventricle during cardio-resynchronisation therapy in patients with congestive heart failure: Randomised pilot study outcomes from parallel groups

“…Для многополюсной стимуляции используют два катода, полученных с помощью четырех электродов [30][31][32]. При сравнении с бивентрикулярной стимуляцией установлено улучшение сократимости, гемодинамики и синхронизации между желудочками [33][34][35][36][37][38][39], особенно у пациентов, которые не склонны отвечать на терапию с помощью стандартной СРТ, то есть имеющих узкий комплекс QRS, атипичную морфологию блокады левой ножки пучка Гиса, I тип активации ЛЖ и рубцы миокарда [40][41][42]. Таким образом, в последнее время появляются сведения о многополюсной стимуляции ЛЖ при СРТ, которая вероятно увеличит количество пациентов, ответивших на лечение (респондеров).…”