Optimizing Hemodynamics in Heart Failure Patients by Systematic Screening of Left Ventricular Pacing Sites

Abstract

The pacing site is a primary determinant of the hemodynamic response to LV pacing in patients with nonischemic dilated cardiomyopathy. Pacing at the best LV site is associated acutely with fewer nonresponders and twice the improvement in +dP/dT(max) observed with CS pacing.

Optimal site selection and image fusion guidance technology to facilitate cardiac resynchronization therapy

“…Acute hemodynamic response (AHR) is a reproducible marker of LV contractility best expressed as the change in the maximum rate of left ventricular pressure (LV-dP/dt max ), from a baseline control state [28,29]. Previous work has evaluated the acute hemodynamic effects of CRT using LV-dP/dt max as an outcome measure [29–32], and this metric has been used to compare the effects of biventricular (BiV) pacing at different locations [28,29,33]. An improvement in LV-dP/dt max of 10% during acute implantation has been shown to predict chronic LV reverse remodeling in patients receiving CRT [34].…”

“…It is worth noting that there is little consensus on a universal optimal site of LV lead deployment and instead, an individualized approach which takes into account etiology, tissue characterization, and the underlying electrical substrate appears to yield the greatest benefit [120]. Similarly, patient-specific RV lead placement may represent a superior strategy, particularly when faced with limited viable LV pacing sites due to the anatomical constraints associated with transvenous, epicardial CRT.…”

Splinting and mechanical disruption of the mitral valve apparatus by an endocardial left ventricular lead while delivering cardiac resynchronization therapy

“…There is evidence from both animal and clinical studies that, compared to epicardial stimulation, LV endocardial stimulation by activating the ventricular myocardium in a more physiological fashion may deliver superior electrical and hemodynamic properties and be less likely to cause phrenic nerve stimulation 2, 3, 4, 5. For a select group of patients who have failed conventional CRT delivered via an epicardial LV lead, this approach may be of value.…”

Interventional and Minimally Invasive Surgical Techniques Facilitating Cardiac Resynchronization Therapy

“…There is considerable variability in the ventricular activation pattern and distribution of mechanical dyssynchrony even in the LBBB population, and consequently inter-individual variability in the most optimal pacing site (Auricchio, 2004 andDerval, 2010). In addition, a significant number of patients don't even have typical LBBB.…”