Transseptal Left Ventricular Endocardial Pacing Reduces Dispersion of Ventricular Repolarization

Scott, Paul A.; Yue, Arthur M.; Watts, Edd; Zeb, Mehmood; Roberts, Paul R.; Morgan, John M.

doi:10.1111/j.1540-8159.2011.03138.x

Cited by 28 publications

(25 citation statements)

References 40 publications

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“…Endocardial pacing has also been shown to result in more rapid ventricular depolarization, shorter global LV activation times, more synchronous LV activation and better acute hemodynamic parameters than epicardial pacing, and may be less arrythmogenic. 21,[32][33][34][35][36] Consistent with the above observations, response to CRT with endocardial pacing in patients who had not responded to epicardial CRT has been reported, and response rates in previous reports of LV endocardial pacing have been high at ≈90%. 9,12,13,20,22,23 During the development of the ventricular transseptal puncture technique, it was found that use of a guidewire combined with radiofrequency energy facilitated a quicker procedure with a more basal or midseptal puncture site.…”

Section: Discussionsupporting

confidence: 73%

Development of a Technique for Left Ventricular Endocardial Pacing via Puncture of the Interventricular Septum

Betts

Gamble

Khiani

et al. 2014

Circ: Arrhythmia and Electrophysiology

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Background-Left ventricular (LV) pacing through the coronary sinus is the standard approach for cardiac resynchronization therapy. When this route is unavailable, the alternatives have major limitations. LV endocardial pacing through the interventriuclar septum may offer a simpler solution. We describe an initial case series to demonstrate technical feasibility and to describe our refinement of the puncture technique. Methods and Results-Ten patients with previous failed coronary sinus lead implant or with nonresponse to cardiac resynchronization therapy and a suboptimal LV lead position were selected. All patients were anticoagulated. Left ventriculography and coronary angiography were performed to identify LV borders and septal vessels. Subclavian vein access was used for a superior approach ventricular transseptal puncture under fluoroscopic guidance, using a steerable sheath and a standard transseptal needle, radiofrequency needle, or radiofrequency energy delivered through a guidewire. An active-fixation pacing lead was successfully delivered to the endocardial wall of the lateral LV in all patients (9 men; age, 62±10 years). LV lead implant procedure time shortened with experience. The use of radiofrequency energy delivered through a guidewire was the most effective technique. Mean threshold and R wave at implant were 0.8±0.3 V and 10.8±3.9 mV. At follow-up (mean, 8.7 months; minimum, 0; and maximum 19), thresholds were stable, and there were no thromboembolic events. Of 9 patients, 8 were classed as clinical responders (1 had inadequate follow-up to assess response). Conclusions-LV endocardial pacing through a ventricular septal puncture is a feasible approach for cardiac resynchronization therapy. (Circ Arrhythm Electrophysiol. 2014;7:17-22.)Key Words: cardiac resynchronization therapy ◼ endocardium ◼ heart ventricles ◼ septal Received September 11, 2013; accepted December 16, 2013. From the Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (T.R.B., J.H.P.G., R.K., Y.B., K.R.); and Department of Cardiology, Milton Keynes Hospital NHS Foundation Trust, Milton Keynes, United Kingdom (R.K. Figure 1). Once a LV pressure trace was seen, a hand injection of contrast media was used to confirm that the needle was in the LV cavity. The dilator and sheath were then advanced 10 to 20 mm into the chamber over the needle. The needle was withdrawn and a 0.032-inch stiff 260-cm J guidewire was advanced through the sheath and dilator and curled in the LV cavity. The sheath and dilator were then advanced through the septum until the sheath tip was 1 to 2 cm inside the LV. The sheath and dilator were withdrawn and exchanged over the stiff guidewire for a slit-able, deflectable lead delivery catheter and dilator (Medtronic Attain or Select Secure; Medtronic, Minneapolis, MN). 2. Radiofrequency needle (cases 2 and 3): the procedure was performed using a stiff 98-cm radiofrequency transseptal needle (NRG; Bayliss Medical, Montreal, Canada). When opposed against the s...

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Section: Discussionsupporting

confidence: 73%

Development of a Technique for Left Ventricular Endocardial Pacing via Puncture of the Interventricular Septum

Betts

Gamble

Khiani

et al. 2014

Circ: Arrhythmia and Electrophysiology

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“…The transseptal approach allows the freedom to choose a stimulation site, as opposed to being constrained by the anat- omy of the coronary sinus. LV endocardial pacing appears more physiologic, preserving the transmural activation and repolarization sequence; therefore, it may lower the risk of arrhythmia development (25). Moreover, we have demonstrated that LV endocardial stimulation and optimization of the pacing site significantly improved systolic function compared with standard LV epicardial pacing.…”

Section: Discussionmentioning

confidence: 63%

Left ventricular endocardial or triventricular pacing to optimize cardiac resynchronization therapy in a chronic canine model of ischemic heart failure

Bordachar

Grenz

Jaı̈s

et al. 2012

American Journal of Physiology-Heart and Circulatory Physiology

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Cardiac resynchronization therapy (CRT) is a proven treatment for heart failure but ~30% of patients appear to not benefit from the therapy. Left ventricular (LV) endocardial and multisite epicardial [triventricular (TriV)] pacing have been proposed as alternatives to traditional LV transvenous epicardial pacing, but no study has directly compared the hemodynamic effects of these approaches. Left bundle branch block ablation and repeated microembolizations were performed in dogs to induce electrical dysynchrony and to reduce LV ejection fraction to <35%. LVdP/dt(max) and other hemodynamic indexes were measured with a conductance catheter during LV epicardial, LV endocardial, biventricular (BiV) epicardial, BiV endocardial, and TriV pacing performed at three atrioventricular delays. LV endocardial pacing was obtained with a clinically available pacing system. The optimal site was defined as the site that increased dP/dt(max) by the largest percentage. Implantation of the endocardial lead was feasible in all canines (n = 8) without increased mitral regurgitation seen with transesophageal echocardiography and with full access to the different LV endocardial pacing sites. BiV endocardial pacing increased dP/dt(max) more than BiV epicardial and TriV pacing on average (P < 0.01) and at the optimal site (P < 0.01). There were no significant differences between BiV epicardial and TriV pacing. BiV endocardial pacing was superior to BiV epicardial and to TriV pacing in terms of acute hemodynamic response. Further investigation is needed to confirm the chronic benefit of this approach in humans.

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“…Recent studies in patients that compared the mean QRSd across multiple pacing sites did not report a significant decrease in QRSd or in the time from first-to-last activation of the LV endocardial surface for ENDO-CRT relative to conventional CRT, 5,39,40 whereas a decrease in QRSd was found in human and canine cases when comparing paired transmural pacing sites. 9,41 One possible explanation for the former finding is that CRT patients tend to have a reduced ejection fraction which is associated with eccentric remodeling, and as we have shown in this article, this remodeling type is less sensitive to LV pacing strategy.…”

Section: Comparison With Previous Studiesmentioning

confidence: 77%

Beneficial Effect on Cardiac Resynchronization From Left Ventricular Endocardial Pacing Is Mediated by Early Access to High Conduction Velocity Tissue

Hyde

Behar

Claridge

et al. 2015

Circ: Arrhythmia and Electrophysiology

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Dyssynchronous heart failure (HF) is routinely treated with cardiac resynchronization therapy (CRT). During conventional biventricular (BV) CRT, pacing is applied to the right ventricle (RV) endocardium and the left ventricle (LV) epicardium via the coronary sinus (EPI-CRT BV ). Current best practice results in 30% to 40% of CRT patients failing to display improved clinical response.1 Recent clinical 2-5 and experimental 6,7 evidence suggests that BV CRT with an endocardial pacing strategy for the LV lead (ENDO-CRT BV ) can provide an improvement in acute hemodynamic response and stroke work over EPI-CRT BV and offers a novel approach for increasing CRT response rates. However, the relative importance of cardiac physiology or better access to optimal pacing sites in causing this improved outcome remains controversial. Identifying and understanding physiological mechanisms behind improved ENDO-CRT BV response are crucial for optimizing clinical procedures and identifying patients who will receive the maximal benefit from this therapy.In acute left bundle branch block (LBBB) canine studies, ENDO-CRT BV improved the systolic LV function over conventional EPI-CRT BV .6 Electric activation times (ATs) as measured by contact mapping were decreased with ENDO-CRT BV © 2015 American Heart Association, Inc. Original Article Circ Arrhythm Electrophysiol Background-Cardiac resynchronization therapy (CRT) delivered via left ventricular (LV) endocardial pacing (ENDO-CRT) is associated with improved acute hemodynamic response compared with LV epicardial pacing (EPI-CRT).The role of cardiac anatomy and physiology in this improved response remains controversial. We used computational electrophysiological models to quantify the role of cardiac geometry, tissue anisotropy, and the presence of fast endocardial conduction on myocardial activation during ENDO-CRT and EPI-CRT. Methods and Results-Cardiac activation was simulated using the monodomain tissue excitation model in 2-dimensional (2D) canine and human and 3D canine biventricular models. The latest activation times (LATs) for LV endocardial and biventricular epicardial tissue were calculated (LVLAT and TLAT), as well the percentage decrease in LATs for endocardial (en) versus epicardial (ep) LV pacing (defined as %dLV=100×(LVLAT ep −LVLAT en )/LVLAT ep and %dT=100×(TLAT ep −TLAT en )/TLAT ep , respectively). Normal canine cardiac anatomy is responsible for %dLV and %dT values of 7.4% and 5.5%, respectively. Concentric and eccentric remodeled anatomies resulted in %dT values of 15.6% and 1.3%, respectively. The 3D biventricular-paced canine model resulted in %dLV and %dT values of −7.1% and 1.5%, in contrast to the experimental observations of 16% and 11%, respectively. Adding fast endocardial conduction to this model altered %dLV and %dT to 13.1% and 10.1%, respectively. Conclusions-Our results provide a physiological explanation for improved response to ENDO-CRT. We predict that patients with viable fast-conducting endocardial tissue or distal Purkinje network or both, as we...

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Transseptal Left Ventricular Endocardial Pacing Reduces Dispersion of Ventricular Repolarization

Cited by 28 publications

References 40 publications

Development of a Technique for Left Ventricular Endocardial Pacing via Puncture of the Interventricular Septum

Development of a Technique for Left Ventricular Endocardial Pacing via Puncture of the Interventricular Septum

Left ventricular endocardial or triventricular pacing to optimize cardiac resynchronization therapy in a chronic canine model of ischemic heart failure

Beneficial Effect on Cardiac Resynchronization From Left Ventricular Endocardial Pacing Is Mediated by Early Access to High Conduction Velocity Tissue

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