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Europace Advance Access published online on October 31, 2009
Europace, doi:10.1093/europace/eup333
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org
The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open access version of this article for non-commercial purposes provided that the original authorship is properly and fully attributed; the Journal, Learned Society and Oxford University Press are attributed as the original place of publication with correct citation details given; if an article is subsequently reproduced or disseminated not in its entirety but only in part or as a derivative work this must be clearly indicated. For commercial re-use, please contact journals.permissions@oxfordjournals.org.

CLINICAL RESEARCH

Midterm ‘super-response’ to cardiac resynchronization therapy by biventricular pacing with fusion: insights from electro-anatomical mapping

Radu Vatasescu {dagger}, Antonio Berruezo* {dagger}, Lluis Mont, David Tamborero, Marta Sitges, Etel Silva, Jose María Tolosana, Bárbara Vidal, David Andreu and Josep Brugada

Cardiology Department, Arrhythmia Section, Hospital Clinic, Thorax Institute, University of Barcelona, Villarroel, 170, Barcelona, 08036 Catalonia, Spain

Aims: Some authors recommend avoiding fusion with left ventricular (LV) intrinsic depolarization during cardiac resynchronization therapy (CRT). If fusion is still present during optimized biventricular (Biv) pacing and its long-term effects on the response to CRT are currently unknown. The aim of the study was to analyse the endocardial LV activation pattern induced by echocardiographically optimized Biv pacing and its influence on LV reverse remodelling.

Methods and results: Contact electro-anatomical mapping was performed in 15 heart failure (HF) patients with left bundle branch block and echocardiographically optimized CRT (seven ischaemic aetiology, 64 ± 8 years, three women, New York Heart Association class 3 ± 0.4, LV ejection fraction 25 ± 5%). Left ventricular activation maps were performed in sinus rhythm (SR), during DDD right ventricular apical (RVA) and optimized Biv pacing. Fusion with intrinsic rhythm during pacing was considered when LV septal activation was produced at least partially by intrinsic depolarization, when compared with LV activation map during SR. Patients were considered responders to CRT if they had ≥10% reduction in LV end-systolic volume (LVESV) after 6 months of CRT. During SR, the LV breakthrough was mid-septal (n = 12), basal septum (n = 2), and apical (n = 1). During RVA pacing, LV breakthrough shifted apical in all patients. Right ventricular apical/Biv pacing proved fusion with intrinsic depolarization in 8 of 15 patients. The PR interval was shorter in patients with fusion RVA/Biv pacing (164 ± 24 vs. 234 ± 55 ms, P = 0.006). There was a trend for shorter LV activation time (LVat) in patients with fusion during RVA pacing (87 ± 33 vs. 113 ± 21 ms, P = 0.08) as well as during optimized Biv pacing (83 ± 18 vs. 104 ± 24 ms, P = 0.07), although LVat was similar in SR (100 ± 22 vs. 106 ± 20, P = NS). In patients with fusion, 6 months responder rate was significantly higher (100 vs. 28.5%, P < 0.007) as was the degree of LVESV reduction (39 ± 17 vs. 1.0 ± 14%, P < 0.001).

Conclusion: Biventricular pacing with fusion may substantially increase the structural responder rate probably by shortening LVat.

Key Words: Cardiac resynchronization therapy, RVA pacing, Fusion, Activation time

* Corresponding author. Tel: +34 932275551, Fax: +34 934513045, Email: berruezo{at}clinic.ub.es

{dagger} These authors contributed equally to this work.

Manuscript submitted 19 August 2009. Accepted after revision 28 September 2009.


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