Simultaneous His Bundle and Left Ventricular Pacing for Optimal Cardiac Resynchronization Therapy Delivery: Acute Hemodynamic Assessment by Pressure-Volume Loops

Luigi Padeletti; Paolo Pieragnoli; Giuseppe Ricciardi; Lisa Innocenti; Luca Checchi; Margherita Padeletti; Antonio Michelucci; Francesco Picariello; Sergio Valsecchi

doi:10.1161/CIRCEP.115.003793

Simultaneous His Bundle and Left Ventricular Pacing for Optimal Cardiac Resynchronization Therapy Delivery: Acute Hemodynamic Assessment by Pressure-Volume Loops

Circ Arrhythm Electrophysiol. 2016 May;9(5):e003793. doi: 10.1161/CIRCEP.115.003793.

Authors

Luigi Padeletti¹, Paolo Pieragnoli², Giuseppe Ricciardi², Lisa Innocenti², Luca Checchi², Margherita Padeletti², Antonio Michelucci², Francesco Picariello², Sergio Valsecchi²

Affiliations

¹ From the Heart and Vessels Department, University of Florence, Florence (L.P., P.P., G.R., L.I., L.C., A.M.); Cardiovascular Department, IRCCS MultiMedica, Sesto San Giovanni (Milan) (L.P.); Department of Cardiovascular Diseases, University of Siena, Siena (M.P.); and CRM Department, Boston Scientific Italia, Milan, Italy (F.P., S.V.). lpadeletti@interfree.it.
² From the Heart and Vessels Department, University of Florence, Florence (L.P., P.P., G.R., L.I., L.C., A.M.); Cardiovascular Department, IRCCS MultiMedica, Sesto San Giovanni (Milan) (L.P.); Department of Cardiovascular Diseases, University of Siena, Siena (M.P.); and CRM Department, Boston Scientific Italia, Milan, Italy (F.P., S.V.).

PMID: 27162032
DOI: 10.1161/CIRCEP.115.003793

Abstract

Background: Previous studies have investigated the role of intrinsic conduction in optimizing cardiac resynchronization therapy. We investigated the role of fusing pacing-induced activation and intrinsic conduction in cardiac resynchronization therapy by evaluating the acute hemodynamic effects of simultaneous His-bundle (HIS) and left ventricular (LV) pacing.

Methods and results: We studied 11 patients with systolic heart failure and left bundle-branch block scheduled for cardiac resynchronization therapy implantation. On implantation, LV pressure-volume data were determined via conductance catheter. Standard leads were placed in the right atrium, at the right ventricular apex, and in a coronary vein. An additional electrode was temporarily positioned in the HIS. The following pacing configurations were systematically assessed: standard biventricular (right ventricular apex+LV), LV-only, HIS, simultaneous HIS and LV (HIS+LV). Each configuration was compared with the AAI mode at multiple atrioventricular delays (AVD). In comparison with the AAI, right ventricular apex+LV and LV-only pacing resulted in improved stroke volume (85±32 mL and 86±33 mL versus 58±23 mL; P<0.001), stroke work, maximum pressure derivative, and systolic dyssynchrony at individually optimized AVD. The optimal AVD was close to the P-H interval in the majority of patients. By contrast, HIS-LV pacing improved hemodynamic indexes at all AVD (stroke volume >76 mL at all fixed intervals and 88±31 mL at optimal interval; all P<0.001).

Conclusions: Standard right ventricular apex+LV and LV-only pacing enhanced systolic function and LV synchrony at individually optimized AVD close to the measured intrinsic P-H interval. By contrast, HIS+LV pacing yielded improvements, regardless of AVD setting. These findings support the hypothesis of the crucial role of intrinsic right ventricular conduction in optimal cardiac resynchronization therapy delivery.

Keywords: CRT; His bundle; fusion; heart failure; pressure volume loop; resynchronization.

Publication types

Randomized Controlled Trial

MeSH terms

Aged
Aged, 80 and over
Bundle of His / physiopathology*
Bundle-Branch Block / physiopathology
Bundle-Branch Block / therapy*
Cardiac Resynchronization Therapy / methods*
Electrocardiography
Female
Follow-Up Studies
Heart Failure / physiopathology
Heart Failure / therapy*
Heart Ventricles / physiopathology
Hemodynamics / physiology*
Humans
Male
Middle Aged
Time Factors
Treatment Outcome
Ventricular Pressure