Biventricular endocardial pacing and left bundle branch area pacing for cardiac resynchronization: Mechanistic insights from electrocardiographic imaging, acute hemodynamic response, and magnetic resonance imaging

Mark K. Elliott; Marina Strocchi; Benjamin J. Sieniewicz; Baldeep Sidhu; Vishal Mehta; Nadeev Wijesuriya; Jonathan M. Behar; Andrew Thorpe; Dejana Martic; Tom Wong; Steven Niederer; Christopher A. Rinaldi

doi:10.1016/j.hrthm.2022.10.019

Biventricular endocardial pacing and left bundle branch area pacing for cardiac resynchronization: Mechanistic insights from electrocardiographic imaging, acute hemodynamic response, and magnetic resonance imaging

Mark K. Elliott^*, Marina Strocchi, Benjamin J. Sieniewicz, Baldeep Sidhu, Vishal Mehta, Nadeev Wijesuriya, Jonathan M. Behar, Andrew Thorpe, Dejana Martic, Tom Wong, Steven Niederer, Christopher A. Rinaldi

^*Corresponding author for this work

Research output: Contribution to journal › Article › peer-review

18 Citations (Scopus)

Abstract

Background: Biventricular endocardial pacing (BiV-endo) has demonstrated superior cardiac resynchronization compared to conventional biventricular epicardial pacing (BiV-epi). Left bundle branch area pacing (LBBAP) may also achieve effective cardiac resynchronization therapy (CRT). Objective: The purpose of this study was to compare the acute electrical and hemodynamic effects of BiV-epi, BiV-endo, and LBBAP delivered from the LV endocardium and to assess how myocardial scar affects response. Methods: Eleven patients with heart failure and indications for CRT underwent a temporary pacing study with electrocardiographic imaging (ECGi) and hemodynamic assessment. BiV-endo was delivered by stimulation of the left ventricular (LV) lateral wall, and LBBAP was delivered by stimulation of the LV septum, at the site of a Purkinje potential. LV activation time (LVAT-95), LV dyssynchrony index (LVDI), biventricular activation time (BIVAT-90), and biventricular dyssynchrony index (BIVDI) were calculated. Myocardial scar was assessed using magnetic resonance imaging (MRI). Results: The protocol was completed in 10 patients. Compared to BiV-epi (LVAT-95: 79.2 ± 13.1 ms; LVDI: 26.6 ± 3.4 ms) LV resynchronization was superior during BiV-endo (LVAT-95: 48.5 ± 14.9 ms; P =.001; LVDI: 16.6 ± 6.4 ms; P =.002) and LBBAP (LVAT-95: 48.9 ± 12.5 ms; P =.001; LVDI: 15.3 ± 3.4 ms; P =.001). Biventricular resynchronization was similarly superior during BiV-endo and LBBAP vs BiV-epi (BIVAT-90 and BIVDI; P <.05). The rate of acute hemodynamic responders was higher during BiV-endo (90%) and LBBAP (70%) vs BiV-epi (50%). The benefits of LBBAP (but not BiV-endo) on LV resynchronization were attenuated when septal scar was present in a subset of 8 patients who underwent MRI. Conclusion: Our findings suggest superior electrical resynchronization and a higher proportion of acute hemodynamic responders during BiV-endo and LBBAP compared to BiV-epi. Electrical resynchronization was similar between BiV-endo and LBBAP; however, septal scar seemed to attenuate response to LBBAP.

Original language	English
Pages (from-to)	207-216
Number of pages	10
Journal	Heart Rhythm
Volume	20
Issue number	2
DOIs	https://doi.org/10.1016/j.hrthm.2022.10.019
Publication status	Published - Feb 2023

Keywords

Acute hemodynamic response
Cardiac resynchronization therapy
Conduction system pacing
Electrocardiographic imaging
Endocardial left ventricular pacing
Left bundle branch pacing
Myocardial scar

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Elliott, M. K., Strocchi, M., Sieniewicz, B. J., Sidhu, B., Mehta, V., Wijesuriya, N., Behar, J. M., Thorpe, A., Martic, D., Wong, T., Niederer, S., & Rinaldi, C. A. (2023). Biventricular endocardial pacing and left bundle branch area pacing for cardiac resynchronization: Mechanistic insights from electrocardiographic imaging, acute hemodynamic response, and magnetic resonance imaging. Heart Rhythm, 20(2), 207-216. https://doi.org/10.1016/j.hrthm.2022.10.019

@article{afc5a61d9118426c8fd8db94d5adde44,

title = "Biventricular endocardial pacing and left bundle branch area pacing for cardiac resynchronization: Mechanistic insights from electrocardiographic imaging, acute hemodynamic response, and magnetic resonance imaging",

abstract = "Background: Biventricular endocardial pacing (BiV-endo) has demonstrated superior cardiac resynchronization compared to conventional biventricular epicardial pacing (BiV-epi). Left bundle branch area pacing (LBBAP) may also achieve effective cardiac resynchronization therapy (CRT). Objective: The purpose of this study was to compare the acute electrical and hemodynamic effects of BiV-epi, BiV-endo, and LBBAP delivered from the LV endocardium and to assess how myocardial scar affects response. Methods: Eleven patients with heart failure and indications for CRT underwent a temporary pacing study with electrocardiographic imaging (ECGi) and hemodynamic assessment. BiV-endo was delivered by stimulation of the left ventricular (LV) lateral wall, and LBBAP was delivered by stimulation of the LV septum, at the site of a Purkinje potential. LV activation time (LVAT-95), LV dyssynchrony index (LVDI), biventricular activation time (BIVAT-90), and biventricular dyssynchrony index (BIVDI) were calculated. Myocardial scar was assessed using magnetic resonance imaging (MRI). Results: The protocol was completed in 10 patients. Compared to BiV-epi (LVAT-95: 79.2 ± 13.1 ms; LVDI: 26.6 ± 3.4 ms) LV resynchronization was superior during BiV-endo (LVAT-95: 48.5 ± 14.9 ms; P =.001; LVDI: 16.6 ± 6.4 ms; P =.002) and LBBAP (LVAT-95: 48.9 ± 12.5 ms; P =.001; LVDI: 15.3 ± 3.4 ms; P =.001). Biventricular resynchronization was similarly superior during BiV-endo and LBBAP vs BiV-epi (BIVAT-90 and BIVDI; P <.05). The rate of acute hemodynamic responders was higher during BiV-endo (90%) and LBBAP (70%) vs BiV-epi (50%). The benefits of LBBAP (but not BiV-endo) on LV resynchronization were attenuated when septal scar was present in a subset of 8 patients who underwent MRI. Conclusion: Our findings suggest superior electrical resynchronization and a higher proportion of acute hemodynamic responders during BiV-endo and LBBAP compared to BiV-epi. Electrical resynchronization was similar between BiV-endo and LBBAP; however, septal scar seemed to attenuate response to LBBAP.",

keywords = "Acute hemodynamic response, Cardiac resynchronization therapy, Conduction system pacing, Electrocardiographic imaging, Endocardial left ventricular pacing, Left bundle branch pacing, Myocardial scar",

author = "Elliott, {Mark K.} and Marina Strocchi and Sieniewicz, {Benjamin J.} and Baldeep Sidhu and Vishal Mehta and Nadeev Wijesuriya and Behar, {Jonathan M.} and Andrew Thorpe and Dejana Martic and Tom Wong and Steven Niederer and Rinaldi, {Christopher A.}",

note = "Publisher Copyright: {\textcopyright} 2022 Heart Rhythm Society",

year = "2023",

month = feb,

doi = "10.1016/j.hrthm.2022.10.019",

language = "English",

volume = "20",

pages = "207--216",

journal = "Heart Rhythm",

issn = "1547-5271",

publisher = "Elsevier",

number = "2",

}

Elliott, MK , Strocchi, M , Sieniewicz, BJ , Sidhu, B , Mehta, V , Wijesuriya, N , Behar, JM, Thorpe, A, Martic, D, Wong, T, Niederer, S & Rinaldi, CA 2023, 'Biventricular endocardial pacing and left bundle branch area pacing for cardiac resynchronization: Mechanistic insights from electrocardiographic imaging, acute hemodynamic response, and magnetic resonance imaging', Heart Rhythm, vol. 20, no. 2, pp. 207-216. https://doi.org/10.1016/j.hrthm.2022.10.019

Biventricular endocardial pacing and left bundle branch area pacing for cardiac resynchronization: Mechanistic insights from electrocardiographic imaging, acute hemodynamic response, and magnetic resonance imaging. / Elliott, Mark K.; Strocchi, Marina ; Sieniewicz, Benjamin J. et al.
In: Heart Rhythm, Vol. 20, No. 2, 02.2023, p. 207-216.

Research output: Contribution to journal › Article › peer-review

TY - JOUR

T1 - Biventricular endocardial pacing and left bundle branch area pacing for cardiac resynchronization

T2 - Mechanistic insights from electrocardiographic imaging, acute hemodynamic response, and magnetic resonance imaging

AU - Elliott, Mark K.

AU - Strocchi, Marina

AU - Sieniewicz, Benjamin J.

AU - Sidhu, Baldeep

AU - Mehta, Vishal

AU - Wijesuriya, Nadeev

AU - Behar, Jonathan M.

AU - Thorpe, Andrew

AU - Martic, Dejana

AU - Wong, Tom

AU - Niederer, Steven

AU - Rinaldi, Christopher A.

PY - 2023/2

Y1 - 2023/2

N2 - Background: Biventricular endocardial pacing (BiV-endo) has demonstrated superior cardiac resynchronization compared to conventional biventricular epicardial pacing (BiV-epi). Left bundle branch area pacing (LBBAP) may also achieve effective cardiac resynchronization therapy (CRT). Objective: The purpose of this study was to compare the acute electrical and hemodynamic effects of BiV-epi, BiV-endo, and LBBAP delivered from the LV endocardium and to assess how myocardial scar affects response. Methods: Eleven patients with heart failure and indications for CRT underwent a temporary pacing study with electrocardiographic imaging (ECGi) and hemodynamic assessment. BiV-endo was delivered by stimulation of the left ventricular (LV) lateral wall, and LBBAP was delivered by stimulation of the LV septum, at the site of a Purkinje potential. LV activation time (LVAT-95), LV dyssynchrony index (LVDI), biventricular activation time (BIVAT-90), and biventricular dyssynchrony index (BIVDI) were calculated. Myocardial scar was assessed using magnetic resonance imaging (MRI). Results: The protocol was completed in 10 patients. Compared to BiV-epi (LVAT-95: 79.2 ± 13.1 ms; LVDI: 26.6 ± 3.4 ms) LV resynchronization was superior during BiV-endo (LVAT-95: 48.5 ± 14.9 ms; P =.001; LVDI: 16.6 ± 6.4 ms; P =.002) and LBBAP (LVAT-95: 48.9 ± 12.5 ms; P =.001; LVDI: 15.3 ± 3.4 ms; P =.001). Biventricular resynchronization was similarly superior during BiV-endo and LBBAP vs BiV-epi (BIVAT-90 and BIVDI; P <.05). The rate of acute hemodynamic responders was higher during BiV-endo (90%) and LBBAP (70%) vs BiV-epi (50%). The benefits of LBBAP (but not BiV-endo) on LV resynchronization were attenuated when septal scar was present in a subset of 8 patients who underwent MRI. Conclusion: Our findings suggest superior electrical resynchronization and a higher proportion of acute hemodynamic responders during BiV-endo and LBBAP compared to BiV-epi. Electrical resynchronization was similar between BiV-endo and LBBAP; however, septal scar seemed to attenuate response to LBBAP.

AB - Background: Biventricular endocardial pacing (BiV-endo) has demonstrated superior cardiac resynchronization compared to conventional biventricular epicardial pacing (BiV-epi). Left bundle branch area pacing (LBBAP) may also achieve effective cardiac resynchronization therapy (CRT). Objective: The purpose of this study was to compare the acute electrical and hemodynamic effects of BiV-epi, BiV-endo, and LBBAP delivered from the LV endocardium and to assess how myocardial scar affects response. Methods: Eleven patients with heart failure and indications for CRT underwent a temporary pacing study with electrocardiographic imaging (ECGi) and hemodynamic assessment. BiV-endo was delivered by stimulation of the left ventricular (LV) lateral wall, and LBBAP was delivered by stimulation of the LV septum, at the site of a Purkinje potential. LV activation time (LVAT-95), LV dyssynchrony index (LVDI), biventricular activation time (BIVAT-90), and biventricular dyssynchrony index (BIVDI) were calculated. Myocardial scar was assessed using magnetic resonance imaging (MRI). Results: The protocol was completed in 10 patients. Compared to BiV-epi (LVAT-95: 79.2 ± 13.1 ms; LVDI: 26.6 ± 3.4 ms) LV resynchronization was superior during BiV-endo (LVAT-95: 48.5 ± 14.9 ms; P =.001; LVDI: 16.6 ± 6.4 ms; P =.002) and LBBAP (LVAT-95: 48.9 ± 12.5 ms; P =.001; LVDI: 15.3 ± 3.4 ms; P =.001). Biventricular resynchronization was similarly superior during BiV-endo and LBBAP vs BiV-epi (BIVAT-90 and BIVDI; P <.05). The rate of acute hemodynamic responders was higher during BiV-endo (90%) and LBBAP (70%) vs BiV-epi (50%). The benefits of LBBAP (but not BiV-endo) on LV resynchronization were attenuated when septal scar was present in a subset of 8 patients who underwent MRI. Conclusion: Our findings suggest superior electrical resynchronization and a higher proportion of acute hemodynamic responders during BiV-endo and LBBAP compared to BiV-epi. Electrical resynchronization was similar between BiV-endo and LBBAP; however, septal scar seemed to attenuate response to LBBAP.

KW - Acute hemodynamic response

KW - Cardiac resynchronization therapy

KW - Conduction system pacing

KW - Electrocardiographic imaging

KW - Endocardial left ventricular pacing

KW - Left bundle branch pacing

KW - Myocardial scar

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U2 - 10.1016/j.hrthm.2022.10.019

DO - 10.1016/j.hrthm.2022.10.019

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AN - SCOPUS:85143883893

SN - 1547-5271

VL - 20

SP - 207

EP - 216

JO - Heart Rhythm

JF - Heart Rhythm

IS - 2

ER -

Biventricular endocardial pacing and left bundle branch area pacing for cardiac resynchronization: Mechanistic insights from electrocardiographic imaging, acute hemodynamic response, and magnetic resonance imaging

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