Optimizing Electrical Efficacy of Leadless Cardiac Resynchronization Therapy and Leadless Left Ventricular Septal Pacing: Insights on Left and Right Ventricular Activation from Electrocardiographic Imaging

Overview

Journal Heart Rhythm O2

Date 2024 Sep 12

PMID 39263609

Authors

Nadeev Wijesuriya

Marina Strocchi

Mark Elliott

Vishal Mehta

Felicity de Vere

Sandra Howell

Nilanka Mannakkara

Baldeep S Sidhu

Jane Kwan

Paolo Bosco

Steven A Niederer

Christopher A Rinaldi

Affiliations

Soon will be listed here.

Abstract

Background: Leadless cardiac resynchronization therapy (CRT) is an emerging heart failure treatment. An implanted electrode delivers lateral or septal endocardial left ventricular (LV) pacing (LVP) upon detection of a right ventricular (RV) pacing stimulus from a coimplanted device, thus generating biventricular pacing (BiVP). Electrical efficacy data regarding this therapy, particularly leadless LV septal pacing (LVSP) for potential conduction system capture, are limited.

Objectives: The purpose of this study was to evaluate the acute performance of leadless CRT using electrocardiographic imaging (ECGi) and assess the optimal pacing modality (OPM) of LVSP on the basis of RV and LV activation.

Methods: Ten WiSE-CRT recipients underwent an ECGi study testing: RV pacing, BiVP, LVP only, and LVP with an optimized atrioventricular delay (LV-OPT). BiV, LV, and RV activation times (shortest time taken to activate 90% of the ventricles [BIVAT-90], shortest time taken to activate 95% of the LV, and shortest time taken to activate 90% of the RV) plus LV and BiV dyssynchrony index (standard deviation of LV activation times and standard deviation of all activation times) were calculated from reconstructed epicardial electrograms. The individual OPM yielding the greatest improvement from baseline was determined.

Results: BiVP generated a 23.7% improvement in BiVAT-90 ( = .002). An improvement of 43.3% was observed at the OPM ( = .0001), primarily through reductions in shortest time taken to activate 90% of the RV. At the OPM, BiVAT-90 improved in patients with lateral (43.3%; = .0001; n = 5) and septal (42.4%; = .009; n = 5) LV implants. The OPM varied by individual. LVP and LV-OPT were mostly superior in patients with LVSP, and in those with sinus rhythm and left bundle branch block (n = 4).

Conclusion: Leadless CRT significantly improves acute ECGi-derived activation and dyssynchrony metrics. Using an individualized OPM improves efficacy in selected patients. Effective LVSP is feasible, with fusion pacing at LV-OPT mitigating the potential deleterious effects on RV activation.

References

Huang W, Chen X, Su L, Wu S, Xia X, Vijayaraman P . A beginner's guide to permanent left bundle branch pacing. Heart Rhythm. 2019; 16(12):1791-1796. DOI: 10.1016/j.hrthm.2019.06.016. View

Strocchi M, Lee A, Neic A, Bouyssier J, Gillette K, Plank G . His-bundle and left bundle pacing with optimized atrioventricular delay achieve superior electrical synchrony over endocardial and epicardial pacing in left bundle branch block patients. Heart Rhythm. 2020; 17(11):1922-1929. DOI: 10.1016/j.hrthm.2020.06.028. View

Curila K, Jurak P, Jastrzebski M, Prinzen F, Waldauf P, Halamek J . Left bundle branch pacing compared to left ventricular septal myocardial pacing increases interventricular dyssynchrony but accelerates left ventricular lateral wall depolarization. Heart Rhythm. 2021; 18(8):1281-1289. DOI: 10.1016/j.hrthm.2021.04.025. View

Carabelli A, Jabeur M, Jacon P, Rinaldi C, Leclercq C, Rovaris G . European experience with a first totally leadless cardiac resynchronization therapy pacemaker system. Europace. 2020; 23(5):740-747. PMC: 8139811. DOI: 10.1093/europace/euaa342. View

Sieniewicz B, Betts T, James S, Turley A, Butter C, Seifert M . Real-world experience of leadless left ventricular endocardial cardiac resynchronization therapy: A multicenter international registry of the WiSE-CRT pacing system. Heart Rhythm. 2020; 17(8):1291-1297. PMC: 7397503. DOI: 10.1016/j.hrthm.2020.03.002. View

Ali N, Arnold A, Miyazawa A, Keene D, Chow J, Little I . Comparison of methods for delivering cardiac resynchronization therapy: an acute electrical and haemodynamic within-patient comparison of left bundle branch area, His bundle, and biventricular pacing. Europace. 2023; 25(3):1060-1067. PMC: 10062293. DOI: 10.1093/europace/euac245. View

Ramanathan C, Ghanem R, Jia P, Ryu K, Rudy Y . Noninvasive electrocardiographic imaging for cardiac electrophysiology and arrhythmia. Nat Med. 2004; 10(4):422-8. PMC: 1950745. DOI: 10.1038/nm1011. View

Okabe T, Hummel J, Bank A, Niazi I, McGrew F, Kindsvater S . Leadless left ventricular stimulation with WiSE-CRT System - Initial experience and results from phase I of SOLVE-CRT Study (nonrandomized, roll-in phase). Heart Rhythm. 2021; 19(1):22-29. DOI: 10.1016/j.hrthm.2021.06.1195. View

Upadhyay G, Cherian T, Shatz D, Beaser A, Aziz Z, Ozcan C . Intracardiac Delineation of Septal Conduction in Left Bundle-Branch Block Patterns. Circulation. 2019; 139(16):1876-1888. DOI: 10.1161/CIRCULATIONAHA.118.038648. View

10.

Zhang W, Huang J, Qi Y, Wang F, Guo L, Shi X . Cardiac resynchronization therapy by left bundle branch area pacing in patients with heart failure and left bundle branch block. Heart Rhythm. 2019; 16(12):1783-1790. DOI: 10.1016/j.hrthm.2019.09.006. View

11.

Salden F, Luermans J, Westra S, Weijs B, Engels E, Heckman L . Short-Term Hemodynamic and Electrophysiological Effects of Cardiac Resynchronization by Left Ventricular Septal Pacing. J Am Coll Cardiol. 2020; 75(4):347-359. DOI: 10.1016/j.jacc.2019.11.040. View

12.

Elliott M, Vergara P, Wijesuriya N, Mehta V, Bosco P, Jacon P . Feasibility of leadless left ventricular septal pacing with the WiSE-CRT system to target the left bundle branch area: A porcine model and multicenter patient experience. Heart Rhythm. 2022; 19(12):1974-1983. DOI: 10.1016/j.hrthm.2022.07.017. View

13.

Auricchio A, Delnoy P, Butter C, Brachmann J, van Erven L, Spitzer S . Feasibility, safety, and short-term outcome of leadless ultrasound-based endocardial left ventricular resynchronization in heart failure patients: results of the wireless stimulation endocardially for CRT (WiSE-CRT) study. Europace. 2014; 16(5):681-8. DOI: 10.1093/europace/eut435. View

14.

Reddy V, Miller M, Neuzil P, Sogaard P, Butter C, Seifert M . Cardiac Resynchronization Therapy With Wireless Left Ventricular Endocardial Pacing: The SELECT-LV Study. J Am Coll Cardiol. 2017; 69(17):2119-2129. DOI: 10.1016/j.jacc.2017.02.059. View

15.

Sieniewicz B, Gould J, Rimington H, Ioannou N, Rinaldi C . Transseptal Delivery of a Leadless Left Ventricular Endocardial Pacing Electrode. JACC Clin Electrophysiol. 2018; 3(11):1333-1335. DOI: 10.1016/j.jacep.2017.04.020. View

16.

Elliott M, Jacon P, Sidhu B, Smith L, Mehta V, Gould J . Technical feasibility of leadless left bundle branch area pacing for cardiac resynchronization: a case series. Eur Heart J Case Rep. 2021; 5(11):ytab379. PMC: 8633604. DOI: 10.1093/ehjcr/ytab379. View

17.

Wijesuriya N, Elliott M, Mehta V, Sidhu B, Behar J, Niederer S . Leadless left ventricular endocardial pacing for cardiac resynchronization therapy: A systematic review and meta-analysis. Heart Rhythm. 2022; 19(7):1176-1183. DOI: 10.1016/j.hrthm.2022.02.018. View

18.

Coveney S, Corrado C, Roney C, OHare D, Williams S, ONeill M . Gaussian process manifold interpolation for probabilistic atrial activation maps and uncertain conduction velocity. Philos Trans A Math Phys Eng Sci. 2020; 378(2173):20190345. PMC: 7287339. DOI: 10.1098/rsta.2019.0345. View

19.

Sidhu B, Porter B, Gould J, Sieniewicz B, Elliott M, Mehta V . Leadless left ventricular endocardial pacing in nonresponders to conventional cardiac resynchronization therapy. Pacing Clin Electrophysiol. 2020; 43(9):966-973. DOI: 10.1111/pace.13926. View

20.

Waddingham P, Mangual J, Orini M, Badie N, Muthumala A, Sporton S . Electrocardiographic imaging demonstrates electrical synchrony improvement by dynamic atrioventricular delays in patients with left bundle branch block and preserved atrioventricular conduction. Europace. 2022; 25(2):536-545. PMC: 9935053. DOI: 10.1093/europace/euac224. View