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Review
. 2015 Apr 30;7(6):1214.
doi: 10.4022/jafib.1214. eCollection 2015 Apr-May.

ECG Patterns In Cardiac Resynchronization Therapy

Antonius van Stipdonk  1 , Sofieke Wijers  2 , Mathias Meine  2 , Kevin Vernooy  1
Affiliations
Review

ECG Patterns In Cardiac Resynchronization Therapy

Antonius van Stipdonk et al. J Atr Fibrillation. .

Abstract

Cardiac resynchronization therapy is an established treatment modality in heart failure. Though non-response is a serious issue. To address this issue, a good understanding of the electrical activation during underlying intrinsic ventricular activation, biventricular as well as right- and left ventricular pacing is needed. By interpreting the 12-lead electrocardiogram, possible reasons for suboptimal treatment can be identified and addressed. This article reviews the literature on QRS morphology in cardiac resynchronization therapy and its role in optimization of therapy.

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Figures

Figure 1.
Figure 1.. QRS morphology in complete left bundle branche block. The LBBB activation sequence and representative QRS-T wave forms are depicted in their anatomic locations for the sagittal, transverse, and frontal planes. Figure used from Strauss et al.[10]
Figure 2.
Figure 2.. Conventional ECG criteria for left bundle branche block. (1) QRS duration >120 ms, (2) QS in lead V1, (3) monophasic R wave with no Q waves in leads V6 and I. Also included ‘notching’ as described by Strauss et al.[10]
Figure 3.
Figure 3.. Increased delay in LV electrical activation during RV apex pacing as compared to intrinsic LBBB. Local electrical activation time has been projected on the coronary venous electro-anatomic maps using the same color coding for both intrinsic LBBB and RV apex pacing. AIV = anterior inter-ventricular vein, ALV-1= first anterolateral vein, ALV-2 = second antero-lateral vein, CS = coronary sinus, LBBB = left bundle branch block, LEAT = local electrical activation time, LV = left ventricle/ventricular, RV = right ventricle/ ventricular, RAO = right anterior oblique view. Figure adapted from Mafi Rad et al.[23]
Figure 4.
Figure 4.. Protocol for determination of the LV lead position using the LV-paced QRS morphology, based on ECGs from LV originating ventricular tachycardia. Step 1: A positive QRS complex in V1 indicates an LV lead position at the LV free wall. Step 2: Lead aVF differentiates the LV lead position in the circumferential direction with a negative QRS complex indicating a more inferolateral position. Step 3: Trace the transition from positive to negative QRS complexes in the precordial leads to determine the apico-basal direction. Figure used from Van Deursen et al.[33]
Figure 5.
Figure 5.. A) ECG obtained from a patient during LV pacing. Note the positive QRS complex in lead I during LV pacing due to B) a very basal LV lateral lead position as can be seen on the chest X-ray
Figure 6.
Figure 6.. Algorithm to evaluate the configuration of the paced ECG in lead V1 in CRT. Figure used from Barold and Herweg.[37]
Figure 7.
Figure 7.. Wave interference for QRS fusion analysis. BV=biventricular; LBBB=left bundle branch block; LV=left ventricular; QRSBV=biventricular-paced QRS; QRSLBBB=LBBB QRS duration (ms); RV=right ventricular. Figure used from Sweeney et al.[45]
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