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. 2017 May-Jun;17(3):72-77.
doi: 10.1016/j.ipej.2017.05.001. Epub 2017 May 6.

'Optimized' LV only pacing using a dual chamber pacemaker as a cost effective alternative to CRT

Maneesh K Rai  1 , Mukund A Prabhu  2 , Abhishek Sharma  3 , Ritesh Vekariya  3 , Padmanabh Kamath  3 , Narasimha Pai  3 , Ramanath L Kamath  3
Affiliations

'Optimized' LV only pacing using a dual chamber pacemaker as a cost effective alternative to CRT

Maneesh K Rai et al. Indian Pacing Electrophysiol J. 2017 May-Jun.

Abstract

Background: Cardiac Resynchronization therapy (CRT) remains largely under-used in developing countries owing to the high cost of therapy. In this pilot study, we explore 'optimized' Left Ventricle Only Pacing (LVOP) as a cost effective alternative to cardiac resynchronization therapy in selected patients with heart failure.

Hypothesis: In economically poorer patients with heart failure, left bundle branch block (LBBB) and intact AV node conduction, synchronization can be obtained using a dual chamber pacemaker (leads in right atrium and Left ventricle) with the help of 2D strain imaging.

Methods and results: 4 patients underwent LVOP for symptomatic heart failure. Post procedure 'optimization' was done using 12 lead electrocardiography and 2D- Strain imaging. Difference between Time to Peak longitudinal strain and Aortic valve Closure (Diff TPL-AC) was calculated for each segment at different AV delays and the AV delay with the smallest Diff TPL-AC was programmed. The mean AV delay that resulted in electrical and mechanical synchrony was 150 ms. After a mean follow up of 6 months, all patients had improved by at least 1 NYHA class. The mean reduction in QRS duration post procedure was -54.5 ± 22.82 ms and the mean improvement in EF was 7 ± 2.75%.

Conclusion: Optimized LVOP using 2D strain and ECG can be a cost-effective alternative to CRT in patients with LBBB, heart failure and normal AV node conduction.

Keywords: Dual chamber CRT; LV only pacing; Optimized LVOP.

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Figures

Fig. 1
Fig. 1
Electrical fusion: Predominant LV pacing (q in I and AVL and R in V1) is evident at SAV of 80–120 ms with Fusion-QRS complexes noted at longer SAVs (140 and 160 ms). SAV of 140 ms results in the narrowest QRS.
Fig. 2
Fig. 2
Mechanical Fusion. The vertical columns represent mechanical fusion at baseline (LBBB) and at different AV delays. The first three rows represent 2D strain images in A4C, APLAX and A2C views at different AV delays. The fourth row represents TPL and the fifth row represents TPL-AC at these delays. The most homogenous contraction is seen to occur at SAV of 160 ms (The least Diff TPL-AC between basal and mid segments). A4C- Apical 4 Chamber, APLAX- Apical Parasternal long axis, A2C- Apical 2 Chamber.
Fig. 3
Fig. 3
Echocardiographic parameters before and after Optimized LV Pacing. EDV-End-diastolic volume, EF-Ejection fraction, ESV end-systolic volume, LVID- Left ventricular end-diastolic dimension, LVIS-Left ventricular end-systolic dimension, MR- Mitral regurgitation.
Fig. 4
Fig. 4
Follow up. The narrowing of the intrinsic QRS within 8 months of LVOP can be clearly noticed. LVOP- LV only pacing.
See this image and copyright information in PMC

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