Adaptive Cardiac Resynchronization Therapy Effect on Electrical Dyssynchrony (aCRT-ELSYNC): A randomized controlled trial

Kazi T Haq, Nichole M Rogovoy, Jason A Thomas, Christopher Hamilton, Katherine J Lutz, Ashley Wirth, Aron B Bender, David M German, Ryle Przybylowicz, Peter van Dam, Thomas A Dewland, Khidir Dalouk, Eric Stecker, Babak Nazer, Peter M Jessel, Karen S MacMurdy, Ignatius Gerardo E Zarraga, Bassel Beitinjaneh, Charles A Henrikson, Merritt Raitt, Cristina Fuss, Maros Ferencik, Larisa G Tereshchenko, Kazi T Haq, Nichole M Rogovoy, Jason A Thomas, Christopher Hamilton, Katherine J Lutz, Ashley Wirth, Aron B Bender, David M German, Ryle Przybylowicz, Peter van Dam, Thomas A Dewland, Khidir Dalouk, Eric Stecker, Babak Nazer, Peter M Jessel, Karen S MacMurdy, Ignatius Gerardo E Zarraga, Bassel Beitinjaneh, Charles A Henrikson, Merritt Raitt, Cristina Fuss, Maros Ferencik, Larisa G Tereshchenko

Abstract

Background: Adaptive cardiac resynchronization therapy (aCRT) is known to have clinical benefits over conventional CRT, but the mechanisms are unclear.

Objective: Compare effects of aCRT and conventional CRT on electrical dyssynchrony.

Methods: A prospective, double-blind, 1:1 parallel-group assignment randomized controlled trial in patients receiving CRT for routine clinical indications. Participants underwent cardiac computed tomography and 128-electrode body surface mapping. The primary outcome was change in electrical dyssynchrony measured on the epicardial surface using noninvasive electrocardiographic imaging before and 6 months post-CRT. Ventricular electrical uncoupling (VEU) was calculated as the difference between the mean left ventricular (LV) and right ventricular (RV) activation times. An electrical dyssynchrony index (EDI) was computed as the standard deviation of local epicardial activation times.

Results: We randomized 27 participants (aged 64 ± 12 years; 34% female; 53% ischemic cardiomyopathy; LV ejection fraction 28% ± 8%; QRS duration 155 ± 21 ms; typical left bundle branch block [LBBB] in 13%) to conventional CRT (n = 15) vs aCRT (n = 12). In atypical LBBB (n = 11; 41%) with S waves in V5-V6, conduction block occurred in the anterior RV, as opposed to the interventricular groove in strict LBBB. As compared to baseline, VEU reduced post-CRT in the aCRT (median reduction 18.9 [interquartile range 4.3-29.2 ms; P = .034]), but not in the conventional CRT (21.4 [-30.0 to 49.9 ms; P = .525]) group. There were no differences in the degree of change in VEU and EDI indices between treatment groups.

Conclusion: The effect of aCRT and conventional CRT on electrical dyssynchrony is largely similar, but only aCRT harmoniously reduced interventricular dyssynchrony by reducing RV uncoupling.

Keywords: AV optimization; Bundle branch block; CRT; Dyssynchrony; ECGI; Electrocardiographic imaging; Heart failure; Noninvasive mapping; Randomized controlled trial; Ventricular conduction abnormalities.

© 2021 Heart Rhythm Society. Published by Elsevier Inc.

Figures

Graphical abstract
Graphical abstract
Figure 1
Figure 1
Study workflow. A: Computed tomography (CT) scan or cardiac magnetic resonance (CMR) provided the geometry of the ventricles and the torso. Images underwent segmentation, structure identification, geometric modeling, and meshing. The 3-D meshes of the ventricles and torso were created. B: Body surface potential (BSP) was recorded using the 128 electrodes. Three-dimensional photography was used to record the electrodes locations on a torso. The torso geometric models based on the 3-D photography and CT/CMR were co-registered. C: Epicardial electrogram (EGM) reconstruction using the SCIRun inverse solution module. Local activation for each epicardial node was obtained as the point of the steepest downward slope (minimum dV/dt) of the corresponding EGM. An epicardial activation map was generated.
Figure 2
Figure 2
Study flowchart.
Figure 3
Figure 3
Change in the ventricular electrical uncoupling (VEU) between 2 study visits (green line) in every randomized study participant (green dot), in (A) conventional cardiac resynchronization therapy (CRT) and (B) adaptive CRT arms.

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Source: PubMed

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