Acute Hemodynamic Effects of Simultaneous and Sequential Multi-Point Pacing in Heart Failure Patients With an Expected Higher Rate of Sub-response to Cardiac Resynchronization Therapy: Results of Multicenter SYNSEQ Study

Abstract

The aim of the SYNSEQ (Left Ventricular Synchronous vs. Sequential MultiSpot Pacing for CRT) study was to evaluate the acute hemodynamic response (AHR) of simultaneous (3P-MPP syn) or sequential (3P-MPP seq) multi-3-point-left-ventricular (LV) pacing vs. single point pacing (SPP) in a group of patients at risk of a suboptimal response to cardiac resynchronization therapy (CRT). Twenty five patients with myocardial scar or QRS ≤ 150 or the absence of LBBB (age: 66 ± 12 years, QRS: 159 ± 12 ms, NYHA class II/III, LVEF ≤ 35%) underwent acute hemodynamic assessment by LV + dP/dtmax with a variety of LV pacing configurations at an optimized AV delay. The change in LV + dP/dt max (%ΔLV + dP/dt max) with 3P-MPP syn (15.6%, 95% CI: 8.8%-22.5%) was neither statistically significantly different to 3P-MPP seq (11.8%, 95% CI: 7.6-16.0%) nor to SPP basal (11.5%, 95% CI:7.1-15.9%) or SPP mid (12.2%, 95% CI:7.9-16.5%), but higher than SPP apical (10.6%, 95% CI:5.3-15.9%, p = 0.03). AHR (defined as a %ΔLV + dP/dt max ≥ 10%) varied between pacing configurations: 36% (9/25) for SPP apical, 44% (11/25) for SPP basal, 54% (13/24) for SPP mid, 56% (14/25) for 3P-MPP syn and 48% (11/23) for 3P-MPP seq.Fifteen patients (15/25, 60%) had an AHR in at least one pacing configuration. AHR was observed in 10/13 (77%) patients with a LBBB but only in 5/12 (42%) patients with a non-LBBB (p = 0.11). To conclude, simultaneous or sequential multipoint pacing compared to single point pacing did not improve the acute hemodynamic effect in a suboptimal CRT response population.

Clinical trial registration: ClinicalTrials.gov, identifier: NCT02914457.

Keywords: acute hemodynamic effect; biventricular pacing; cardiac resynchronization therapy; heart failure; multipoint pacing; quadripolar lead for left ventricle pacing.

Conflict of interest statement

VS, FLem, and BS were employed by the company Medtronic Inc. BM and RC were an employee of Medtronic and holds Medtronic stocks. MS, AM, AS, and FLey they received fees from commercial companies. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Sterliński, Zakrzewska-Koperska, Maciąg, Sokal, Osca-Asensi, Wang, Spyropoulou, Maus, Lemme, Okafor, Stegemann, Cornelussen and Leyva.

Figures

Figure 1

Fluoro-images at AP, LAO 30° and RAO 30° displaying position of the different CRT leads. Note that in this case the vision wire administered through the lumen of the quadripolar was used to obtain true apical position. MPP was delivered on the vision wire, and on the distal and most proximal electrodes of the short bipole of the quadripolar lead.

Figure 2

SYNSEQ study flowchart.

Figure 3

Primary objective: % ΔLV + dPdtmax boxplot at best AV-delay. SPP, RV-LV Single-point pacing and MPP, RV-LV Multi-point pacing. MPPseq, Sequential MPP; MPPsyn, Synchronous (simultaneous) MPP; SPPbasal,mid,apical, SPP from base, mid, apical LV electrode. Solid line depicts the median value, and boxes are 25th and 75th percentile. Whiskers represent the most extreme data point within 1.5x interquartile range from the boxes. Diamonds represent mean value, and dots are outliers.

Figure 4

% change ΔLV + dPdtmax boxplot at best AV-delay in the subgroups LBBB and non-LBBB. SPP, RV-LV Single-point pacing and MPP, RV-LV Multi-point pacing. MPPseq, Sequential MPP; MPPsyn, Synchronous (simultaneous) MPP; SPPbasal,mid,apical, SPP from base, mid, apical LV electrode. Solid line depicts the median value, and boxes are 25th and 75th percentile. Whiskers represent the most extreme data point within 1.5x interquartile range from the boxes. Diamonds represent mean value, and dots are outliers.