Differential effect with septal and apical RV pacing on ventricular activation in patients with left bundle branch block assessed by non-invasive electrical imaging and in silico modelling

T Jackson, S Claridge, J Behar, B Sieniewicz, J Gould, B Porter, B Sidhu, C Yao, A Lee, S Niederer, C A Rinaldi, T Jackson, S Claridge, J Behar, B Sieniewicz, J Gould, B Porter, B Sidhu, C Yao, A Lee, S Niederer, C A Rinaldi

Abstract

Purpose: It is uncertain whether right ventricular (RV) lead position in cardiac resynchronization therapy impacts response. There has been little detailed analysis of the activation patterns in RV septal pacing (RVSP), especially in the CRT population. We compare left bundle branch block (LBBB) activation patterns with RV pacing (RVP) within the same patients with further comparison between RV apical pacing (RVAP) and RVSP.

Methods: Body surface mapping was undertaken in 14 LBBB patients after CRT implantation. Nine patients had RVAP, 5 patients had RVSP. Activation parameters included left ventricular total activation time (LVtat), biventricular total activation time (VVtat), interventricular electrical synchronicity (VVsync), and dispersion of left ventricular activation times (LVdisp). The direction of activation wave front was also compared in each patient (wave front angle (WFA)). In silico computer modelling was applied to assess the effect of RVAP and RVSP in order to validate the clinical results.

Results: Patients were aged 64.6 ± 12.2 years, 12 were male, 8 were ischemic. Baseline QRS durations were 157 ± 18 ms. There was no difference in VVtat between RVP and LBBB but a longer LVtat in RVP (102.8 ± 19.6 vs. 87.4 ± 21.1 ms, p = 0.046). VVsync was significantly greater in LBBB (45.1 ± 20.2 vs. 35.9 ± 17.1 ms, p = 0.01) but LVdisp was greater in RVP (33.4 ± 5.9 vs. 27.6 ± 6.9 ms, p = 0.025). WFA did rotate clockwise with RVP vs. LBBB (82.5 ± 25.2 vs. 62.1 ± 31.7 op = 0.026). None of the measurements were different to LBBB with RVSP; however, the differences were preserved with RVAP for VVsync, LVdisp, and WFA. In silico modelling corroborated these results.

Conclusions: RVAP activation differs from LBBB where RVSP appears similar.

Trial registration: (ClinicalTrials.gov identifier: NCT01831518).

Keywords: Body surface mapping; Cardiac resynchronization therapy; Computer modelling; Left bundle branch block; RV septal pacing.

Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
Screenshot of calculation of wave front angle. On-screen protractor (Protractor Version 10.0, Softlibs) superimposed on the activation map. The predominant wave front angle is then measured (pink dashed lines); the angle of the same isochrones is then directly compared between the right ventricular pacing map and the LBBB map as both activation maps are identically aligned
Fig. 2
Fig. 2
Box and whisker plots for activation times and wave front angles for intrinsic left bundle branch block (LBBB) and right ventricular pacing (RVP). VVsync—right/left ventricular electrical synchrony, VVtat—biventricular total activation time, LVtat—left ventricular total activation time, LVdisp—left ventricular dispersion of activation, WFA—wave front angle
Fig. 3
Fig. 3
Individual changes in activation times and wave from angles. The black dots represent right ventricular apical pacing and the red squares represent right ventricular septal pacing. Abbreviations as per Fig. 2
Fig. 4
Fig. 4
Sixteen segment American Heart Association models depicting the absolute number and percentage of patients with each segment as the final or one of the final activated segment(s) in intrinsic LBBB, right ventricular pacing (RVP), right ventricular septal pacing, and right ventricular apical pacing
Fig. 5
Fig. 5
The spread of electrical activation was simulated in intrinsic LBBB, pacing at the RV apex at anterior (RVAP-A), middle (RVAP-M) and posterior (RVAP-P) sites, and pacing at the mid wall of the RV septum (RVSP). The latest activation regions (black circles) are shown on the 16 segment American Heart Association models of the activation across the LV epicardium and endocardium
Fig. 6
Fig. 6
Schematic representation of the activation patterns seen in right ventricular apical pacing in red and LBBB/right ventricular septal pacing in blue

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