Effect of Interventricular Electrical Delay on Atrioventricular Optimization for Cardiac Resynchronization Therapy

Michael R Gold, Yinghong Yu, Jagmeet P Singh, Ulrika Birgersdotter-Green, Kenneth M Stein, Nicholas Wold, Timothy E Meyer, Kenneth A Ellenbogen, Michael R Gold, Yinghong Yu, Jagmeet P Singh, Ulrika Birgersdotter-Green, Kenneth M Stein, Nicholas Wold, Timothy E Meyer, Kenneth A Ellenbogen

Abstract

Background: Routine atrioventricular optimization (AVO) has not been shown to improve outcomes with cardiac resynchronization therapy (CRT). However, more recently subgroup analyses of multicenter CRT trials have identified electrocardiographic or lead positions associated with benefit from AVO. Therefore, the purpose of this analysis was to evaluate whether interventricular electrical delay modifies the impact of AVO on reverse remodeling with CRT.

Methods: This substudy of the SMART-AV trial (SMARTDELAY Determined AV Optimization) included 275 subjects who were randomized to either an electrogram-based AVO (SmartDelay) or nominal atrioventricular delay (120 ms). Interventricular delay was defined as the time between the peaks of the right ventricular (RV) and left ventricular (LV) electrograms (RV-LV duration). CRT response was defined prospectively as a >15% reduction in LV end-systolic volume from implant to 6 months.

Results: The cohort was 68% men, with a mean age of 65±11 years and LV ejection fraction of 28±8%. Longer RV-LV durations were significantly associated with CRT response ( P<0.01) for the entire cohort. Moreover, the benefit of AVO increased as RV-LV duration prolonged. At the longest quartile, there was a 4.26× greater odds of a remodeling response compared with nominal atrioventricular delays ( P=0.010).

Conclusions: Baseline interventricular delay predicted CRT response. At long RV-LV durations, AVO can increase the likelihood of reverse remodeling with CRT. AVO and LV lead location optimized to maximize interventricular delay may work synergistically to increase CRT response.

Clinical trial registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00874445.

Keywords: cardiac resynchronization therapy; heart failure; heart ventricles; treatment outcome.

Figures

Figure 1.
Figure 1.
Two examples of right ventricular (RV)-left ventricular (LV) duration measurements in study patients. The calipers are aligned with the peaks of the RV and LV electrogram (EGM).
Figure 2.
Figure 2.
The relationship of atrioventricular optimization (AVO) subgroups and right ventricular-left ventricular duration on the percentage change in left ventricular end-systolic volume (LVESV).
Figure 3.
Figure 3.
Multivariable logistic regression model of the impact of SD on cardiac resynchronization therapy response as defined by >15% decrease in left ventricular end-systolic volume (LVESV). The LVESV responses of AVO (SD) vs fixed AV delay are shown at different right ventricular-left ventricular cutoffs after adjusting for baseline ejection fraction, LVESV, pathogenesis of heart failure, left bundle branch block (LBBB), sex, NYHA (New York Heart Association classification), QRS, and age. AVO indicates atrioventricular optimization; CI, confidence interval; and OR, odds ratio.
Figure 4.
Figure 4.
Univariable logistic regression results for cardiac resynchronization therapy (CRT) response at right ventricular (RV)-left ventricular (LV) duration < 70 ms (A) and RV-LV ≥ 70 ms (B) by subgroups. CRT response as defined by >15% decrease in left ventricular end-systolic volume. AVO indicates atrioventricular optimization; CI, confidence interval; and OR, odds ratio.

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