Impact of ventricular arrhythmia management on suboptimal biventricular pacing in cardiac resynchronization therapy

Jan-Hendrik van den Bruck, Melissa Middeldorp, Arian Sultan, Cornelia Scheurlen, Katharina Seuthe, Jonas Wörmann, Karlo Filipovic, Kadhim Kadhim, Prashanthan Sanders, Daniel Steven, Jakob Lüker, Jan-Hendrik van den Bruck, Melissa Middeldorp, Arian Sultan, Cornelia Scheurlen, Katharina Seuthe, Jonas Wörmann, Karlo Filipovic, Kadhim Kadhim, Prashanthan Sanders, Daniel Steven, Jakob Lüker

Abstract

Background: Reduced biventricular pacing (BiVP) is a common phenomenon in cardiac resynchronization therapy (CRT) with impact on CRT-response and patients' prognosis. Data on treatment strategies for patients with ventricular arrhythmia and BiVP reduction is sparse. We sought to assess the effects of ventricular arrhythmia treatment on BiVP.

Methods: In this retrospective analysis, the data of CRT patients with a reduced BiVP ≤ 97% due to ventricular arrhythmia were analyzed. Catheter ablation or intensified medical therapy was performed to optimize BiVP.

Results: We included 64 consecutive patients (73 ± 10 years, 89% male, LVEF 30 ± 7%). Of those, 22/64 patients (34%) underwent ablation of premature ventricular contractions (PVC) and 15/64 patients (23%) underwent ventricular tachycardia (VT) ablation while 27/64 patients (42%) received intensified medical treatment. Baseline BiVP was 88.1% ± 10.9%. An overall increase in BiVP percentage points of 8.8% (range - 5 to + 47.6%) at 6-month follow-up was achieved. No changes in left ventricular function were observed but improvement in BiVP led to an improvement in NYHA class in 24/64 patients (38%). PVC ablation led to a significantly better improvement in BiVP [9.9% (range 4 to 22%) vs. 3.2% (range - 5 to + 10.7%); p = < 0.001] and NYHA class (12/22 patients vs. 4/27 patients; p = 0.003) than intensified medical therapy. All patients with VT and reduced BiVP underwent VT ablation with an increase of BiVP of 16.3 ± 13.4%.

Conclusion: In this evaluation of ventricular arrhythmia treatment aiming for CRT optimization, both medical therapy and catheter ablation were shown to be effective. Compared to medical therapy, a higher increase in BiVP was observed after PVC ablation, and more patients improved in NYHA class.

Clinical trial registration: The study was registered at clinical trials.org in August 2019: NCT04065893.

Keywords: Catheter ablation for Optimization of biventricular pacing; Catheter ablation of ventricular ectopy; Optimization of Cardiac resynchronization therapy.

Conflict of interest statement

The authors declare no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Study design. A total of 64 CRT patients (pts) presented a reduced biventricular pacing (BiVP) percentage ≤ 97% due to ventricular arrhythmia. Of those in 49/64 pts, BiVP was impaired by ventricular ectopy. Consequently, 22/49 pts underwent ablation of ventricular ectopy and 27/49 received intensified medical therapy aiming for optimization of BiVP. All pts with BiVP reduction due to ventricular tachycardia (VT) underwent VT ablation
Fig. 2
Fig. 2
Impact of PVC ablation and intensified medical treatment biventricular pacing percentage. After PVC ablation an overall increase of 9.9 ± 4.8% was achieved resulting in a mean BiVP of 98.2 ± 1.2%. In 16/22 patients (73%), the target range of a BiVP percentage ≥ 98% was reached. After an intensified treatment, an increase of 3.2% (range − 5 to + 10.7%) was achieved resulting in a mean BiVP of 95.5 ± 2.9%. In 6 pts (22%), the target range of a BiVP percentage ≥ 98% was reached
Fig. 3
Fig. 3
Impact of PVC ablation and intensified medical therapy on NYHA class. After PVC ablation, the functional status of 12/22 patients (55%) improved from NYHA class III to NYHA class II. After an intensified medical treatment, the functional status of 2/27 patients (7%) improved from NYHA class III to NYHA class II

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