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BASIC SCIENCE

Intra-ventricular resynchronization for optimal left ventricular function during pacing in experimental left bundle branch block

^* Department of Physiology, Cardiovascular Research Institute, Maastricht University, Maastricht, The Netherlands

Manuscript received February 7, 2003; revised manuscript received March 27, 2003, accepted April 4, 2003.

^* Reprint requests and correspondence: Dr. Xander Verbeek, Department of Physiology, Cardiovascular Research Institute, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands.
x.verbeek{at}fys.unimaas.nl

OBJECTIVES: We sought to investigate to what extent intra-ventricular asynchrony (intraVA) and inter-ventricular asynchrony (interVA) determine left ventricular (LV) function in canine hearts with left bundle branch block (LBBB) during ventricular pacing.

BACKGROUND: Pacing therapy improves LV pump function in patients with heart failure and abnormal ventricular conduction supposedly due to resynchronization. However, the relationship between LV pump function and measures of asynchrony is not well established.

METHODS: In 15 experiments, LV (various sites) and biventricular (BiV) pacing was performed at atrioventricular (AV) delays of 20 to 140 ms. Measured were the maximum rate of increase (dP/dt_max) of LV pressure and LV stroke work (SW) (conductance catheter), interVA (time delay between the upslope of LV and RV pressures), and intraVA (from endocardial electrical activation maps).

RESULTS: Induction of LBBB increased interVA (–6.4 ± 8.6 to –28.4 ± 8.5 ms [RV earlier]) and intraVA (4.9 ± 2.4 to 18.0 ± 3.3 ms), whereas LV dP/dt_max and SW decreased (–13 ± 18% and –39 ± 24%, respectively). During LBBB, LV and BiV pacing increased LV dP/dt_max and SW (mean increases 14% to 21% and 11% to 15%, respectively) without changing diastolic function or preload. Optimal improvement in LV function was obtained consistently when intraVA returned to pre-LBBB values, while interVA remained elevated. Normalization of intraVA required AV delays shorter than the baseline PQ time during LV apex and BiV pacing, thus excluding endogenous LV activation, but AV delays virtually equal to the baseline PQ time (difference 4 ± 9 ms, p = NS) during pacing at (mid)lateral LV sites to obtain fusion between pacing-induced and endogenous activation.

CONCLUSIONS: In LBBB hearts, optimal restoration of LV systolic function by pacing requires intra-ventricular resynchronization. The optimal AV delay to achieve this depends on both the site of pacing and baseline PQ time.

Abbreviations and Acronyms   ADV   activation delay vector   AV   atrioventricular   BiV   biventricular   dP/dtmax   maximum rate of increase in pressure   dP/dtmin   maximum rate of decrease in pressure   ECG   electrocardiogram or electrocardiographic   interVA   inter-ventricular asynchrony   intraVA   intra-ventricular asynchrony   LBBB   left bundle branch block   LV   left ventricle/ventricular   RV   right ventricle/ventricular   SW   stroke work   TVV   excitation time difference between LV and RV

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