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Optimizing Hemodynamics in Heart Failure Patients by Systematic Screening of Left Ventricular Pacing Sites

The Lateral Left Ventricular Wall and the Coronary Sinus Are Rarely the Best Sites

Nicolas Derval, MD^_*,_*, Paul Steendijk, PhD, Lorne J. Gula, MD, Antoine Deplagne, MD^_*, Julien Laborderie, MD^_*, Frederic Sacher, MD^_*, Sebastien Knecht, MD^_*, Matthew Wright, PhD^_*, Isabelle Nault, MD^_*, Sylvain Ploux, MD^_*, Philippe Ritter, MD^_*, Pierre Bordachar, MD^_*, Stephane Lafitte, MD, PhD^_*, Patricia Réant, MD^_*, George J. Klein, MD, Sanjiv M. Narayan, MD, Stephane Garrigue, MD^_*, Mélèze Hocini, MD^_*, Michel Haissaguerre, MD^_*, Jacques Clementy, MD^_* and Pierre Jaïs, MD^_*

^_* Hôpital Cardiologique du Haut Lévêque, CHU Bordeaux, Université Bordeaux 2 Victor Segalen, Pessac, France
Leiden University Medical Center, Leiden, the Netherlands
Arrhythmia Department, University of Western Ontario, London, Ontario, Canada; and the
University of California and Veterans Affairs Medical Center, San Diego, California

Manuscript received April 26, 2009; revised manuscript received August 17, 2009, accepted August 26, 2009.

^_* Reprints and correspondence: Dr. Nicolas Derval, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, 1, Avenue Magellan, 33600 Pessac, France (Email: dervalnicolas{at}gmail.com).

Objectives: We sought to evaluate the impact of the left ventricular (LV) pacing site on hemodynamic response to cardiac resynchronization therapy (CRT).

Background: CRT reduces morbidity and mortality in heart failure patients. However, 20% to 40% of eligible patients may not fully benefit from CRT device implantation. We hypothesized that selecting the optimal LV pacing site could be critical in this issue.

Methods: Thirty-five patients with nonischemic dilated cardiomyopathy referred for CRT device implantation were studied. Intraventricular dyssynchrony and latest activated LV wall were defined by tissue Doppler imaging analysis before the study. Eleven predetermined LV pacing sites were systematically assessed in random order: basal and mid-cavity (septal, anterior, lateral, inferior), apex, coronary sinus (CS), and the endocardial site facing the CS pacing site. For each patient, +dP/dT_max, –dP/dT_min, pulse pressure, and end-systolic pressure during baseline (AAI) and DDD LV pacing were compared. Two atrioventricular delays were tested.

Results: Major interindividual and intraindividual variations of hemodynamic response depending on the LV pacing site were observed. Compared with baseline, LV DDD pacing at the best LV position significantly improved +dP/dT_max (+31 ± 26%, p < 0.001) and was superior to pacing the CS (+15 ± 23%, p < 0.001), the lateral LV wall (+18 ± 22%, p < 0.001), or the latest activated LV wall (+11 ± 17%, p < 0.001).

Conclusions: The pacing site is a primary determinant of the hemodynamic response to LV pacing in patients with nonischemic dilated cardiomyopathy. Pacing at the best LV site is associated acutely with fewer nonresponders and twice the improvement in +dP/dT_max observed with CS pacing.

Key Words: heart failure • resynchronization • pacing • hemodynamic

Abbreviations and Acronyms   AVD = atrioventricular delay   BiV = biventricular   CRT = cardiac resynchronization therapy   CS = coronary sinus   ESP = end-systolic pressure   LV = left ventricular   PP = pulse pressure   TDI = tissue Doppler imaging

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