title: Optimizing sequential biventricular pacing using radionuclide ventriculography.
abstract: BACKGROUND
  Biventricular pacemakers are usually programmed with the default setting of synchronous biventricular pacing, although the ventricles may be paced sequentially. Whether this parameter is important for optimizing resynchronization therapy is not clear.
  
  
  OBJECTIVE
  The purpose of this study was to investigate whether sequential pacing acutely improves left ventricular ejection fraction (LVEF) and dyssynchrony and to assess the feasibility of nuclear ventriculography for device optimization.
  
  
  METHODS
  Twenty-seven patients implanted with a biventricular pacemaker or implantable cardioverter-defibrillator for heart failure were studied. LVEF was measured using planar radionuclide ventriculography during simultaneous biventricular pacing and during sequential pacing at four different interventricular intervals ranging from LV-40 (preexciting the left ventricle by 40 ms) to LV+40 (preexciting the right ventricle). Interventricular and intraventricular dyssynchrony were analyzed by phase analysis at each setting.
  
  
  RESULTS
  There was great heterogeneity in individual response to VV interval programming. Twenty-four of 27 patients (89%) had significant changes (both favorable and unfavorable) in LVEF at different interventricular delays, with variations of up to 10% in absolute terms. Simultaneous biventricular pacing yielded maximal LVEF in 9 of 27 patients (33%), with a relative increase in LVEF of 18 +/- 14% by optimized sequential pacing in the remaining patients. Interventricular dyssynchrony varied significantly, with least dyssynchrony at the LV-20 setting (P = .024). There were no significant differences in intraventricular dyssynchrony at the different settings.
  
  
  CONCLUSIONS
  Programming VV intervals has considerable impact on LVEF. However, there is a great degree of variation between patients in response to these settings, requiring individual assessment for device optimization.
authors.affiliation: Cardiology Service, Geneva University Hospitals, Geneva, Switzerland. haran.burri@hcuge.ch
authors.forename: Haran
authors.initials: H
authors.lastname: Burri
authors.forename: Henri
authors.initials: H
authors.lastname: Sunthorn
authors.forename: Aernout
authors.initials: A
authors.lastname: Somsen
authors.forename: Stéphane
authors.initials: S
authors.lastname: Zaza
authors.forename: Eric
authors.initials: E
authors.lastname: Fleury
authors.forename: Dipen
authors.initials: D
authors.lastname: Shah
authors.forename: Alberto
authors.initials: A
authors.lastname: Righetti
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002304:Cardiac Pacing, Artificial / Q000379:methods; D017147:Defibrillators, Implantable; D005240:Feasibility Studies; D005260:Female; D006333:Heart Failure / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D015635:Radionuclide Ventriculography; D015203:Reproducibility of Results; D012107:Research Design; D013318:Stroke Volume; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging / Q000503:physiopathology* / Q000628:therapy*