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.
OBJECTIVE
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.
Derval
Nicolas
N
Hôpital Cardiologique du Haut Lévêque, CHU Bordeaux, Université Bordeaux 2 Victor Segalen, Pessac, France. dervalnicolas@gmail.com
Steendijk
Paul
P
Gula
Lorne J
LJ
Deplagne
Antoine
A
Laborderie
Julien
J
Sacher
Frederic
F
Knecht
Sebastien
S
Wright
Matthew
M
Nault
Isabelle
I
Ploux
Sylvain
S
Ritter
Philippe
P
Bordachar
Pierre
P
Lafitte
Stephane
S
Réant
Patricia
P
Klein
George J
GJ
Narayan
Sanjiv M
SM
Garrigue
Stephane
S
Hocini
Mélèze
M
Haissaguerre
Michel
M
Clementy
Jacques
J
Jaïs
Pierre
P
D000368:Aged; D002304:Cardiac Pacing, Artificial; D054326:Coronary Sinus; D005260:Female; D006333:Heart Failure / Q000628:therapy*; D006352:Heart Ventricles; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial