title: 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.
abstract: 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.
authors.affiliation: Hôpital Cardiologique du Haut Lévêque, CHU Bordeaux, Université Bordeaux 2 Victor Segalen, Pessac, France. dervalnicolas@gmail.com
authors.forename: Nicolas
authors.initials: N
authors.lastname: Derval
authors.forename: Paul
authors.initials: P
authors.lastname: Steendijk
authors.forename: Lorne J
authors.initials: LJ
authors.lastname: Gula
authors.forename: Antoine
authors.initials: A
authors.lastname: Deplagne
authors.forename: Julien
authors.initials: J
authors.lastname: Laborderie
authors.forename: Frederic
authors.initials: F
authors.lastname: Sacher
authors.forename: Sebastien
authors.initials: S
authors.lastname: Knecht
authors.forename: Matthew
authors.initials: M
authors.lastname: Wright
authors.forename: Isabelle
authors.initials: I
authors.lastname: Nault
authors.forename: Sylvain
authors.initials: S
authors.lastname: Ploux
authors.forename: Philippe
authors.initials: P
authors.lastname: Ritter
authors.forename: Pierre
authors.initials: P
authors.lastname: Bordachar
authors.forename: Stephane
authors.initials: S
authors.lastname: Lafitte
authors.forename: Patricia
authors.initials: P
authors.lastname: Réant
authors.forename: George J
authors.initials: GJ
authors.lastname: Klein
authors.forename: Sanjiv M
authors.initials: SM
authors.lastname: Narayan
authors.forename: Stephane
authors.initials: S
authors.lastname: Garrigue
authors.forename: Mélèze
authors.initials: M
authors.lastname: Hocini
authors.forename: Michel
authors.initials: M
authors.lastname: Haissaguerre
authors.forename: Jacques
authors.initials: J
authors.lastname: Clementy
authors.forename: Pierre
authors.initials: P
authors.lastname: Jaïs
mesh_terms: 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