title: Anodal stimulation: an underrecognized cause of nonresponders to cardiac resynchronization therapy.
abstract: OBJECTIVE
  The purpose of this study was to determine if anodal stimulation accounts for failure to benefit from cardiac resynchronization therapy (CRT) in some patients.
  
  
  BACKGROUND
  Approximately 30-40% of patients with moderate to severe heart failure do not have symptomatic nor echocardiographic improvement in cardiac function following CRT. Modern CRT devices allow the option of programming left ventricular (LV) lead pacing as LV tip to right ventricular (RV) lead coil to potentially improve pacing thresholds. However, anodal stimulation can result in unintentional RV pacing (anode) instead of LV pacing (cathode).
  
  
  METHODS
  Patients enrolled in our center's CRT registry had an echocardiogram, 6-minute walk (6MW), and Minnesota Living with HF Questionnaire (MLHFQ) pre-implant and 6 months after CRT. Electrocardiograms (12 lead) during RV, LV, and biventricular (BiV) pacing were obtained at the end of the implant in 102 patients. Anodal stimulation was defined as LV pacing QRS morphology on EKG being identical to RV pacing or consistent with fusion with RV and LV electrode capture. LV end systolic volume (LVESV) was measured by echo biplane Simpson's method and CRT responder was defined as 15% or greater reduction in LVESV.
  
  
  RESULTS
  Of the 102 patients, 46 (45.1%) had the final LV lead pacing configuration programmed LV (tip or ring) to RV (coil or ring). 3 of the 46 subjects (6.5%) had EKG findings consistent with anodal stimulation, not corrected intraoperatively. All anodal stimulation patients were nonresponders to CRT by echo criteria (reduction in LVESV 13.3 ± 0.6%, increase in EF 5.0 ± 1.4%) compared to 46% responders for those without anodal stimulation, (change in LVESV 18.7 ± 25.6%, EF 7.6 ±10.9%). None of the anodal stimulation patients were responders for the 6 minute walk, compared to 32 of 66 (48%) of those without anodal stimulation.
  
  
  CONCLUSIONS
  Anodal stimulation is a potential underrecognized and ameliorable cause of poor response to CRT.
authors.affiliation: Department of Internal Medicine; Mayo Clinic, Rochester, Minnesota.
authors.forename: Khalin F
authors.initials: KF
authors.lastname: Dendy
authors.forename: Brian D
authors.initials: BD
authors.lastname: Powell
authors.forename: Yong-Mei
authors.initials: YM
authors.lastname: Cha
authors.forename: Raul E
authors.initials: RE
authors.lastname: Espinosa
authors.forename: Paul A
authors.initials: PA
authors.lastname: Friedman
authors.forename: Robert F
authors.initials: RF
authors.lastname: Rea
authors.forename: David L
authors.initials: DL
authors.lastname: Hayes
authors.forename: Margaret M
authors.initials: MM
authors.lastname: Redfield
authors.forename: Samuel J
authors.initials: SJ
authors.lastname: Asirvatham