First experience of intraoperative echocardiography-guided optimization of cardiac resynchronization therapy delivery.
BACKGROUND
Insufficient correction of mechanical dyssynchrony is a cause of non-response to cardiac resynchronization therapy (CRT).


OBJECTIVE
To determine if CRT delivery could be optimized during the implantation procedure by choosing the number and location of pacing sites using echocardiography guidance.


METHODS
In patients with a QRS ≥ 150 ms or a QRS < 150 ms and criteria for mechanical dyssynchrony, the objective of the implantation procedure was to shorten the left pre-ejection interval (LPEI), measured online, by at least 10 ms compared with standard biventricular configuration, by moving the right ventricular (RV) lead at different locations and, if necessary, by adding a second RV lead.


RESULTS
Ninety-one patients (70 men; mean age 73 ± 10 years; left ventricular [LV] ejection fraction 29 ± 10%) were included. The final pacing configuration was standard biventricular in 15 (17%) patients, optimized biventricular in 22 (24%) and triple-site ventricular in 54 (59%). LPEI was shortened by ≥ 10 ms compared with standard biventricular stimulation in 73 (80%) patients. Compared with standard biventricular pacing, the final optimized pacing configuration improved global intraventricular synchrony (decreasing LPEI from 158 ± 36 ms to 134 ± 29 ms; P<0.001), LV systolic efficiency (decreasing LPEI/LV ejection time from 0.58 ± 0.18 to 0.46 ± 0.13; P<0.001) and LV filling (increasing LV filling time/RR from 44 ± 8% to 47 ± 7%; P<0.001) and decreased mitral valve regurgitation.


CONCLUSIONS
Intraoperative echocardiography-guided placement of RV lead(s) during CRT implantation is feasible and acutely improves LV synchrony compared with standard biventricular stimulation.
Department of Pacing and Interventional Electrophysiology, Groupe Hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France. Electronic address: ghassan.moubarak@gmail.com.
Ghassan
G
Moubarak
Department of Cardiology, Haut-Lévèque Hospital, Bordeaux University Hospital, 33600 Pessac, France.
Philippe
P
Ritter
Department of Cardiology and Vascular Medicine, Pontchaillou University Hospital, 35000 Rennes, France.
Jean-Claude
JC
Daubert
Department of Pacing and Interventional Electrophysiology, Groupe Hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France.
Serge
S
Cazeau
D000368:Aged; D001145:Arrhythmias, Cardiac / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000628:therapy*; D058406:Cardiac Resynchronization Therapy / Q000379:methods*; D058409:Cardiac Resynchronization Therapy Devices; D002317:Cardiovascular Agents / Q000627:therapeutic use; D003131:Combined Modality Therapy; D004567:Electrodes, Implanted; D005260:Female; D006801:Humans; D007430:Intraoperative Care; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D019919:Prosthesis Implantation / Q000379:methods*; D013318:Stroke Volume; D018084:Ultrasonography, Interventional; D016277:Ventricular Function, Left
D002317:Cardiovascular Agents
Cardiac resynchronization therapy; Délai pré-éjectionnel gauche; Désynchronisation mécanique; Intraoperative echocardiography; Left pre-ejection interval; Mechanical dyssynchrony; Stimulation triple-site ventriculaire; Thérapie de resynchronisation cardiaque; Triple-site ventricular stimulation; Échocardiographie peropératoire