The influence of right ventricular pacing on response to biventricular stimulation

1. The influence of right ventricular pacing on response to biventricular stimulation -An acute pressure-volume loop study- L. Wu, MD; C.P. Allaart, MD, PhD; G.J. de Roest, MD; M.L. Hendriks, MA; A.C. van Rossum, MD, PhD; C.C. de Cock MD, PhD ACC Scientific Sessions, San Francisco, CA 9 March 2013

2. Cardiac resynchronization therapy • Standard therapy in end-stage heart failure • LV only versus biventricular pacing p=0.001 Leclercq et al. JACC 2002 Thibault et al., Circ 2011 Kass et al., Circ 1999

3. Cardiac resynchronization therapy • Contribution RV only pacing? • Detrimental effects on LV • In LBBB patients • Higher degree of mechanical dyssynchrony • Decrease in contractility Thambo et al., Circ 2004 Sweeney et al., JACC 2006 Auricchio et al., JACC 2002 Tops et al., JACC 2009

4. Aim • To investigate the influence of RV pacing on hemodynamic response during biventricular stimulation

5. Methods • Patients eligible for CRT • Temporary pacing leads • Conductance measurements RA lead PL lead Conductance catheter RV lead

6. Pressure-volume loop Baseline RV only LV only Biventricular

7. Results

8. Acute effect of pacing on SW p=NS p<0.001 p=NS p<0.001

9. Acute effect of pacing on dP/dtmax p=NS p=NS p=0.002 p<0.001

10. Correlation RV only and Biv response Biv gives a larger SW improvement than LV only ∆ SW Biv - ∆ SW LV only (%) LV only gives a larger SW improvement than Biv

11. Clinical consequences • Response > 20% SW increase Responders 68% de Roest et al., Eur J HF 2012

12. SW improvement < 20% 52% better SW response 34% responders Non-responders Biv LV only

13. Conclusion Acute SW change during CRT is significantly modulated by RV pacing The amount of modulation is similar to the SW response during RV pacing Addition of RV pacing to LV pacing may positively or negatively affect outcome In CRT non-responders, the effect of switching off RV pacing should be evaluated individually

14. Acknowledgement • VU University Medical Center Amsterdam • C.P. Allaart, MD, PhD • G.J. de Roest, MD • M.T. Rijnierse, MD • M.L. Hendriks, MA • A.C. van Rossum, MD, PhD • C.C. de Cock, MD, PhD Thank you!

15. SW response to Biv pacing

16. SW response to LV pacing

17. Non-response • Reverse response > 20% SW decrease Reverse responders 21%

18. Correlation dP/dtmax Biv gives a larger SW improvement than LV only ∆ SW Biv - ∆ SW LV only (%) ∆SW RV (%) LV only gives a larger SW improvement than Biv