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Association of ECG characteristics with clinical and echocardiographic outcome to CRT in a non-LBBB patient population

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Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Purpose

Effectiveness of cardiac resynchronization therapy (CRT) in patients without left bundle branch block (non-LBBB) QRS morphology is limited. Additional selection criteria are needed to identify these patients.

Methods

Seven hundred ninety consecutive patients with non-LBBB morphology, who received a CRT-device in 3 university centers in the Netherlands, were selected. Pre-implantation 12-lead ECGs were evaluated on morphology, duration, and area of the QRS complex, as well as on PR interval, left ventricular activation time (LVAT), and the presence of fragmented QRS (fQRS). Association of these ECG features with the primary endpoint: a combination of left ventricular assist device (LVAD) implantation, cardiac transplantation and all-cause mortality, and secondary endpoint—echocardiographic reduction of left ventricular end-systolic volume (LVESV)—were evaluated.

Results

The primary endpoint occurred more often in non-LBBB patients with with PR interval ≥ 230ms, QRS area < 109μVs, and with fQRS. Multivariable regression analysis showed independent associations of QRS area (HR 2.33 [1.44, 3.77], p = 0.001) and PR interval (HR 2.03 [1.51, 2.74], p < 0.001) only. Mean LVESV reduction was significantly lower in patients with baseline RBBB, QRS duration < 150 ms, PR interval ≥ 230 ms, and in QRS area < 109 μVs. Multivariable regression analyses only showed significant associations between QRS area ≥ 109 μVs (OR 2.00 [1.09, 3.66] p = 0.025) and probability of echocardiographic response to CRT.

Conclusions

In the heterogeneous non-LBBB patient population, QRS area and PR prolongation rather than traditional QRS duration and morphology are associated to both clinical and echocardiographic outcomes of CRT.

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Author notes

  1. Muhammet Dural and Antonius M. W. van Stipdonk contributed equally to this work.

Authors and Affiliations

  1. Department of Cardiology, Eskişehir Osmangazi University Faculty of Medicine, 26040, Odunpazarı, Eskişehir, Turkey

    Muhammet Dural

  2. Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht, the Netherlands

    Antonius M. W. van Stipdonk, Floor. C. W. M. Salden, Harry J. G. M. Crijns & Kevin Vernooy

  3. Department of Cardiology, University Medical Centre Utrecht, Utrecht, the Netherlands

    Iris Ter Horst & Mathias Meine

  4. Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands

    Alexander H. Maass & Mariëlle Kloosterman

  5. Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands

    Kevin Vernooy

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  1. Muhammet Dural
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Supplementary Figure 1

Example of ECG-parameters in non-LBBB. Figure including normal 12-lead ECG on left and respesentative ECG-parameters evaluated in non-LBBB patients in the current study. ECG parameters included from upper-left to lower right box are; (1) QRS morphology with example of lead V1 RSR pattern indicative of RBBB morphology, (2) QRS duration measurement, (3) PR interval measurement with evident PR prolongation in example, (4) QRS area measurement with vector X-axis displayed. QRS area requiring area measurement in X-, Y- and Z-axis and calculation of total QRS area according to formula: (QRS areaX2 + QRS areaY2 + QRS areaZ2)1/2, (5) fQRS assessment and (6) LVAT measurement from notch or slurring to end of the QRS complex. The 12-lead ECG is representative of the QRS duration, QRS area and LVAT measurement. fQRS fragmented QRS, LVAT left ventricular activation time, non-LBBB non-left bundle branch block, RBBB right bundle branch block.(PNG 176 kb)

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Dural, M., van Stipdonk, A.M.W., Salden, F.C.W.M. et al. Association of ECG characteristics with clinical and echocardiographic outcome to CRT in a non-LBBB patient population. J Interv Card Electrophysiol 62, 9–19 (2021). https://doi.org/10.1007/s10840-020-00866-z

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