Right ventricular lead adjustment in cardiac resynchronization therapy and acute hemodynamic response: a pilot study
Optimal left ventricular (LV) lead position has emerged as an important determinant of response after cardiac resynchronization therapy (CRT). Comparatively, strategy for right ventricular (RV) lead optimization remains uncertain.
Three variations of RV lead position (apex, mid-septal, and high septal) were tested in seven consecutive patients. At each location, intra-procedural measurement of LV lead electrical delay (LVLED) was obtained during intrinsic rhythm and RV pacing (RV-LVLED). Simultaneous cardiac output assessment was performed using the LiDCO™ (lithium chloride indicator dilution) system. Final RV lead location was selected based on best-measured cardiac output. Clinical and echocardiographic outcomes were assessed at baseline and 6 months.
Adjustment of RV lead position after securing a LV lead site led to an incremental change of 30 ± 18 % (range, 7–52 %) in the cardiac index (CI). There was substantial variation in acute hemodynamic response (∆CI, 14 ± 13 %; range, 3–41 %) seen with pacing from each patient’s worst to best RV lead position; no single RV lead position emerged as optimal across all patients. Paced RV-LVLED was not correlated with percent change in CI (r = 0.18; p = NS). LV ejection fraction (LVEF) increased significantly (28 ± 4 to 40 ± 8 %, p = 0.006) at 6 months. LVLED measured during intrinsic rhythm, but not during RV pacing, correlated with percent change in LVEF (r = 0.88, p = 0.02).
RV lead position adjustment can be used to enhance acute hemodynamic response during CRT. Measurement of paced RV-LVLED, however, does not reliably predict change in cardiac output.
KeywordsCardiac resynchronization therapy Right ventricular lead position Left ventricular lead position Left ventricular lead electrical delay Hemodynamic response
Cardiac resynchronization therapy
Left ventricular lead electrical delay
RV-LV interlead electrical delay
LV ejection fraction
New York Heart Association
Minnesota living with heart failure questionnaire
This study was supported in part by a research grant from Medtronic Inc.
Conflict of interest
Christine Cavaliere is an employee of and receives salary support from Medtronic. E. Kevin Heist receives honoraria from Biotronik, Boston Scientific, Medtronic, St. Jude Medical, and Sorin group; receives research grants from Biotronik, St. Jude Medical, and Boston Scientific; and is consultant to Boston Scientific, St. Jude Medical, and Sorin group (all modest). Kimberly A. Parks received honoraria from Sorin Group and Research grants from Medtronic, St. Jude Medical, and Sorin Group. Jagmeet P Singh has received research grants from St. Jude Medical, Medtronic Inc., Boston Scientific Corp., and Biotronik; has received honoraria/speaker fees from Medtronic Inc., Biotronik, Guidant Corp, Sorin group, and St. Jude Medical; and has served on advisory Board/Steering Committee and as consultant to Boston Scientific Corp., Biotronik, St. Jude Medical, Medtronic, Sorin Group, Cardioinsight, and Thoratec Inc. All other authors have no potential conflicts of interest.
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