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Non-invasive assessment of ventricular electrical heterogeneity to optimize left bundle branch area pacing

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Abstract

Background

Left bundle branch area pacing (LBBAP) is a novel therapeutic option for bradycardia and heart failure patients. ECG belt is a novel technology for assessment of ventricular electrical heterogeneity (VEH) using multi-electrode ECG. A metric of overall VEH based on standard deviation of activation times (SDAT) from all electrodes in the ECG belt has been previously shown to predict cardiac resynchronization therapy (CRT) response. The aim of the study is to evaluate non-invasive assessment of VEH using ECG belt to optimize LBBAP.

Methods

VEH from a 40-electrode ECG belt was characterized in 20 patients (male 15, EF 33 ± 13%, NYHA class 3.05 ± 0.6; CRT indication 18) during LBBAP (20) and LBBAP-Optimized CRT (LOT-CRT-7), anodal capture (16), NS-LBBP (18), S-LBBP (5), LVSP (9). In addition to SDAT, regional (LV/RV) VEH was assessed with average left ventricular activation times (LVAT), SDAT of left-sided (LV dispersion) and right-sided (RV dispersion) electrodes. Optimal LBBAP was determined based on maximal SDAT and QRS duration (d) change.

Results

All metrics were significantly reduced (p < 0.0001 for ECG belt metrics, p = 0.0027 for QRSd) during LBBAP and LOT-CRT compared to intrinsic. QRSd, SDAT, LVAT, and LV and RV dispersion during optimal LBBAP were significantly lower (133 ± 20/157 ± 24; 20.5 ± 7.5/38.6 ± 9; 44.4 ± 14.3/61.4 ± 21; 11.6 ± 11.6/29.5 ± 15; 21.1 ± 7.8/42.5 ± 9.3; p < 0.0001) compared to intrinsic rhythm. However, they were not significantly different among selective, non-selective, anodal, and LV septal captures. EF and NYHA class improved to 46 ± 11% and 1.9 ± 0.6 (p < 0.001).

Conclusions

LBBAP significantly reduced overall and regional (RV/LV) VEH, irrespective of the mechanism of capture. Detailed assessment of electrical heterogeneity using ECG belt may add valuable insights on effects of LBBAP.

Trial registration

ClinicalTrials.gov Identifier: NCT04583709.

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Abbreviations

CRT:

Cardiac resynchronization therapy

HBP:

His Bundle Pacing

LBBAP:

Left bundle branch area pacing

LBBB:

Left bundle branch block

LVAT:

Left ventricular activation time

SDAT:

Standard deviation of activation times

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Funding

This study is supported by a grant from Medtronic External Research Program.

Author information

Authors and Affiliations

  1. Cardiac Electrophysiology, Geisinger Heart Institute, Geisinger Commonwealth School of Medicine, MC 36-10, 1000 E Mountain Blvd, Wilkes Barre, PA, 18711, USA

    Pugazhendhi Vijayaraman

  2. Clinical Trials Unit, Geisinger Health System, Wilkes Barre, PA, USA

    Grace Hughes & Marilee Manganiello

  3. Department of Population Health Sciences, Geisinger Health System, Danville, PA, USA

    Alicia Johns

  4. Medtronic Inc, Mounds View, MN, USA

    Subham Ghosh

Authors
  1. Pugazhendhi Vijayaraman
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  2. Grace Hughes
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  3. Marilee Manganiello
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  4. Alicia Johns
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  5. Subham Ghosh
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Corresponding author

Correspondence to Pugazhendhi Vijayaraman.

Ethics declarations

Ethics approval

Approved by the Institutional Review Board.

Consent to participate

Informed consent (IRB approved) was obtained from each patient prior to performing ECG belt study.

Conflict of interest

PV: speaker, consultant, research, fellowship support—Medtronic; consultant—Abbott, Biotronik, Boston Scientific; Patent- HBP delivery tool. SG: employee, Medtronic. All other authors declare no competing interests.

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Vijayaraman, P., Hughes, G., Manganiello, M. et al. Non-invasive assessment of ventricular electrical heterogeneity to optimize left bundle branch area pacing. J Interv Card Electrophysiol 66, 1103–1112 (2023). https://doi.org/10.1007/s10840-022-01315-9

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  • DOI: https://doi.org/10.1007/s10840-022-01315-9

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