Left ventricular endocardial pacing improves the clinical efficacy in a non-responder to cardiac resynchronization therapy: role of acute haemodynamic testing
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Left ventricular endocardial pacing improves the clinical efficacy in a non-responder to cardiac resynchronization therapy: role of acute haemodynamic testing
Frank A. Bracke 1
Patrick Houthuizen 1
Braim M. Rahel 0
Berry M. van Gelder 1
0 Department of Cardiology, Hospital Vie Curie , Venlo , The Netherlands
1 Department of Cardiology, Catharina Hospital , Michelangelolaan 2, 5623 EJ Eindhoven , The Netherlands
SHORT COMMUNICATION doi:10.1093/europace/euq043 Online publish-ahead-of-print 2 March 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recently, emphasis has been shifted from patient selection to more optimal pacing sites in non-responders to cardiac resynchronization therapy (CRT). We present a patient who was a non-responder during both acute haemodynamic testing at implant as well as clinically thereafter. After first demonstrating acute haemodynamic improvement using LV dP/dtmax during a temporary left ventricular (LV) endocardial pacing setup, a permanent LV endocardial lead was transseptally implanted with substantial and persistent clinical improvement.
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prohibitive, left ventricular endocardial pacing was investigated in a temporary setup. For this purpose, pacing was performed with a
steerable electrophysiology catheter advanced retrogradely into the left ventricle (Figure 1). A temporary pacing wire in the right
atrium was used to synchronize with intrinsic or paced atrial activation. Both pacing catheters were connected through a custom-made
adaptor with a dual-chamber temporary pacemaker. By simultaneously adjusting the settings of the pacemaker and CRT-D device,
biventricular endocardial pacing could be obtained.
The effect of pacing at different endocardial sites was evaluated and compared with baseline and coronary sinus pacing via the
CRT-D device (Figure 2). Of note, endocardial pacing opposite to the epicardial lead did not improve the LV dP/dtmax. We
subsequently implanted a LV endocardial lead (SelectSecure 3830 – 69, Medtronic, Minneapolis, MN, USA) by a transseptal approach
at the site were the previous optimal improvement was observed (Figure 3).1
Five months later, the ejection fraction had improved to 45% and the end-diastolic and systolic diameter decreased to 61 and
47 mm, respectively, with only minor mitral regurgitation. Two weeks after an electric cardioversion for atrial fibrillation, but with
inadequate anticoagulation (International normalized ratio 1.3),
the patient had a cerebrovascular accident which resolved
except for a minor aphasia. The further follow-up was uneventful
and he improved to NYHA Class II, remaining so during the
12-month follow-up.
Discussion
Most attention in non-responders to CRT has been focused on
patient selection. However, inadequate delivery of therapy may
play an important role.
Transseptal left ventricular endocardial pacing has been shown
to be an alternative in case of failed coronary sinus lead
positioning, with the potential of a more unrestricted access to different
pacing sites.1 – 3 However, there is only limited evidence of its
superiority. In animals, van Deursen et al.4 demonstrated a
better haemodynamic effect compared with epicardial pacing,
also less dependent on timing and site of stimulation. Garrigue
et al.5 found that endocardial pacing provided better
resynchronization with better LV filling and systolic performance. Our
result is ambivalent: endocardial pacing opposite the epicardial
lead did not yield a better acute haemodynamic effect. The
latter was obtained at a remote site and it might be argued
that, if feasible, epicardial pacing at this site might have resulted in the same improvement.
Although the relation with long-term clinical benefit has not been confirmed, the LV dP/dt max at the respective pacing sites
correlated well with the clinical response. This suggests the potential of temporary left ventricular endocardial pacing to screen
nonresponders for suboptimal lead position. Stimulation in other coronary sinus branches is an alternative, but this is limited by the
availability of adequate side branches for permanent lead implantation.
There is a concern regarding thromboembolic complications with endocardial stimulation. A transient ischaemic attack occurred in
one of the six endocardially paced patients reported by Pasquie´ et al.3 No complications have been described by Garrigue et al.5 and
van Gelder et al.1, although follow-up is limited. Inadequate anticoagulation was present in our patient at the time of his
cerebrovascular accident, but follow-up was uneventful (...truncated)