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Biophysical modeling to simulate the response to multisite left ventricular stimulation using a quadripolar pacing

Steven A Niederer¹, A K Shetty, G Plank

¹Imaging Sciences & Biomedical Engineering Division, King's College London, London, United Kingdom. steven.niederer@kcl.ac.uk

Pacing and Clinical Electrophysiology : PACE

|November 2, 2011

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Multisite cardiac resynchronization therapy (CRT) using multipolar leads improves heart function in patients with scar tissue. Maximizing left ventricular activation wave area is key for optimizing CRT response.

Area of Science:

Cardiology
Biomedical Engineering
Computational Biology

Background:

Cardiac resynchronization therapy (CRT) response is diminished in patients with posterolateral scar.
Multipolar pacing leads allow for selection of optimal pacing sites and concurrent stimulation from multiple sites.
Clinical evaluation and optimization metrics for multisite CRT (MCRT) are not well-established.

Purpose of the Study:

To evaluate the efficacy of multisite CRT (MCRT) compared to standard CRT in a computational model.
To identify optimal pacing strategies and metrics for MCRT in the presence of scar tissue.

Main Methods:

A coupled electromechanical biophysical model of the human heart was used.
The model simulated MCRT with a quadripolar lead (two left ventricular pacing sites plus right ventricular pacing) versus single-site LV pacing.

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Simulations included varying degrees of scar in the LV posterolateral wall (none, mild, severe).

Main Results:

MCRT demonstrated improved maximal dP/dt(max) compared to standard CRT, particularly in the presence of severe scar (25% vs 21% improvement).
Minimizing total activation time or short-axis activation time did not correlate with CRT response.
Peak electrical activation wave area in the left ventricle showed a strong correlation with CRT response (R² = 0.42–0.75).

Conclusions:

Biophysical modeling suggests MCRT improves response over conventional CRT in patients with posterolateral scar.
Maximizing the left ventricular activation wave area is a consistent predictor of CRT response, irrespective of pacing protocol, scar size, or lead position.