Influence of left ventricular lead position relative to scar location on response to cardiac resynchronization
Peter R Huntjens1, John Walmsley1, Sylvain Ploux2
1Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 50, P.O. Box 616, 6229 ER Maastricht, The Netherlands.
Insights
Optimal left ventricular (LV) lead placement for cardiac resynchronization therapy in heart failure with scar depends on scar location. Pacing away from both the septum and scar maximizes hemodynamic response and pump work.
Area of Science:
- Cardiovascular Physiology
- Medical Imaging and Simulation
- Biomedical Engineering
Background:
- Cardiac resynchronization therapy (CRT) is used for dyssynchronous heart failure.
- The impact of left ventricular (LV) lead position relative to myocardial scar on CRT outcomes is not fully understood.
- Left bundle branch block (LBBB) is a common indication for CRT.
Purpose of the Study:
- To investigate the effect of LV lead position relative to myocardial scar on hemodynamic response during CRT.
- To identify optimal LV lead placement strategies in patients with LBBB and LV scar.
- To utilize a computational model to simulate the complex interaction between scar, lead position, and cardiac function.
Main Methods:
- A computational cardiovascular system model (CircAdapt) was employed to simulate heart failure with LBBB.
- Myocardial scar was simulated in four distinct regions of the LV free wall.
- Biventricular pacing (BVP) was simulated with varied LV lead positions to determine the optimal placement for maximal LV stroke volume (SV) increase.
Main Results:
- In LBBB without scar, maximal SV increase occurred with pacing the LV free wall region most distant from the septum.
- With septal scar, optimal pacing was remote from both septum and scar.
- When scar was further from the septum, BVP-induced SV increase was diminished.
- Optimal LV lead positioning promoted homogeneous myofibre work and increased overall ventricular pump work.
Conclusions:
- Optimal LV lead position in LBBB with scar requires balancing proximity to the septum and scar.
- Effective hemodynamic response in infarcted hearts depends on maximizing electromechanical resynchronization of viable myocardium.
- Computational modeling provides insights into optimizing CRT lead placement for improved patient outcomes.
Aims:
It is unclear how the position of the left ventricular (LV) lead relative to a scar affects the haemodynamic response in patients with dyssynchronous heart failure receiving cardiac resynchronization therapy. We investigated this complex interaction using a computational model.
Methods And Results:
The CircAdapt computational cardiovascular system model was used to simulate heart failure with left bundle branch block (LBBB). Myocardial scar was induced in four different regions of the LV free wall (LVFW). We then simulated biventricular pacing (BVP) in each heart, in which LV lead position was varied. The LV lead position leading to maximal acute change in LV stroke volume (SV) was defined as optimal lead position. In LBBB without scar, SV increase was maximal when pacing the LVFW region most distant from the septum. With a scar adjacent to the septum, maximal response was achieved when pacing remote from both the septum and the scar. When the scar was located further from the septum, the BVP-induced increase of SV was small. For all hearts, pacing from the optimal LV lead position resulted in the most homogeneous distribution of local ventricular myofibre work and the largest increase in summed left and right ventricular pump work.
Conclusions:
These computer simulations suggest that, in hearts with LBBB and scar, the optimal LV lead position is a compromise between a position distant from the scar and from the septum. In infarcted hearts, the best haemodynamic effect is achieved when electromechanical resynchronization of the remaining viable myocardium is most effective.
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