New insights from a computational model on the relation between pacing site and CRT response

Cardiac resynchronization therapy (CRT) produces clinical benefits in chronic heart failure patients with left bundle-branch block (LBBB). The position of the pacing site on the left ventricle (LV) is considered an important determinant of CRT response, but the mechanism how the LV pacing site determines CRT response is not completely understood. The objective of this study is to investigate the relation between LV pacing site during biventricular (BiV) pacing and cardiac function.

We used a finite element model of BiV electromechanics. Cardiac function, assessed as LV dp/dt_max and stroke work, was evaluated during normal electrical activation, typical LBBB, fascicular blocks and BiV pacing with different LV pacing sites. The model replicated clinical observations such as increase of LV dp/dt_max and stroke work, and the disappearance of a septal flash during BiV pacing. The largest hemodynamic response was achieved when BiV pacing led to best resynchronization of LV electrical activation but this did not coincide with reduction in total BiV activation time (∼ QRS duration). Maximum response was achieved when pacing the mid-basal lateral wall and this was close to the latest activated region during intrinsic activation in the typical LBBB, but not in the fascicular block simulations.

In these model simulations, the best cardiac function was obtained when pacing the mid-basal LV lateral wall, because of fastest recruitment of LV activation. This study illustrates how computer modeling can shed new light on optimizing pacing therapies for CRT. The results from this study may help to design new clinical studies to further investigate the importance of the pacing site for CRT response.