Differential effect with septal and apical RV pacing on ventricular activation in patients with left bundle branch
T Jackson1,2, S Claridge3, J Behar3
1Department of Imaging Sciences, St Thomas' Hospital, King's College London, London, SE1, UK. Thomas.jackson@kcl.ac.uk.
Insights
Right ventricular apical pacing (RVAP) alters cardiac activation patterns compared to left bundle branch block (LBBB), unlike right ventricular septal pacing (RVSP). This study clarifies pacing effects in cardiac resynchronization therapy (CRT).
Area of Science:
- Electrophysiology
- Cardiology
- Medical Imaging
Background:
- Right ventricular (RV) lead positioning in cardiac resynchronization therapy (CRT) may influence patient response.
- Detailed analysis of RV septal pacing (RVSP) activation patterns, particularly in CRT patients, is limited.
Purpose of the Study:
- To compare left bundle branch block (LBBB) activation patterns with RV pacing (RVP) in the same patients.
- To further compare RV apical pacing (RVAP) and RVSP activation patterns within the LBBB population.
Main Methods:
- Body surface mapping in 14 LBBB patients post-CRT implantation.
- Comparison of activation parameters including LV total activation time (LVtat), biventricular total activation time (VVtat), interventricular electrical synchronicity (VVsync), and LV activation dispersion (LVdisp).
- In silico computer modeling to validate clinical findings on RVAP and RVSP effects.
Main Results:
- RV pacing (RVP) showed a longer LVtat compared to LBBB (p=0.046).
- Interventricular synchronicity (VVsync) was greater in LBBB (p=0.01), while LV activation dispersion (LVdisp) was greater in RVP (p=0.025).
- RVSP activation patterns were similar to LBBB, whereas RVAP showed preserved differences in VVsync, LVdisp, and wave front angle (WFA).
Conclusions:
- Right ventricular apical pacing (RVAP) demonstrates distinct activation patterns compared to left bundle branch block (LBBB).
- Right ventricular septal pacing (RVSP) activation patterns appear similar to LBBB in this cohort.
Purpose:
It is uncertain whether right ventricular (RV) lead position in cardiac resynchronization therapy impacts response. There has been little detailed analysis of the activation patterns in RV septal pacing (RVSP), especially in the CRT population. We compare left bundle branch block (LBBB) activation patterns with RV pacing (RVP) within the same patients with further comparison between RV apical pacing (RVAP) and RVSP.
Methods:
Body surface mapping was undertaken in 14 LBBB patients after CRT implantation. Nine patients had RVAP, 5 patients had RVSP. Activation parameters included left ventricular total activation time (LVtat), biventricular total activation time (VVtat), interventricular electrical synchronicity (VVsync), and dispersion of left ventricular activation times (LVdisp). The direction of activation wave front was also compared in each patient (wave front angle (WFA)). In silico computer modelling was applied to assess the effect of RVAP and RVSP in order to validate the clinical results.
Results:
Patients were aged 64.6 ± 12.2 years, 12 were male, 8 were ischemic. Baseline QRS durations were 157 ± 18 ms. There was no difference in VVtat between RVP and LBBB but a longer LVtat in RVP (102.8 ± 19.6 vs. 87.4 ± 21.1 ms, p = 0.046). VVsync was significantly greater in LBBB (45.1 ± 20.2 vs. 35.9 ± 17.1 ms, p = 0.01) but LVdisp was greater in RVP (33.4 ± 5.9 vs. 27.6 ± 6.9 ms, p = 0.025). WFA did rotate clockwise with RVP vs. LBBB (82.5 ± 25.2 vs. 62.1 ± 31.7 op = 0.026). None of the measurements were different to LBBB with RVSP; however, the differences were preserved with RVAP for VVsync, LVdisp, and WFA. In silico modelling corroborated these results.
Conclusions:
RVAP activation differs from LBBB where RVSP appears similar.
Trial Registration:
(ClinicalTrials.gov identifier: NCT01831518).
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