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An in silico guide for ventriculo-ventricular delay programming for left bundle branch-optimized cardiac

Marina Strocchi1, Jack W Samways1, Akriti Naraen1

  • 1National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, London W12 0NN, UK.

Europace : European Pacing, Arrhythmias, and Cardiac Electrophysiology : Journal of the Working Groups on Cardiac Pacing, Arrhythmias, and Cardiac Cellular Electrophysiology of the European Society of Cardiology
|May 21, 2025
PubMed
Summary

Optimizing ventriculo-ventricular delay (VVD) for Left bundle branch pacing (LBBP)-optimized cardiac resynchronization therapy (LOT-CRT) is crucial. The ideal VVD setting depends on the specific cause of left ventricular (LV) delay and pacing capture method for improved LV activation.

Keywords:
Cardiac resynchronization therapyComputational modelConduction substrateConduction system pacingVentriculo-ventricular delay

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Area of Science:

  • Cardiology
  • Biomedical Engineering
  • Computational Modeling

Background:

  • Cardiac resynchronization therapy (CRT) optimizes left ventricular (LV) activation.
  • Left bundle branch pacing (LBBP)-optimized CRT (LOT-CRT) offers an alternative when standard CRT is ineffective.
  • Optimal programming of ventriculo-ventricular delay (VVD) for LOT-CRT remains undetermined.

Purpose of the Study:

  • To determine optimal VVD programming for LOT-CRT.
  • To investigate the influence of different LV conduction substrates on VVD optimization.
  • To assess the impact of pacing capture type on VVD settings.

Main Methods:

  • Computational modeling of ventricular activation across 24 anatomies.
  • Simulation of diffuse LV conduction system delay and intra-myocardial delay.
  • Modeling LOT-CRT with selective or myocardial capture (LV septal pacing) and varying VVD.
  • Validation of models against clinical data.

Main Results:

  • Optimal VVD for diffuse LV conduction delay was negative (LBBP pacing first).
  • Optimal VVD for LV intra-myocardial disease favored pacing the coronary sinus LV first.
  • Myocardial capture in LOT-CRT favored negative VVD settings.

Conclusions:

  • Optimal VVD for LOT-CRT is contingent upon the underlying mechanism of LV activation delay.
  • The type of electrical capture achieved during LOT-CRT significantly influences optimal VVD.
  • Personalized VVD optimization is essential for effective LOT-CRT therapy.