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Association of interventricular activation delay with clinical outcomes in cardiac resynchronization therapy

Published:November 23, 2022DOI:https://doi.org/10.1016/j.hrthm.2022.11.012

      Background

      Pacing at sites of longest interventricular delay has been associated with greater reverse remodeling in cardiac resynchronization therapy (CRT). However, the effects of pacing at such sites on clinical outcomes is less well studied.

      Objective

      The purpose of this study was to assess the association between interventricular delay and clinical outcomes in CRT patients implanted with quadripolar left ventricular (LV) leads.

      Methods

      RALLY-X4 was a registry study of the Acuity X4 quadripolar LV leads. Interventricular delay was measured during unpaced basal rhythm from the right ventricular (RV) lead to the LV lead electrode (E1 to E4) chosen for CRT pacing. Patients were stratified by median RV-LV delay (80 ms) into short and long delay groups; they also were analyzed by multivariable modeling. The primary composite outcome measure was all-cause mortality and heart failure hospitalization (HFH) at 18 months.

      Results

      A total of 581 patients had complete RV-LV delay data. Mean LV ejection fraction was 27%, and 73% had typical left bundle branch block. Predictors of long RV-LV delay included female sex, left bundle branch block, and QRS duration >150 ms. Survival free of the primary outcome at 18-month follow-up was 87% in the long activation delay group compared with 77% in the short delay group (P = .0042). Multivariate analysis showed that RV-LV delay was an independent predictor of survival free of HFH (P = .028).

      Conclusion

      Among CRT patients with quadripolar LV pacing leads, longer baseline interventricular activation delay was significantly associated with the composite endpoint of all-cause mortality and HFH.

      Keywords

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      Linked Article

      • In the right place at the right (conduction) time
        Heart Rhythm
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          Approximately one-third of patients with cardiac resynchronization therapy (CRT) do not experience clinical benefit despite fulfilling the criteria for guideline-recommended device implant. To reduce the non-responder rate and enhance the benefit of CRT in responders, robust research studies on CRT have concentrated on the optimal selection of CRT candidates and ideal sites of ventricular leads. Based on acute hemodynamic data from early CRT studies, the left ventricular (LV) lead position was guided by anatomical criteria with the lateral wall being the preferable location.
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