Key result
In a computational model of heart failure with left bundle branch block, optimal cardiac resynchronization therapy lead placement in the right ventricular upper septum reduced QRS duration from 190 ms to 143 ms.
Why the study?
Around one third of patients with heart failure and left bundle branch block do not respond favorably to CRT, making the optimization of lead locations and timing delays crucial.
Does pacing from alternative right ventricular locations and left ventricular endocardium improve biventricular synchrony in a computational model of heart failure with LBBB?
Does pacing from alternative right ventricular locations and left ventricular endocardium improve biventricular synchrony in a computational model of heart failure with LBBB?
Absolute Event Rate: 143% vs 190%
Computational modeling suggests that pacing the right ventricular upper septum and left ventricular endocardium may improve CRT response, and the time to reach 90% of the QRS area could serve as an index for biventricular synchrony.
Hypothesis-generating for alternative RV pacing in CRT models; leaves open clinical translation to patients with HF and LBBB.
Patients suffering from heart failure and left bundle branch block show electrical ventricular dyssynchrony causing an abnormal blood pumping. Cardiac resynchronization therapy (CRT) is recommended for these patients. Patients with positive therapy response normally present QRS shortening and an increased left ventricle (LV) ejection fraction. However, around one third do not respond favorably. Therefore, optimal location of pacing leads, timing delays between leads and/or choosing related biomarkers is crucial to achieve the best possible degree of ventricular synchrony during CRT application. In this study, computational modeling is used to predict the optimal location and delay of pacing leads to improve CRT response. We use a 3D electrophysiological computational model of the heart and torso to get insight into the changes in the activation patterns obtained when the heart is paced from different regions and for different atrioventricular and interventricular delays. The model represents a heart with left bundle branch block and heart failure, and allows a detailed and accurate analysis of the electrical changes observed simultaneously in the myocardium and in the QRS complex computed in the precordial leads. Computational simulations were performed using a modified version of the O'Hara et al. action potential model, the most recent mathematical model developed for human ventricular electrophysiology. The optimal location for the pacing leads was determined by QRS maximal reduction. Additionally, the influence of Purkinje system on CRT response was assessed and correlation analysis between several parameters of the QRS was made. Simulation results showed that the right ventricle (RV) upper septum near the outflow tract is an alternative location to the RV apical lead. Furthermore, LV endocardial pacing provided better results as compared to epicardial stimulation. Finally, the time to reach the 90% of the QRS area was a good predictor of the instant at which 90% of the ventricular tissue was activated. Thus, the time to reach the 90% of the QRS area is suggested as an additional index to assess CRT effectiveness to improve biventricular synchrony.
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Carpio et al. (2019) studied Heart failure with left bundle branch block (n=1). Optimized cardiac resynchronization therapy lead placement vs. Baseline heart failure with left bundle branch block was evaluated on QRS duration. In a computational model of heart failure with left bundle branch block, optimal cardiac resynchronization therapy lead placement in the right ventricular upper septum reduced QRS duration from 190 ms to 143 ms.
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