Reproducibility of measuring QRS duration and implications for optimization of interventricular pacing delay in cardiac resynchronization therapy

BACKGROUND: QRS narrowing after CRT is a predictor of patient outcome. Further narrowing can be obtained by interventricular pacing delay (VVd) optimization, raising interest to inter and intraobserver variation in manual measurements of QRS duration. METHODS: (a) Variation in intrinsic rhythm QRS duration in CRT patients with LBBB: In 40 intrinsic 12-lead ECGs, six observers measured QRS duration defined as widest QRS in any lead. In 20 of these ECGs, two observers repeated the measurements. (b) Variation in paced QRS duration at different VVd settings and agreement in selecting the narrowest QRS: In 20 CRT patients, five paced ECGs were recorded at different VVds. The most frequently selected VVd(s) estimated to cause the narrowest QRS in each patient defined the optimal VVd. Two observers repeated the measurements and VVd selections. RESULTS: Absolute interobserver difference in measured QRS duration in intrinsic rhythm ECGs was mean 2 ms, range (-40; 40 ms), mean limits of agreement (LoA): -21; 25 ms. Absolute interobserver difference in measured QRS duration in paced ECGs was mean 3 ms, range (-50; 60 ms), mean LoA: -20; 27 ms. There was no difference in LoA between intrinsic and paced QRS duration (lower limit p = 0.68; upper limit p = 0.44). The optimal VVd was included in 17/20 (85%) of the VVd selections by six observers. Interobserver variation was comparable with the intraobserver variation. CONCLUSIONS: Interobserver variation and intraobserver variation in manually measured paced and intrinsic rhythm QRS duration are clinically acceptable and comparable in a cohort of CRT patients. Inter and intraobserver reproducibility for selecting the optimal VVd is good and warrants manual VVd optimization for QRS narrowing in CRT.