Assessment of myocardial electrical dissynchrony by noninvasive activation mapping and its role in achieving the success of cardiac resynchronization

Purpose. To assess and to compare the ventricular myocardium activation patern obtained by non-invasive epi- and endocardial mapping (NIEEM), as well as electrocardiographic (ECG) variants of lef bundle branch block (LBBB) and to estimate the value of these data for the success of cardiac resynchronization therapy (CRT).

Materials and methods. Te study included 23 patients (mean age 59,6±9,9 years) with LBBB, QRS duration ≥ 130 ms, lef ventricular ejection fraction (LVEF) ≤ 35%, heart failure (HF) NYHA II-IV despite optimal pharmacological therapy during 3 month. All patients had undergone CRT-D implantation. Depending on presence or absence of LBBB ECG-criteria, proposed by Strauss D.G. et. al, patients were divided into 2 groups: 1group - strict LBBB, proposed by Strauss D.G. et. al. (n=14) and 2 group – other ECG morphologies of LBBB (n=9). NIEEM by the Amycard 01C system with an analysis of epi- and endocardial ventricular electrical activation was performed in all patients and 5 healthy volunteers (mean age 29±1,0years). Response to CRT was estimated by echo and was defned as decrease in lef ventricular (LV) end-systolic volume by > 15% afer 6 months of follow-up.

Results. LBBB ECG-criteria, proposed by Strauss D.G. et. al, was detected in 14 patients (61% of all included). According to the results of NIEEM, these patients had more pronounced ventricular electrical uncoupling (VEU) (р=0,002). Most ofen the line of block was detected in the anteroseptal or posterolateral region of the LV. Te zone of late LV activation, which is the most optimal position for the LV pacing electrode, was located in the basal and middle segments of the lateral and posterior walls. Afer 6 months of CRT 15 patients (65%) were included in the "response" group, the remaining 8 patients (35%) formed the "non-response" group according to echo criteria. In the "response" group the morphology of the QRS complex more frequently met the criteria, proposed by Strauss D.G. et al, than other ECG variants of LBBB (12 vs. 3 respectively, p = 0.023). Initially, VEU was more pronounced in the "response" group (VEU 55 [51, 64] ms in the "response" group vs 22 [8, 38] ms in the "non-response" group).

Сonclusions. LBBB ECG criteria, proposed by Strauss D.G., identify patients with delayed transseptal interventricular conduction due to complete LBBB, what is a good target for CPT. Identifcation of individual ventricular activation properties may help to reveal responders to CRT in patients with LBBB.

1. Ageev F.T., Danielyan M.O., Mareev V.Yu., Belenkov Yu.N. Patients with chronic heart failure in the Russian ambulatory practice: contingent features, diagnosis and treatment (studies of AGE-OCHF). Russian Heart Failure Journal. 2004;5 (1):4–7. [Russian]

2. Fomin I.V., Belenkov Yu.N., Mareev V.Yu., Ageev F.T., Badin Yu.V., Galyavich A.S. et al. Prevalence of CHF in European part of the Russian Federation: data from EPOCH-CHF. Russian Heart Failure Journal. 2006;7 (1):4–7. [Russian]

3. Bart B.Ya., Larina V.N., Brodskyi M.S. Cardiac remodeling and clinical prognosis in patient with chronic heart failure and complete lef bundle branch block. Russian Journal of Cardiology. 2011;16 (6):4–8. [Russian]

4. Padeleti L. Influence of QRS prolongation on the natural history of CHF. European Heart Journal Supplements. 2004;6(Suppl. D):D79–82. DOI: 10.1016/j.ehjsup.2004.05.023

5. Tabrizi F, Englund A, Rosenqvist M, Wallentin L, Stenestrand U. Influence of lef bundle branch block on long-term mortality in a population with heart failure. European Heart Journal. 2007;28(20):2449–55. DOI: 10.1093/eurheartj/ehm262

6. Masoudi FA, Havranek EP, Smith G, Fish RH, Steiner JF, Ordin DL et al. Gender, age, and heart failure with preserved lef ventricular systolic function. Journal of the American College of Cardiology. 2003;41(2):217– 23. DOI: 10.1016/S0735-1097(02)02696-7

7. Zareba W, Klein H, Cygankiewicz I, Hall WJ, McNit S, Brown M et al. Effectiveness of cardiac resynchronization therapy by QRS morphology in the Multicenter Automatic Defbrillator Implantation Trial-Cardiac Resynchronization Terapy (MADITCRT). Circulation. 2011;123(10):1061–72. DOI: 10.1161/CIRCULATIONAHA.110.960898

8. Strauss DG, Selvester RH, Wagner GS. Defning Lef Bundle Branch Block in the Era of Cardiac Resynchronization Terapy. Te American Journal of Cardiology. 2011;107(6):927–34. DOI: 10.1016/j.amjcard.2010.11.010

9. Van Deursen CJM, Blaauw Y, Witjens MI, Debie L, Wecke L, Crijns HJGM et al. Te value of the 12-lead ECG for evaluation and optimization of cardiac resynchronization therapy in daily clinical practice. Journal of Electrocardiology. 2014;47(2):202–11. DOI: 10.1016/j.jelectrocard.2014.01.007

10. Tian Y, Zhang P, Li X, Gao Y, Zhu T, Wang L et al. True complete lef bundle branch block morphology strongly predicts good response to cardiac resynchronization therapy. EP Europace. 2013;15(10):1499–506. DOI: 10.1093/europace/eut049

11. Varma N, Ploux S, Riter P, Wilkoff B, Eschalier R, Bordachar P. Noninvasive Mapping of Electrical Dyssynchrony in Heart Failure and Cardiac Resynchronization Terapy. Cardiac Electrophysiology Clinics. 2015;7(1):125–34. DOI: 10.1016/j.ccep.2014.11.012

12. Auricchio A, Fantoni C, Regoli F, Carbucicchio C, Goete A, Geller C et al. Characterization of Lef Ventricular Activation in Patients with Heart Failure and Lef Bundle-Branch Block. Circulation. 2004;109(9):1133– 9. DOI: 10.1161/01.CIR.0000118502.91105.F6

13. Orlov V.N. Guide to electrocardiography. 9th ed. -M.: OOO «MIA», 560 p. [Russian]. ISBN 978-5-89481- 983-9

14. Zubarev S.V., Chmelevsky M.P., Budanova M.A., Trukshina M.A., Lyubimtseva T.A., Lebedeva V.K. et al. Non-invasive electrophysiological mapping of the patients undergoing cardiac resynchronization therapy: the role of lef ventricular lead position. Translational Medicine. 2016;3 (3):7–16. [Russian]

15. Cerqueira MD, Weissman NJ, Dilsizian V, Jacobs AK, Kaul S, Laskey WK et al. Standardized Myocardial Segmentation and Nomenclature for Tomographic Imaging of the Heart: A Statement for Healthcare Professionals From the Cardiac Imaging Commitee of the Council on Clinical Cardiology of the American Heart Association. Circulation. 2002;105(4):539–42. DOI: 10.1161/hc0402.102975

16. Ploux S, Lumens J, Whinnet Z, Montaudon M, Strom M, Ramanathan C et al. Noninvasive Electrocardiographic Mapping to Improve Patient Selection for Cardiac Resynchronization Terapy. Journal of the American College of Cardiology. 2013;61(24):2435–43. DOI: 10.1016/j.jacc.2013.01.093

17. Ghosh S, Silva JNA, Canham RM, Bowman TM, Zhang J, Rhee EK et al. Electrophysiologic substrate and intraventricular lef ventricular dyssynchrony in nonischemic heart failure patients undergoing cardiac resynchronization therapy. Heart Rhythm. 2011;8(5):692–9. DOI: 10.1016/j.hrthm.2011.01.017

18. Kashtanova S.Yu., Mironova N.A., Shitov V.N., Gupalo E.M., Kiktev V.G., Saidova M.A. et al. Role of electrocardiographic and echocardiographic types of lef bundle branch block in prediction of response to cardiac resynchronization therapy. Terapeutic Archive. 2018;90 (12):76–83. [Russian]. DOI: 10.26442/00403660.2018.12.000012

19. Caputo ML, van Stipdonk A, Illner A, D’Ambrosio G, Regoli F, Conte G et al. Te defnition of lef bundle branch block influences the response to cardiac resynchronization therapy. International Journal of Cardiology. 2018;269:165–9. DOI: 10.1016/j.ijcard.2018.07.060

20. Fung JW-H. Variable lef ventricular activation patern in patients with heart failure and lef bundle branch block. Heart. 2004;90(1):17–9. DOI: 10.1136/heart.90.1.17

21. Kanawati J, Sy RW. Contemporary Review of Lef Bundle Branch Block in the Failing Heart – Pathogenesis, Prognosis, and Terapy. Heart, Lung and Circulation. 2018,27(3):291–300. DOI: 10.1016/j.hlc.2017.09.007

22. Sohal M, Shety A, Ducket S, Chen Z, Sammut E, Amraoui S et al. Noninvasive Assessment of LV Contraction Paterns Using CMR to Identify Responders to CRT. JACC: Cardiovascular Imaging. 2013;6(8):864–73. DOI: 10.1016/j.jcmg.2012.11.019

23. Jackson T, Sohal M, Chen Z, Child N, Sammut E, Behar J et al. A U-shaped type II contraction patern in patients with strict lef bundle branch block predicts super-response to cardiac resynchronization therapy. Heart Rhythm. 2014;11(10):1790–7. DOI: 10.1016/j.hrthm.2014.06.005

24. Kosztin A, Kutyifa V, Nagy VK, Geller L, Zima E, Molnar L et al. Longer right to lef ventricular activation delay at cardiac resynchronization therapy implantation is associated with improved clinical outcome in lef bundle branch block patients. Europace. 2016;18(4):550–9. DOI: 10.1093/europace/euv117

25. Kuznetsov V.A., Soldatova A.M., Krinochkin D.V., Enina T.N. Cardiac resynchronisation therapy in patients with congestive heart failure: whether we should expect for an «early» response? Russian Heart Failure Journal. 2017;18 (3):172–7. [Russian]. DOI: 10.18087/rhf.2017.3.2341