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Objectives This study hypothesized that the shorter intrinsic PR interval observed in women allows a greater degree of fusion with intrinsic conduction, achieving a shorter QRS interval du...

Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Grant of the Catalan Society of Cardiology, 2019; Research Grant Josep Font 2019, Hospital Clínic de Barcelona His-Purkinje conduction system pacing (HPCSP) has been proposed as an alternative to cardiac resynchronization therapy (CRT); however, no predictors of echocardiographic response have been described. Septal flash (SF) is a marker of intraventricular dyssynchrony. Methods The study aimed to analyze whether HPCSP corrects SF in patients with CRT indication, and if correction of SF predicts echocardiographic response. Prospective observational study (n=30). Left ventricular ejection fraction (LVEF) was measured with echocardiography at baseline and at 6-month follow-up. Echocardiographic response was defined as increase in 5 points LVEF. ECG Imaging was performed in 2 patients to validate ventricular activation shortening and to study the basal and HPCSP activation pattern. Results HPCSP shortened QRS duration by 48±21ms and SF was significantly decreased (baseline 3.6±2.2mm vs HPCSP 1.5±1.5mm p1.5mm had 81% sensitivity and 80% specificity to predict echocardiographic response (area under curve 0.86, p=0.019). Conclusion HPCSP improves intraventricular dyssynchrony and results in 64% echocardiographic responders at 6-month follow-up. Dyssynchrony improvement with SF correction may predict echocardiographic response at 6-month follow-up (Fig.2.).

It is unknown whether His-Purkinje conduction system pacing (HPCSP), as either His bundle or left bundle branch pacing, could be an alternative to cardiac resynchronization therapy (BiVCRT) for patients with left ventricular dysfunction needing ventricular pacing due to atrioventricular block. The aim of the study is to compare the echocardiographic response and clinical improvement between HPCSP and BiVCRT.Consecutive patients who successfully received HPCSP were compared with a historical cohort of BiVCRT patients. Patients were 1:1 matched by age, LVEF, atrial fibrillation, renal function and cardiomyopathy type. Responders were defined as patients who survived, did not require heart transplantation and increased LVEF ≥5 points at 6-month follow-up.HPCSP was successfully achieved in 92.5% (25/27) of patients. During follow-up, 8% (2/25) of HPCSP patients died and 4% (1/25) received a heart transplant, whereas 4% (1/25) of those in the BiVCRT cohort died. LVEF improvement was 10% ± 8% HPCSP versus 7% ± 5% BiVCRT (p = .24), and the percentage of responders was 76% (19/25) HPCSP versus 64% (16/25) BiVCRT (p = .33). Among survivors, the percentage of patients who improved from baseline II-IV mitral regurgitation (MR) to 0-I MR was 9/11 (82%) versus 2/8 (25%) (p = .02). Compared to those with BiVCRT, patients with HPCSP achieved better NYHA improvement: 1 point versus 0.5 (OR 0.34; p = .02).HPCSP in patients with LVEF ≤45% and atrioventricular block improved the LVEF and induced a response similar to that of BiVCRT. HPCSP significantly improved MR and NYHA functional class. HPCSP may be an alternative to BiVCRT in these patients. (Figure 1. Central Illustration). [Figure: see text].

His bundle pacing was developed while seeking a physiological alternative to biventricular cardiac resynchronization therapy. However, His bundle pacing may not be adequate in all patients. In this scenario, left bundle branch pacing has arisen as a new cardiac resynchronization therapy modality to correct left bundle branch block and restore ventricular synchrony. (Level of Difficulty: Intermediate.), Graphical abstract

[EN] Background Multipoint pacing (MPP) in cardiac resynchronization therapy (CRT) activates the left ventricle from two locations, thereby shortening the QRS duration and enabling better resynchronization; however, compared with conventional CRT, MPP reduces battery longevity. On the other hand, electrocardiogram-based optimization using the fusion-optimized intervals (FOI) method achieves more significant reverse remodeling than nominal CRT programming. Our study aimed to determine whether MPP could attain better resynchronization than single-point pacing (SPP) optimized by FOI. Methods This prospective study included 32 consecutive patients who successfully received CRT devices with MPP capabilities. After implantation, the QRS duration was measured during intrinsic rhythm and with three pacing configurations: MPP, SPP-FOI, and MPP-FOI. In 14 patients, biventricular activation times (by electrocardiographic imaging, ECGI) were obtained during intrinsic rhythm and for each pacing configuration to validate the findings. Device battery longevity was estimated at the 45-day follow-up. Results The SPP-FOI method achieved greater QRS shortening than MPP (-56 +/- 16 vs. -42 +/- 17 ms, p < .001). Adding MPP to the best FOI programming did not result in further shortening (MPP-FOI: -58 +/- 14 ms, p = .69). Although biventricular activation times did not differ significantly among the three pacing configurations, only the two FOI configurations achieved significant shortening compared with intrinsic rhythm. The estimated battery longevity was longer with SPP than with MPP (8.1 +/- 2.3 vs. 6.3 +/- 2.0 years, p = .03). Conclusions SPP optimized by FOI resulted in better resynchronization and longer battery duration than MPP., Centro de Investigacion Biomedica en Red Enfermedades Cardiovasculares, Grant/Award Number: CB16/11/00354; Instituto de Salud Carlos III, Grant/Award Numbers: DTS16/0160, PI16/00435, PI16/00703, PI17/01059, PI17/01106; Sociedad Espanola de Cardiologia, Grant/Award Numbers: 2018, SEC_ESTIM_01; Agencia deGestio d'Ajuts Universitaris i de Recerca, Grant/AwardNumber: 2017_SGR_1548; Fundacio laMarato de TV3, Grant/Award Number: 20152730; Horizon 2020 Framework Programme, Grant/Award Number: 633196 - CATCH MEproject; European Regional Development Fund, Grant/Award Number: EITHealth 19600 AFFINE

This study hypothesized that the shorter intrinsic PR interval observed in women allows a greater degree of fusion with intrinsic conduction, achieving a shorter QRS interval duration and, thus, a better response.Women benefit more from cardiac resynchronization therapy (CRT) than men. However, the reason for this difference remains elusive.A cohort of 180 patients included in the BEST (Fusion based optimization in resynchronization therapy [ECG Optimization of CRT: Evaluation of Mid-Term Response]; NCT01439529) study were retrospectively analyzed. Patients were initially randomized to either nonoptimized CRT (NON-OPT group; n = 89) or electrocardiographically optimized CRT based on the fusion-optimized intervals (FOI) method (FOI group; n = 91). Echocardiographic response was defined as a15% decrease in left ventricular end-systolic volume at the 12-month follow-up.The basal PR interval was shorter in women as compared to men. In the NON-OPT group, CRT resulted in a shorter paced QRS interval in women than in men (134 ± 21 ms vs. 151 ± 21 ms, respectively; p = 0.003, 95% confidence interval [CI]: -27 to -5.6) and better response in women than in men: 70.4% vs. 46.4%, respectively (odds ratio: 0.37; p = 0.04; 95% CI: 0.14 to 0.97). There were no differences in paced QRS interval duration (126 ± 13 ms vs. 129 ± 17 ms; p = 0.47) or response between women and men in the FOI group (68% vs. 70.5%; odds ratio: 1.12; p = 0.82; 95% CI: 0.41 to 3.07). FOI extended the atrioventricular interval to obtain the best fusion; the atrioventricular intervals tended to require greater extension in men than in women (22 ± 33 ms vs. 8 ± 28 ms, respectively; p = 0.07).Women had a shorter PR interval, which was associated with a shorter QRS interval and better response to CRT. The difference in QRS interval duration and response between men and women did not persist when CRT was optimized using fusion with intrinsic conduction (FOI programming).

Background: Multipoint pacing (MPP) in cardiac resynchronization therapy (CRT) activates the left ventricle from two locations, thereby shortening the QRS duration and enabling better resynchronization; however, compared with conventional CRT, MPP reduces battery longevity. On the other hand, electrocardiogram-based optimization using the fusion-optimized intervals (FOI) method achieves more significant reverse remodeling than nominal CRT programming. Our study aimed to determine whether MPP could attain better resynchronization than single-point pacing (SPP) optimized by FOI. Methods: This prospective study included 32 consecutive patients who successfully received CRT devices with MPP capabilities. After implantation, the QRS duration was measured during intrinsic rhythm and with three pacing configurations: MPP, SPP-FOI, and MPP-FOI. In 14 patients, biventricular activation times (by electrocardiographic imaging, ECGI) were obtained during intrinsic rhythm and for each pacing configuration to validate the findings. Device battery longevity was estimated at the 45-day follow-up. Results: The SPP-FOI method achieved greater QRS shortening than MPP (-56±16 vs. -42±17 ms, P

Funding Acknowledgements Cardiac Pacing Scholarship from the Spanish Society of Cardiology (SEC) Background Electrocardiogram-based optimization of cardiac resynchronization therapy (CRT) using the fusion-optimized intervals (FOI) method has demonstrated to improve both acute hemodynamic response and left ventricle (LV) reverse remodeling compared to nominal programming of CRT. FOI optimizes the atrioventricular (AV) and ventriculo-ventricular (VV) intervals to achieve the shortest paced-QRS duration. The recent development of multipoint pacing (MPP) enables the activation of the LV from 2 locations, also shortening the QRS duration compared to conventional biventricular pacing. Purpose To determine if MPP reduces the paced-QRS duration compared to FOI optimization. Methods This prospective clinical study included 25 consecutive patients who successfully received a CRT with MPP pacing capability. All patients were in sinus rhythm and had an PR interval below 250 ms. The QRS duration was measured with a 12-lead digital electrocardiography (screen speed of 200 mm/s) at baseline and using 3 different configurations: MPP, FOI and a combined FOI-MPP strategy. In MPP, the intervals were (based on previous studies): 1) AV 130 ms, 2) Right ventricular (RV)-LV2 (Δ1) 5 ms, and 3) LV1-LV2 (Δ2) 5 ms. In FOI, AV and VV intervals were optimized to achieve fusion between intrinsic conduction and biventricular pacing. In FOI-MPP, the Δ2 was set at 5 ms, while AV and Δ1 intervals were optimized using the FOI method. The CRT device was programmed with the configuration that achieved a greater paced-QRS shortening. After 45 days, battery life was estimated. Results Mean age was 65 ± 10 years, 20 were men (80%) and baseline QRS duration was 177 ± 17 ms. The FOI method bested nominal MPP (QRS shortened by 58 ± 16 ms vs 43 ± 16 ms, respectively, p = 0.002). Adding MPP to the narrowest QRS by FOI did not result in further shortening (FOI: 58 ± 16 ms vs FOI-MPP: 59 ± 13 ms, p = 0.81). The final configuration was FOI method alone in most cases (n = 16, 64%) and FOI-MPP in all others (n = 9, 36%; figure). In total, 10 out of 25 patients (40%) were not candidates to MPP due to: 1) pacing thresholds exceeding 3.5 V/0.4 ms at the distal or proximal electrode (8, 32%), and 2) phrenic stimulation (2, 8%). Estimated battery longevity was longer in patients receiving FOI as compared to MPP (8.3 ± 2.1 years vs. 6.2 ± 2.2 years, p = 0.04). Conclusion In CRT, the FOI method is not improved by coupling with MPP. Up to 40% of patients are not candidates for MPP due to high thresholds or phrenic stimulation. The use of MPP in unselected patients would result in a decrease of battery longevity, without any additional benefit over FOI. Abstract Figure.