PURPOSE: Optimal left ventricular (LV) lead position has emerged as an important determinant of response after cardiac resynchronization therapy (CRT). Comparatively, strategy for right ventricular (RV) lead optimization remains uncertain. METHODS: Three variations of RV lead position (apex, mid-septal, and high septal) were tested in seven consecutive patients. At each location, intra-procedural measurement of LV lead electrical delay (LVLED) was obtained during intrinsic rhythm and RV pacing (RV-LVLED). Simultaneous cardiac output assessment was performed using the LiDCO™ (lithium chloride indicator dilution) system. Final RV lead location was selected based on best-measured cardiac output. Clinical and echocardiographic outcomes were assessed at baseline and 6 months. RESULTS: Adjustment of RV lead position after securing a LV lead site led to an incremental change of 30 ± 18 % (range, 7-52 %) in the cardiac index (CI). There was substantial variation in acute hemodynamic response (∆CI, 14 ± 13 %; range, 3-41 %) seen with pacing from each patient's worst to best RV lead position; no single RV lead position emerged as optimal across all patients. Paced RV-LVLED was not correlated with percent change in CI (r = 0.18; p = NS). LV ejection fraction (LVEF) increased significantly (28 ± 4 to 40 ± 8 %, p = 0.006) at 6 months. LVLED measured during intrinsic rhythm, but not during RV pacing, correlated with percent change in LVEF (r = 0.88, p = 0.02). CONCLUSIONS: RV lead position adjustment can be used to enhance acute hemodynamic response during CRT. Measurement of paced RV-LVLED, however, does not reliably predict change in cardiac output.
PURPOSE: Optimal left ventricular (LV) lead position has emerged as an important determinant of response after cardiac resynchronization therapy (CRT). Comparatively, strategy for right ventricular (RV) lead optimization remains uncertain. METHODS: Three variations of RV lead position (apex, mid-septal, and high septal) were tested in seven consecutive patients. At each location, intra-procedural measurement of LV lead electrical delay (LVLED) was obtained during intrinsic rhythm and RV pacing (RV-LVLED). Simultaneous cardiac output assessment was performed using the LiDCO™ (lithium chloride indicator dilution) system. Final RV lead location was selected based on best-measured cardiac output. Clinical and echocardiographic outcomes were assessed at baseline and 6 months. RESULTS: Adjustment of RV lead position after securing a LV lead site led to an incremental change of 30 ± 18 % (range, 7-52 %) in the cardiac index (CI). There was substantial variation in acute hemodynamic response (∆CI, 14 ± 13 %; range, 3-41 %) seen with pacing from each patient's worst to best RV lead position; no single RV lead position emerged as optimal across all patients. Paced RV-LVLED was not correlated with percent change in CI (r = 0.18; p = NS). LV ejection fraction (LVEF) increased significantly (28 ± 4 to 40 ± 8 %, p = 0.006) at 6 months. LVLED measured during intrinsic rhythm, but not during RV pacing, correlated with percent change in LVEF (r = 0.88, p = 0.02). CONCLUSIONS: RV lead position adjustment can be used to enhance acute hemodynamic response during CRT. Measurement of paced RV-LVLED, however, does not reliably predict change in cardiac output.
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