Brett D Atwater1, Galen S Wagner1, Joseph Kisslo1, Niels Risum2. 1. Department of Medicine, Duke University Medical Center, Durham, NC, USA. 2. Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark.
Abstract
BACKGROUND: Some patients with RBBB may respond to cardiac resynchronization therapy (CRT). However, little is known regarding the electromechanical substrate for CRT and whether this is the optimal pacing strategy. METHODS: This was a pilot prospective double crossover randomized controlled clinical study comparing ventricular back up pacing (VVI-40), RV fusion pacing (DDD-40, RV only), and biventricular (BIV) pacing (DDD-40 BIV) in nine patients with RBBB and depressed EF. The study compared the frequency of dyssynchrony on baseline echocardiogram in patients with RBBB (n = 4), RBBB + anterior MI (RBBB with left axis deviation + left ventricular (LV) anterior wall thinning, n = 3), and RBBB + LAFB (RBBB with left axis deviation without LV anterior wallthinning n = 2). Echocardiographic assessment of LV dyssynchrony, LV size, and LV function was repeated after 6 months in each pacing mode. RESULTS:Patients with RBBB + LAFB demonstrated baseline echocardiographic dyssynchrony between the LV anterior and inferior wall. Both DDD-40RV-only pacing and DDD-40BIV pacing resulted in improved LV function and clinical status compared to VVI-40 back up pacing. Patients with RBBB alone and RBBB with anterior MI had no baseline dyssynchrony and CRT using either RV only or BIV pacing resulted in LV dilation, worsened left ventricular ejection fraction and worsened clinical status compared to VVI-40 back up pacing. CONCLUSION:Patients with RBBB, left axis deviation, and no prior anterior MI may have LV dyssynchrony between the anterior and inferior walls that is correctable with CRT.
RCT Entities:
BACKGROUND: Some patients with RBBB may respond to cardiac resynchronization therapy (CRT). However, little is known regarding the electromechanical substrate for CRT and whether this is the optimal pacing strategy. METHODS: This was a pilot prospective double crossover randomized controlled clinical study comparing ventricular back up pacing (VVI-40), RV fusion pacing (DDD-40, RV only), and biventricular (BIV) pacing (DDD-40 BIV) in nine patients with RBBB and depressed EF. The study compared the frequency of dyssynchrony on baseline echocardiogram in patients with RBBB (n = 4), RBBB + anterior MI (RBBB with left axis deviation + left ventricular (LV) anterior wall thinning, n = 3), and RBBB + LAFB (RBBB with left axis deviation without LV anterior wall thinning n = 2). Echocardiographic assessment of LV dyssynchrony, LV size, and LV function was repeated after 6 months in each pacing mode. RESULTS:Patients with RBBB + LAFB demonstrated baseline echocardiographic dyssynchrony between the LV anterior and inferior wall. Both DDD-40 RV-only pacing and DDD-40 BIV pacing resulted in improved LV function and clinical status compared to VVI-40 back up pacing. Patients with RBBB alone and RBBB with anterior MI had no baseline dyssynchrony and CRT using either RV only or BIV pacing resulted in LV dilation, worsened left ventricular ejection fraction and worsened clinical status compared to VVI-40 back up pacing. CONCLUSION:Patients with RBBB, left axis deviation, and no prior anterior MI may have LV dyssynchrony between the anterior and inferior walls that is correctable with CRT.