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Twelve-lead ECG and chest x-ray (PA and lateral views) of a patient with CRT-D with LV lead in PLCV and RV lead in RVA. ECG is characterized by dominant R wave in V1, QS in leads I and aVL, and left superior axis. (Abbreviations: PA: posteroanterior; CRT-D: defibrillator cardiac resynchronization device; LV: left ventricle; PLCV: posterolateral coronary vein; RV: right ventricle; RVA: right ventricular apex).
Source publication
Background:
With increasing use of cardiac resynchronization therapy (CRT), treating physicians should be familiar with different electrocardiographic (ECG) patterns of left ventricular (LV) lead and biventricular (BiV) pacing. However, there are a few publications on ECG patterns during BiV pacing.
Purpose:
This study was sought to determine di...
Context in source publication
Context 1
... consisted of 181 patients with CRT device. One patient with epicardial LV lead was excluded. The mean age was 62 ± 13.5 years. Overall, 67% were male, and 54% had an ischemic cardiomyopathy (ICM). In this cohort, all patients had RV lead implanted in the apex. LV leads were implanted in LCV (Fig. 1) in 50%, ALCV (Fig. 2) in 20% and PLCV (Fig. 3) in 30%. In this series, we had no case of LV lead implantation in vein collaterals. CRT delivered either as simultaneous (n ¼ 78) or sequential (LV first, n ¼ 103) BiV pacing. In total, BiV stimulation resulted in dominant R wave in V1 in 65% of the patients; a Q/q wave was detected in 85% of patients in lead I and 78% in lead aVL. ...
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Background:
Left bundle branch area pacing (LBBAP) has recently been introduced as a novel physiological pacing strategy. Within LBBAP, distinction is made between left bundle branch pacing (LBBP) and left ventricular septal pacing (LVSP, no left bundle capture).
Objective:
To investigate acute electrophysiological effects of LBBP and LVSP as co...
Background
. The placement of the left ventricular (LV) lead in an area free of myocardial scar is an important determinant of cardiac resynchronization therapy (CRT) response. We sought to develop and validate a simple, practical and novel electrocardiographic (ECG) based approach to intra-operatively identify the presence of LV scar. We hypothesi...
Cardiac resynchronization therapy (CRT) is a cornerstone therapeutic opportunity for selected patients with heart failure. For optimal patient selection, no other method has been proven to be more effective than the 12-lead ECG, and hence ECG characteristics are extensively researched. The evaluation of particular ECG signs before the implantation...
(1) Background: Periodic repetitive AV interval optimization using a device-based algorithm in cardiac resynchronization therapy (CRT) devices may improve clinical outcomes. There is an unmet need to successfully transform its application into clinical routine. (2) Methods: Non-invasive imaging of cardiac electrophysiology was performed in differen...
Intraventricular conduction disturbances (IVCD) are currently generally accepted as ECG diagnostic categories. They are characterized by defined QRS complex patterns that reflect the abnormalities in the intraventricular sequence of activation that can be caused by pathology in the His-Purkinje conduction system (HP) or ventricular myocardium. Howe...
Citations
... R or r waves in V 1 were observed in 65% to 93% of patients with biventricular pacing. 526,527 CRT loss may occur during exercise in the presence of AF with high ventricular rate or due to AV interval shortening; 24hour Holter monitoring and exercise stress test may be useful to identify such cases. Increased LV capture thresholds account for 10% of cases of CRT pacing loss. ...
... Ondas r ou R em V1 estão presentes em 65% a 93% das estimulações biventriculares. 526,527 A perda da ressincronização pode ocorrer ao esforço, na presença de FA de alta resposta e devido ao encurtamento do intervalo AV; Holter-24h e teste ergométrico podem ser úteis para identificar tais cenários. Aumento do limiar de captura do VE é responsável por 10% dos casos de perda da ressincronização. ...
... interkostal aralıklardan) alınması gibi durumlarda da V1'de negatif bir QRS konfigürasyonu izlenebilmektedir. [10,14,15] Herweg ve ark., [10] V1'de negatif QRS kompleksinin varlığının SV uyarı bölgesinde uzamış latansı (≥40 ms) öngörmedeki duyarlılığını %80, özgüllüğünü ise %97 olarak belirlemişlerdir. Bunun dışında, SğV elektrodunun SğV çıkış yoluna veya interventriküler septuma yerleştirildiği biventriküler uyarı zamanı da genellikle V1'de negatif QRS kompleks olarak izlenmektedir (Şekil 3). ...
Objectives
In this cohort study, we analyzed if a specific pattern in three leads of the electrocardiogram (Rs in V1, Qr in aVL, or rS in I) was associated with outcomes after cardiac resynchronization therapy (CRT) depending on age.
Methods
Patients with CRT devices were included from January 2012 to April 2019. We divided the sample into 2 groups, those with age ≥ 75 years old and those younger. The primary endpoint was a composite of all-cause death and heart failure (HF) hospitalization at 1 year.
Results
We included 111 patients. Patients older than 75 years (26.1%, n=29) had a significantly higher rate of hypertension and atrial fibrillation and received less frequently optimal medical therapy. The patterns were observed in 32 (39.0%) younger patients and 11 (37.9%) older patients. Patients who presented any of them had a lower incidence of the primary endpoint in the younger group (0 vs. 14%, p=0.029), but not in the older group (9.1 vs. 27.8%, p=0.24). The presence of a basal QRS duration greater than 160 milliseconds was associated with a higher rate of the primary endpoint in the elderly (50 vs. 13%, p=0.015), but not in the younger group (16.7 vs. 7.1%, p=0.254).
Conclusions
The presence of the selected patterns after CRT is associated with a lower incidence of all-cause death and hospitalization for HF in patients younger than 75 years, but not in those older than 75 years. Conversely, baseline QRS duration was associated with worse outcomes in older patients, but not in the younger group.
Cardiac resynchronization therapy (CRT) has been established as an effective mode of therapy in patients with heart failure and concurrent cardiac dyssynchrony, principally in the form of left bundle branch block (LBBB). The wide-spread use of CRT has ushered in a new landscape in 12-lead electrocardiography (ECG). ECG readings in these patients are most important to guide troubleshooting and also appropriate device programming, as well as discerning and managing non-responders. A set of 4 ECG recordings need to accompany each patient with a CRT device, including a baseline ECG and recordings from monochamber (right and left ventricular) and biventricular pacing, which can be compared against a new recording to facilitate evaluation of proper vs problematic biventricular pacing. Precordial ECG leads V1/2 acquired at the 4th intercostal space and limb leads, I and III, together with a quick assessment of perpendicular leads I and aVF to determine quadrant of the QRS axis in the hexaxial diagram, may provide the framework for proper ECG interpretation in these patients. This important issue of 12-lead electrocardiography in CRT patients is herein reviewed, pitfalls are pointed out and practical tips are provided for ECG reading to help recognize and manage problems with CRT device function. Furthermore, several pertinent ECG recordings and tabulated data are provided, and an algorithm is suggested that integrates prior algorithms and relevant information from current literature.
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Introduction:
Dyssynchrony persists in many patients despite cardiac resynchronization therapy (CRT). Aim of this proof-of-concept study was to achieve better CRT, with a QRS approximating the normal width and axis, by using His bundle pacing and non-conventional pacing configurations.
Methods and results:
In 20 patients with CRT indications, we performed an acute intra-patient comparison between conventional biventricular (CONV) and three non-conventional pacing modalities: His bundle pacing alone (HBP), His bundle and coronary sinus pacing (HBP+CS) and HBP+CS plus right ventricular pacing (TRIPLE). Electrical dyssynchrony was assessed by means of QRS width and axis; "quasi-normal" axis meant an R/S ratio ≥1 in leads I and V6 and ≤1 in V1. Mechanical dyssynchrony was assessed by speckle tracking echocardiography. QRS width was 153±18 ms on CONV, shortened to 137±16 ms on HBP+CS (p=0.001) and to 130±14 ms on TRIPLE (p=0.001), while it remained unchanged on HBP (159±32 ms, p=0.17). The rate of patients with "quasi-normal" axis was 5% on CONV, and increased to 90% on HBP (p=0.0001), to 63% on HBP+CS (p=0.001) and to 44% on TRIPLE (p=0.02). On radial strain analysis, the time-to-peak difference between antero-septal and postero-lateral segments was 143±116 ms on CONV, shortened to 121±127 ms on HBP (p=0.79), to 67±70 ms on HBP+CS (p=0.02) and to 76±55 ms on TRIPLE (p=0.05). On discharge, HBP was chosen in 15% of patients, HBP+CS in 55% and TRIPLE in 30%; CONV was never chosen.
Conclusion:
Non-conventional modalities of CRT provide acute additional electrical and mechanical resynchronization. An inter-patient variability exists. This article is protected by copyright. All rights reserved.
