The Non-Invasive Application of Electrocardiography in the Optimization of Cardiac Resynchronization Therapy

Abstract

Cardiac resynchronization therapy (CRT) is intended to reverse electrical dyssynchrony and improve systolic function in heart failure patients. However, roughly 30% of recipients do not clinically or echocardiography benefit, despite advancements with implant techniques and pacing technology, and are considered to be non-responders (Auricchio & Prinzen, 2011). Suboptimal postoperative device programming of the interventricular and atrioventricular delays, and the left ventricular (LV) pacing vector in quadripolar leads, is thought to be a prevailing cause of this persistent non-response (Mullens et al., 2009). Device optimization of pacing configurations is highly underutilized, and research has yet to establish a standardized, patient-specific methodology that can be routinely used in outpatient heart failure clinics (Gras, Gupta, Boulogne, Guzzo, & Abraham, 2009; N. Varma et al., 2019). The use of electrocardiography in device optimization is supported by the notion that synchronous ventricular electrical activation is a requisite for adequate systolic and diastolic function (Nguyen, Verzaal, van Nieuwenhoven, Vernooy, & Prinzen, 2018). Electrocardiography has furthermore shown promise in routine CRT device optimization owning to its non-invasive, inexpensive, and practical attributes. QRS duration shortening during the paced rhythm, as well as metrics of wavefront fusion and cancellation, on 12-lead electrocardiograms have been reported to correlate with subsequent LV reverse remodeling (Gage et al., 2018; Sweeney et al., 2014; Sweeney et al., 2010). Innovations in technology allow for the application of multiple unipolar electrodes placed over the upper anterior and posterior torso (Bank et al., 2018; Johnson et al., 2017; Rickard et al., 2020). The intent of this technology, as depicted in its ability to simultaneously acquire ventricular activation from both anterior and posterior surfaces, is to provide a better assessment of electrical dyssynchrony relative to that of a 12-lead electrocardiogram. Previous reports have shown that this technology can accurately, non-invasively, and efficiently measure electrical heterogeneity in patients with CRT devices (Gage et al., 2017). The purpose of this dissertation is to use this technology to: (1) quantify how a device-based pacing algorithm improves electrical resynchronization, and (2) evaluate the therapeutic window on the corresponding potential of electrical resynchronization during left ventricular unipolar pacing.