Left ventricular paced activation in cardiac resynchronization therapy patients with left bundle branch block and relationship to its electrical substrate

BACKGROUND: Cardiac resynchronization therapy (CRT) uses left ventricular (LV) pacing to restore rapid synchronized LV activation when it is delayed in patients with myocardial disease. OBJECTIVE: Although intrinsic LV activation delays are understood, little is known about reactions to LV stimulation and whether they are affected by QRS duration (QRSd), morphology, LV substrate, or choice of electrode pair. The purpose of this study was to test these interactions. METHODS: In 120 heart failure patients with left bundle branch block (LBBB) and QRS >120 ms receiving CRT with quadripolar LV leads, device-based measurements of intrinsic activation delay (qLV) and paced inter- (and intra-) LV conduction times were evaluated at the proximal and distal LV bipoles. RESULTS: During intrinsic conduction, qLV varied little between the proximal and distal pairs in patients with LBBB (n = 120; age 68 ± 11 years; 63% male; ejection fraction 25% ± 7%; 33% ischemic cardiomyopathy; QRSd 162 ± 19 ms). A minority (30%) had conduction barriers (ie, gradients) (ΔqLV 29 ± 8 ms vs 9 ± 5 ms in patients without gradients; P <.01), which occurred equally in ischemic and nonischemic patients. A majority were functional (and not scar-mediated), as they resolved with pacing in most patients (75%). Importantly, LV-paced conduction times were unrelated to baseline QRS morphology (LBBB 166 ± 30 ms vs RBBB control 172 ± 30 ms; P = NS), longer than intrinsic conduction (166 ± 30 ms vs 129 ± 28 ms; P <.01), and varied significantly by electrode pair (ie, small distances) and etiology. Correlation between intrinsic activation delay (qLV) and LV-paced conduction time was poor (R(2) = 0.278; P <.05). CONCLUSION: LV-paced effect, which is core to CRT, is unpredictable based on conventionally used measures and should be considered during CRT optimization.