Outcome of Resynchronization Therapy on Superficial and Endocardial Electrophysiological Findings
Authors: KITTNAR O. , RIEDLBAUCHOVÁ L. , ADLA T. , SUCHÁNEK V. , TOMIS J. , LOŽEK M. , VALERIÁNOVÁ A. , HRACHOVINA M. , POPKOVÁ M. , VESELKA J. , JANOUŠEK J. , LHOTSKÁ L. 
Published: November 2019

Cardiac resynchronization therapy (CRT) has proven efficacious in the treatment of patients with heart failure and dyssynchronous activation. Currently, we select suitable CRT candidates based on the QRS complex duration (QRSd) and morphology with left bundle branch block being the optimal substrate for resynchronization. To improve CRT response rates, recommendations emphasize attention to electrical parameters both before implant and after it. Therefore, we decided to study activation times before and after CRT on the body surface potential maps (BSPM) and to compare thus obtained results with data from electroanatomical mapping using the CARTO system. Total of 21 CRT recipients with symptomatic heart failure (NYHA II-IV), sinus rhythm, and QRSd ≥150 ms and 7 healthy controls were studied. The maximum QRSd and the longest and shortest activation times (ATmax and ATmin) were set in the BSPM maps and their locations on the chest were compared with CARTO derived time interval and site of the latest (LATmax) and earliest (LATmin) ventricular activation. In CRT patients, all these parameters were measured during both spontaneous rhythm and biventricular pacing (BVP) and compared with the findings during the spontaneous sinus rhythm in the healthy controls. QRSd was 169.7±12.1 ms during spontaneous rhythm in the CRT group and 104.3±10.2 ms after CRT (p<0.01). In the control group the QRSd was significantly shorter: 95.1±5.6 ms (p<0.01). There was a good correlation between LATmin(CARTO) and ATmin(BSPM). Both LATmin and ATmin were shorter in the control group (LATmin(CARTO) 24.8±7.1 ms and ATmin(BSPM) 29.6±11.3 ms, NS) than in CRT group (LATmin(CARTO) was 48.1±6.8 ms and ATmin(BSPM) 51.6±10.1 ms, NS). BVP produced shortening compared to the spontaneous rhythm of CRT recipients (LATmin(CARTO) 31.6±5.3 ms and ATmin(BSPM) 35.2±12.6 ms; p<0.01 spontaneous rhythm versus BVP). ATmax exhibited greater differences between both methods with higher values in BSPM: in the control group LATmax(CARTO) was 72.0±4.1 ms and ATmax (BSPM) 92.5±9.4 ms (p<0.01), in the CRT candidates LATmax(CARTO) reached only 106.1±6.8 ms whereas ATmax(BSPM) 146.0±12.1 ms (p<0.05), and BVP paced rhythm in CRT group produced improvement with LATmax(CARTO) 92.2±7.1 ms and ATmax(BSPM) 130.9±11.0 ms (p<0.01 before and during BVP). With regard to the propagation of ATmin and ATmax on the body surface, earliest activation projected most often frontally in all 3 groups, whereas projection of ATmax on the body surface was more variable. Our results suggest that compared to invasive electroanatomical mapping BSPM reflects well time of the earliest activation, however provides longer time-intervals for sites of late activation. Projection of both early and late activated regions of the heart on the body surface is more variable than expected, very likely due to changed LV geometry and interposed tissues between the heart and superficial ECG electrode.