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Multiple BiV Stimulation Combinations by using Two RV Leads Improve Potential for Response to CRT: Results of the TriV HF ICD Study

Wolfgang Kranig, Rainer Grove, Endrik Wolff, Marek Kowalski, Joachim Thale

Aims: Cardiac resynchronization therapy (CRT) nonresponder rates continue to be approximately 30%. To demonstrate the potential benefit of multiple pacing site combination options, the effect of three CRT pacing configurations with differing right ventricular (RV) lead placements were evaluated.

Methods: This single center, randomized, feasibility trial evaluated three CRT pacing configurations with two RV lead positions-RV-apex (“BiV Apex”), RV-septum close to His Bundle (“BiV His”) and RV-apex+RV-septum close to His Bundle (“TriV”)-with a left ventricular (LV) lead. Changes in intraoperative LV dP/dtmax were evaluated and acute response was defined as an increase of ≥10% versus intrinsic rhythm. Chronic measures included the Packer Heart Failure Composite Response score, 6 minute hall walk (6MHW); echocardiographic, electrocardiographic and exercise tolerance parameters, B-type natriuretic peptide (BNP) and Quality of Life.

Results: Acute hemodynamic testing was completed in 34/39 patients and resulted in significant increases in LV dP/dtmax in each CRT configuration. Choosing the best of the tested BiV configurations 85% of all patients showed at least one configuration with significant dP/dtmax rise. During follow up, Packer scores improved for the majority (73%) of patients, which was consistent with improvements in QRS width, 6MHW, BNP, ejection fraction, mitral regurgitation, NYHA class, quality of life, CPX workload and peak VO2, but overall there were no significant differences in either acute or chronic response rates between the three configurations.

Conclusions: Concomitant multisite pacing at the RV apex and septum nearby His bundle is feasible and effective and may provide an additional option for CRT nonresponders.