Post on 20-Sep-2018
ECG and cardiac resynchronization
Case report of a non responder
Pierre Bordachar, MDCHU de Bordeaux
Hôpital Haut Lévêque
• Man 57 years old• Ischemic cardiomyopathy• Ejection fraction 20%• NYHA class III• Optimal medical therapy• QRS 145 ms
DI
DII
DIIIaVRaVL
aVF
V1
V2• QRS 145 ms• Aspect of left bundle branch
block
Class I recommandation for DAI-CRT
V2
V3
V4
V5
V6
DI
DII
DIIIaVRaVL
aVF
V1
Implantation
V1
V2
V3
V4
V5
V6
Aspect of biventricular pacingRight ventricular lead: apexLeft ventricular lead: lateral wall
• After one month: hospitalization for severe heart fa ilure • 100% ventricular pacing
DI
DII
DIIIaVRaVL
aVFaVF
V1
V2
V3
V4
V5
V6
Aspect of apical right ventricular pacing
Dislodgement of the left ventricular lead
Repositionning of the left ventricular lead
Optimization of AV delays- sensed P AV delay: 140 ms- paced P AV delay: 180 ms
DI
DII
DIII
aVR
aVL
LBBB LV RV BIV
ECG for different pacing configurations
aVF
V1
V2
V3
V4
V5
V6
• After 6 months, clinical non-response: NYHA class I II• 100% ventricular pacing
DI
DII
DIII
aVR
aVL Fusion between intrinsic and pacedaVF
V1
V2
V3
V4
V5
V6
activations
DI
DII
DIII
aVR
aVL
AV 200
AV160
AV140
AV120
AV100
AV70
• In patients without AV blockMajor impact of the AV delay on the ventricular activation sequence
Electrocardiographic aspect during optimization of the AV delay
aVL
aVF
V1
V2
V3
V4
V5
V6
Programming of a shorter AV delay
LV LV60
LV40
LV20
BV RV20
RV40
RV60
RV
DI
DII
DIII
aVR
aVL
Electrocardiographic aspect during optimization of the VV delay
aVL
aVF
V1
V2
V3
V4
V5
V6
DI
DII
DIII
aVR
• After 3 months: poor clinical improvement• 81% ventricular pacing
Atrial undersensingaVR
aVL
aVFAtrial sensing
reprogramming
Take away messages
• ECG is mandatory during follow-up of patients with cardiac resynchronization
• ECG recording in the different pacing configuration s is mandatory to diagnose loss of capture at follow-up
• ECG should be controlled before echocardiographic o ptimization of AV delays
• VV delay programming impacts the ECG pattern but is difficult
• Correct functioning of the atrial lead is mandatory during biventricular pacing
In ICD patients, analysis of systematic remotely tr ansmitted EGMs is as important as interpretation of tachycardia episodes
Jacques Clémenty, MDUniversity Hospital of
Bordeaux
Systematic transmitted ECG: R wave double counting, but no therapy delivered
Large QRS complex: 200 ms
Real-time telemetry at follow-up extra-visit
R wave double counting
FF
Surface ECG
Markers
RV
A
FF
Change in the detection modality
Only the positive part
of the ventricular EGM
will be sensed
After Reprogramming. Real-time telemetry
No R wave double counting
Surface ECG
Markers
RV
A
FF