Published Online
on February 12, 2007

A more recent version of this article appeared on February 27, 2007

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Submitted on June 5, 2006
Accepted on November 15, 2006

Three-Dimensional Mapping of Optimal Left Ventricular Pacing Site for Cardiac Resynchronization

Robert H. Helm MD, Melissa Byrne PhD, Patrick A. Helm PhD, Samantapudi K. Daya MD, MRP, Nael Osman PhD, Richard Tunin MS, Henry R. Halperin MD, Ronald D. Berger MD, PhD, David A. Kass MD, and Albert C. Lardo PhD^*

From the Department of Medicine, Division of Cardiology (R.H.H., M.B., S.K.D., R.T., H.R.H., R.D.B., D.A.K., A.C.L.), Department of Biomedical Engineering (P.A.H., H.R.H., R.D.B., D.A.K., A.C.L.), Department of Surgery (A.C.L.), and Department of Radiology (N.O., H.R.H., A.C.L.), Johns Hopkins University, Baltimore, Md.

^* To whom correspondence should be addressed. E-mail: al{at}jhmi.edu.

Background--The efficacy of cardiac resynchronization therapy (CRT) depends on placement of the left ventricular lead within the late-activated territory. The geographic extent and 3-dimensional distribution of left ventricular (LV) locations yielding optimal CRT remain unknown.

Methods and Results--Normal or tachypacing-induced failing canine hearts made dyssynchronous by right ventricular free wall pacing or chronic left bundle-branch ablation were acutely instrumented with a nonconstraining epicardial elastic sock containing 128 electrodes interfaced with a computer-controlled stimulation/recording system. Biventricular CRT was performed using a fixed right ventricular site and randomly selected LV sites covering the entire free wall. For each LV site, global cardiac function (conductance catheter) and mechanical synchrony (magnetic resonance imaging tagging) were determined to yield 3-dimensional maps reflecting CRT impact. Optimal CRT was achieved from LV lateral wall sites, slightly more anterior than posterior and more apical than basal. LV sites yielding 70% of the maximal dP/dtmax increase covered 43% of the LV free wall. This distribution and size were similar in both normal and failing hearts. The region was similar for various systolic and diastolic parameters and correlated with 3-dimensional maps based on mechanical synchrony from magnetic resonance imaging strain analysis.

Conclusions--In hearts with delayed lateral contraction, optimized CRT is achieved over a fairly broad area of LV lateral wall in both nonfailing and failing hearts, with modest anterior or posterior deviation still capable of providing effective CRT. Sites selected to achieve the most mechanical synchrony are generally similar to those that most improve global function, confirming a key assumption underlying the use of wall motion analysis to optimize CRT.

Key words: bundle-branch block • heart failure • pacing

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