ARYA Atherosclerosis Journal

Lead one ratio: A new electrocardiogram marker for cardiac resynchronization therapy response

Document Type : Original Article(s)

Authors

Ajay Raj 1
Ranjit Kumar Nath 1
Bhagya Narayan Pandit 1
Ajay Pratap Singh 2
Neeraj Pandit 3
Puneet Aggarwal 4

1 Department of Cardiology, Atal Bihari Vajpayee Institute of Medical Sciences AND Dr. Ram Manohar Lohia Hospital, New Delhi, India

2 Resident, Department of Cardiology, Atal Bihari Vajpayee Institute of Medical Sciences AND Dr. Ram Manohar Lohia Hospital, New Delhi, India

3 Professor, Department of Cardiology, Atal Bihari Vajpayee Institute of Medical Sciences AND Dr. Ram Manohar Lohia Hospital, New Delhi, India

4 Assistant Professor, Department of Cardiology, Atal Bihari Vajpayee Institute of Medical Sciences AND Dr. Ram Manohar Lohia Hospital, New Delhi, India

https://doi.org/10.22122/arya.v17i0.2247
Abstract
BACKGROUND: Wider QRS duration and presence of left bundle branch block (LBBB) predict better cardiac resynchronization therapy (CRT) response. Despite strict patient selection, one-third of patients have a sub-optimal response. We aim to evaluate the impact of lead one ratio (LOR) on CRT response.METHODS: We enrolled 93 patients receiving CRT from August 2016 to August 2019. Pre-implant 12-lead electrocardiogram (ECG) was recorded, and LOR was derived by dividing the maximum positive deflection of QRS complex in ECG lead I by the maximum negative deflection in lead I; cut-off value of 12 was used to divide the cohort into two groups. Patients were followed for 6 months, and outcomes were compared for CRT response, New York Heart Association (NYHA) class improvement, all-cause mortality, and heart failure (HF) hospitalization events.RESULTS: At the end of 6-month follow-up, LOR ≥ 12 was associated with significantly better CRT response (75.76% vs. 51.85% in LOR < 12, P = 0.02), lower mortality per 100 patient-years (9.09 vs. 14.81 in LOR < 12, P = 0.012), and more improvement in HF symptoms (NYHA improvement) (78.79% vs. 55.56% in LOR < 12, P = 0.02). Patients with LOR < 12 had more HF hospitalization events (2.04 vs. 1.81 episodes in LOR ≥ 12, P = 0.029) and less QRS narrowing (∆5.74 ± 2.09 vs. ∆7.10 ± 3.97 ms in LOR ≥ 12, P = 0.01). QRS duration and LBBB morphology were predictors of response in both groups of patients.CONCLUSION: LOR ≥ 12 was associated with better response to CRT, less HF hospitalization, and more relief in HF symptoms. This ratio helps to identify possible sub-optimal response among patients with an indication for CRT.

Keywords

Electrocardiography
Left Bundle Branch Block
Cardiac Resynchronization Therapy
Heart Failure
  1. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2016; 18(8): 891-975.
  2. Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, et al. 2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy: The task force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Europace 2013; 15(8): 1070-118.
  3. Yang S, Liu Z, Li W, Hu Y, Liu S, Jing R, et al. Validation of three European risk scores to predict long-term outcomes for patients receiving cardiac resynchronization therapy in an Asian population. J Cardiovasc Transl Res 2021; 14(4): 754-60.
  4. Brunet-Bernard A, Marechaux S, Fauchier L, Guiot A, Fournet M, Reynaud A, et al. Combined score using clinical, electrocardiographic, and echocardiographic parameters to predict left ventricular remodeling in patients having had cardiac resynchronization therapy six months earlier. Am J Cardiol 2014; 113(12): 2045-51.
  5. Guo Z, Liu X, Cheng X, Liu C, Li P, He Y, et al. Combination of left ventricular end-diastolic diameter and QRS duration strongly predicts good response to and prognosis of cardiac resynchronization therapy. Cardiol Res Pract 2020; 2020: 1257578.
  6. van Stipdonk AMW, Ter H, I, Kloosterman M, Engels EB, Rienstra M, Crijns HJGM, et al. QRS area is a strong determinant of outcome in cardiac resynchronization therapy. Circ Arrhythm Electrophysiol 2018; 11(12): e006497.
  7. Bortolotto AL, Verrier RL, Nearing BD, Marum AA, Araujo SB, Pedreira GC, et al. Preimplantation interlead ECG heterogeneity is superior to QRS complex duration in predicting mechanical super-response in patients with non-left bundle branch block receiving cardiac resynchronization therapy. Heart Rhythm 2020; 17(11): 1887-96.
  8. Rattanawong P, Prasitlumkum N, Riangwiwat T, Kanjanahattakij N, Vutthikraivit W, Chongsathidkiet P, et al. Baseline prolonged pr interval and outcome of cardiac resynchronization therapy: A systematic review and meta-analysis. Arq Bras Cardiol 2018; 111(5): 710-9.
  9. Jiang Z, Qiu Y, Qian Z, Wang Y, Zhao Y, Hou X, et al. An S wave in ECG lead V6 predicts poor response to cardiac resynchronization therapy and long-term outcome. Heart Rhythm 2020; 17(2): 265-72.
  10. Mollo R, Cosenza A, Coviello I, Stazi A, Russo G, Villano A, et al. A novel electrocardiographic predictor of clinical response to cardiac resynchronization therapy. Europace 2013; 15(11): 1615-21.
  11. Engels EB, Vegh EM, Van Deursen CJ, Vernooy K, Singh JP, Prinzen FW. T-wave area predicts response to cardiac resynchronization therapy in patients with left bundle branch block. J Cardiovasc Electrophysiol 2015; 26(2): 176-83.
  12. Loring Z, Atwater BD, Xia X, Axelsson J, Klem I, Nijveldt R, et al. Low lead one ratio predicts clinical outcomes in left bundle branch block. J Cardiovasc Electrophysiol 2019; 30(5): 709-16.
  13. Hartlage GR, Suever JD, Clement-Guinaudeau S, Strickland PT, Ghasemzadeh N, Magrath RP 3rd, et al. Prediction of response to cardiac resynchronization therapy using left ventricular pacing lead position and cardiovascular magnetic resonance derived wall motion patterns: a prospective cohort study. J Cardiovasc Magn Reson 2015; 17: 57.
  14. Cavallino C, Rondano E, Magnani A, Leva L, Inglese E, Dell'era G, et al. Baseline asynchrony, assessed circumferentially using temporal uniformity of strain, besides coincidence between site of latest mechanical activation and presumed left ventricular lead position, predicts favourable prognosis after resynchronization therapy. Int J Cardiovasc Imaging 2012; 28(5): 1011-21.
  15. Loring Z, Friedman DJ, Emerek K, Graff C, Sorensen PL, Hansen SM, et al. Lead one ratio in left bundle branch block predicts poor cardiac resynchronization therapy response. Pacing Clin Electrophysiol 2020; 43(5): 503-10.
  16. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart-failure: Executive summary. J Am Coll Cardiol 2013; 62(16): 1495-539.
  17. Fornwalt BK, Sprague WW, BeDell P, Suever JD, Gerritse B, Merlino JD, et al. Agreement is poor among current criteria used to define response to cardiac resynchronization therapy. Circulation 2010; 121(18): 1985-91.
  18. Molhoek SG, Bax JJ, van EL, Bootsma M, Boersma E, Steendijk P, et al. Comparison of benefits from cardiac resynchronization therapy in patients with ischemic cardiomyopathy versus idiopathic dilated cardiomyopathy. Am J Cardiol 2004; 93(7): 860-3.
  19. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015; 28(1): 1-39.
  20. Cheng YJ, Zhang J, Li WJ, Lin XX, Zeng WT, Tang K, et al. More favorable response to cardiac resynchronization therapy in women than in men. Circ Arrhythm Electrophysiol 2014; 7(5): 807-15.
  21. Auricchio A, Lumens J, Prinzen FW. Does cardiac resynchronization therapy benefit patients with right bundle branch block: Cardiac resynchronization therapy has a role in patients with right bundle branch block. Circ Arrhythm Electrophysiol 2014; 7(3): 532-42.
  22. Linde C, Daubert C, Abraham WT, St John SM, Ghio S, Hassager C, et al. Impact of ejection fraction on the clinical response to cardiac resynchronization therapy in mild heart failure. Circ Heart Fail 2013; 6(6): 1180-9.
  23. Healey JS, Hohnloser SH, Exner DV, Birnie DH, Parkash R, Connolly SJ, et al. Cardiac resynchronization therapy in patients with permanent atrial fibrillation: Results from the Resynchronization for Ambulatory Heart Failure Trial (RAFT). Circ Heart Fail 2012; 5(5): 566-70.
  24. Daoulah A, Alsheikh-Ali AA, Al-Faifi SM, Ocheltree SR, Haq E, Asrar FM, et al. Cardiac resynchronization therapy in patients with postero-lateral scar by cardiac magnetic resonance: A systematic review and meta-analysis. J Electrocardiol 2015; 48(5): 783-90.
  25. Auricchio A, Fantoni C, Regoli F, Carbucicchio C, Goette A, Geller C, et al. Characterization of left ventricular activation in patients with heart failure and left bundle-branch block. Circulation 2004; 109(9): 1133-9.
ARYA Atherosclerosis Journal
Volume 17, Issue 1
January and February 2021
Pages 1-8

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