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1 Declaration of conflict of interest
2 Electrical activation pattern in Left Bundle Branch Block Patients Angelo Auricchio, MD FESC Director, Cardiac Electrophysiology Programme, Fondazione Cardiocentro Ticino, Lugano, Switzerland Professor of Cardiology, University of Magdeburg,, Germany President European Heart Rhythm Association Session Title: From Bench to Practice: Cardiac Resynchronization Therapy Room: Tallin, Vilage: 7 27/08/2012; 08:30 10:00 2
3 Electrical activation in patients with normal QRS duration 3D map, 700 electrodes LAO 45 View Postero-Anterior View RV RV LV LV Durrer et al, 1970 RV Endocardial Breakthrough LV Endocardial Breakthrough Latest Region of Endocardial Activation 3
4 Electrical activation in Left Bundle Branch Block Single LV breakthrough point (67%) Dual LV breakthrough point (33%) Mid septum: 9/12 Apex:3/12 Mid septum: 5/6 Apex: 1/6 Basal anter free wall: 3/6 Apex: 2/6 Sup Base: 1/6 Vassallo et al. Circulation 1984; 5: , 4
5 Right and left ventricular activation in LBBB RAO 30 LAO 60 LAO 90 His RV RV LV LV T V LV RV Coronary Sinus Apex Apex 5
6 Large heterogeneity in activation time Early QRS onset to earliest LV activated point: Time to LV Breakthrough Time to LV breakthrough Total endocardial activation time Time to end of QRS complex (V6) All mappings conducted using Carto system N=83 CAD (n=27) DCM (n=56) Latest endocardial activated point to end of QRS complex on surface ECG Prinzen and Auricchio. Circulation Cardiovasc Imaging 2008 Total QRS Duration 168 ±19 ms 169 ± 21 ms Time to LV breakthrough 36 ± 12 ms 47 ± 14 ms Total LV activation time 116 ± 27 ms 108 ± 23 ms 6
7 Time to LV breakthrough in LBBB Time to LV breakthrough Total endocardial activation time Time to end of QRS complex (QRS max) 20 ms 40 ms Time to LV Breakthrough : 70 ms All mappings conducted using Carto system Time to LV Breakthrough 10 ms Prinzen and Auricchio. Circulation Cardiovasc Imaging 2008 Strauss et al. AJC
8 How time to LV breakthrough changes with heart failure development? Courtesy Prof Prinzen, University of Mastricht, NL 8
9 Sweeney et al. Circulation 2010;121:
10 RV and LV Endocardial Activation in LBBB Patients LAO 60 Total Ventricular Activation Time: 157 msec RV Activation Time: 57 msec LV Activation Time: 105 msec Total Ventricular Activation Time: 189 msec RV Activation Time: 85 msec LV Activation Time: 137 msec Total Ventricular Activation Time: 205 msec RV Activation Time: 130 msec LV Activation Time: 145 msec 10
11 Heart failure development in LBBB results in changes of conduction velocity Strik et al. Circ A & E
12 Local EGMs in complete LBBB Unipolar EGM (NOGA) Unipolar EGM (EnSite) Line of Block Unipolar EGM (NOGA) Unipolar EGM (NOGA) Auricchio et al. Circulation
13 Changes of line of block position and length with QRS change in LBBB patients Normal QRS QRS ms QRS >140 Appearance of Line of Block (Basal region) Lengthening and anterior displacement
14 LV activation sequence in dilated cardiomyopathy and heart failure U-shaped activation sequence Normal QRS Morphology and Duration QRS Duration: 125 ms QRS Duration: 158 ms
15 Consistent findings with different mapping technologies QRS Duration: 135 ms LBBB QRS Duration: 173 ms LBBB Duckett et al. Europace 2012 Gosh et al. Heart Rhythm
16 Mechanical consequences Large Septal Flash U-shaped Activation Sequence No Septal Flash Uniform Activation Sequence Duckett et al. Europace 2012
17 QRS Duration (ms) Etiology has little impact on activation timing and sequence in sinus rhythm DCM CAD 180 QRS duration QRS Duration: 205 msec QRS Duration: 243 msec 160 Total LV Activation Time 140 Time to LV breakthrough Anterior myocardial Infarction (scar zone) DCM (LBBB) CAD (LBBB) LAO 60
18 Electrical activation in dog model of chronic myocardial infarction Rademakers et al. Circ A & E
19 Importance of LV lead location in chronic canine model of myocardial infarction RV RV LV LV Rademakers et al. Circ A & E
20 CRT Model development, validation and implementation Simulated Intracardiac Activation Map and Voltage Simulated ECG Local activation time (ms) Unipolar Voltage (mv) Bipolar Voltage (mv) NOGA Mapping System
21 Acknowledgments Fondazione Cardiocentro Ticino, Switzerland - Tiziano Moccetti - Francois Regoli - Marta Aceňa Ramos Institute of Computational Science, University of Lugano, Switzerland - Rolf Krause - Mark Potse - Wilco Kroon - Dorian Krause CARIM, Maastricht University, The Netherlands - Frits Prinzen - Mark Strik 21
22 Thank you for your attention
23 THANK YOU for your attention 23
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