Effect of optimizing the VV interval on left ventricular contractility in cardiac resynchronization therapy

Simultaneous biventricular pacing improves left ventricular (LV) function in patients with heart failure and LV asynchrony. Proper timing of the interventricular pacing interval (VV interval) may further optimize LV function. We investigated the acute hemodynamic response of changing the VV interval using maximum LV dP/dt (LV dP/dt_max) as a parameter for LV function. A biventricular pacemaker was implanted in 53 patients with severely impaired LV function, New York Heart Association class III and IV heart failure, left bundle branch block, LV asynchrony, and a QRS interval >150 ms. Optimization of the atrioventricular and VV intervals was based on measurement of LV dP/dt_max by a 0.014-in sensor-tipped pressure guidewire. Measurement of LV dP/dt_max was obtained without complications in all patients. In patients in sinus rhythm with ischemic cardiomyopathy or idiopathic dilated cardiomyopathy, mean improvements by simultaneous biventricular pacing were 17% and 18%, respectively. Patients in atrial fibrillation showed an improvement of 21%. Optimizing the VV interval resulted in further absolute increases of 8%, 7%, and 3%, respectively, in dP/dt_max in the 3 groups. Maximum dP/dt was achieved with LV pacing first in 44 patients, simultaneous right and left ventricular pacing in 6 patients, and right ventricular pacing first in 3 patients. The mean optimal VV intervals were 37 ± 32 ms in the atrial fibrillation group, 28 ± 30 ms in the idiopathic dilated cardiomyopathy group, and 52 ± 31 ms in the ischemic cardiomyopathy group. Optimization of the VV interval significantly increased LV dP/dt_max compared with simultaneous biventricular pacing, and such optimization could be easily, accurately, and reliably evaluated by a 0.014-in sensor-tipped pressure guidewire.