Atrioventricular optimization in cardiac resynchronization therapy with quadripolar leads: should we optimize every pacing configuration including multi-point pacing?

Wouter M. van Everdingen*, Alwin Zweerink, Odette A. E. Salden, Maarten J. Cramer, Pieter A. Doevendans, Albert C. van Rossum, Frits W. Prinzen, Kevin Vernooy, Cornelis P. Allaart, Mathias Meine

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

124 Downloads (Pure)


Aims This study aims to define an atrioventricular (AV) delay optimization method for cardiac resynchronization therapy (CRT) with a quadripolar left ventricular (LV) lead based on intrinsic conduction intervals.

Methods and results Heart failure patients with a left bundle branch block underwent CRT implantation with a quadripolar LV lead. Invasive LV pressure-volume loops were recorded during four biventricular and three multi-point pacing (MPP) settings, using four patient-specific paced AV delays. Haemodynamic response was defined as change in stroke work (A%SW) compared to intrinsic rhythm and was related to the following conduction intervals: right atrial pacing to right ventricular sensing interval (RAp-RVs), Q to LV sensing interval normalized to QRS duration (QLV/QRSd), PR-interval, and P-wave duration. In 44 patients, the largest Delta%SW (104 +/- 76%) occurred at a paced AV delay of 128 +/- 32 ms, at 47 +/- 9% of RAp-RVs. Optimal AV delay of biventricular pacing (126 +/- 26 ms) did not differ from MPP (126 +/- 21 ms, P = 0.29). Intra-class correlation coefficient between optimal AV delays of different pacing configurations was 0.64 (0.45-0.78, P <0.001). Although not statistically significant, Delta%SW at 50% of RAp-RVs (98 +/- 74%) was closer to the maximal achievable Delta%SW increase than a fixed interval of 120ms (96 +/- 73%, P = 0.60). RAp-RVs, QLV/QRSd, PR interval, and P-wave duration were associated with the optimal AV delay in univariate analysis, but only RAp-RVs remained significantly associated in multivariate analysis (R = 0.69).

Conclusion The AV delay that provides highest haemodynamic response is similar for various LV pacing configurations and for MPP. An AV delay similar to 50% of RAp-RVs creates an acute haemodynamic response close to the maximal patient-specific response.

Original languageEnglish
Pages (from-to)E11-E19
Number of pages9
JournalEP Europace
Issue number1
Publication statusPublished - Jan 2019


  • Cardiac resynchronization therapy
  • Atrioventricular delay
  • Pressure-volume loops
  • Optimization
  • Multi-point pacing
  • Quadripolar lead

Cite this