Hemodynamic Optimization in Cardiac Resynchronization Therapy: Should We Aim for dP/dtmax or Stroke Work?

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

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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OBJECTIVES: This study evaluated the acute effect of dP/dtmax- versus stroke work (SW)-guided cardiac resynchronization therapy (CRT) optimization and the related acute hemodynamic changes to long-term CRT response.

BACKGROUND: Hemodynamic optimization may increase benefit from CRT. Typically, maximal left ventricular (LV) pressure rise dP/dtmax is used as an index of ventricular performance. Alternatively, SW can be derived from pressure-volume (PV) loops.

METHODS: Forty-one patients underwent CRT implantation followed by invasive PV loop measurements. The stimulation protocol included 16 LV pacing configurations using each individual electrode of the quadripolar lead with 4 atrioventricular (AV) delays. Conventional CRT was defined as pacing from the distal electrode with an AV delay of approximately 120 ms.

RESULTS: Compared with conventional CRT, dP/dtmax-guided optimization resulted in a one-third additional dP/dtmax increase (17 ± 11% vs. 12 ± 9%; p < 0.001). Similarly, SW-guided optimization resulted in a one-third additional SW increase (80 ± 55% vs. 53 ± 48%; p < 0.001). Comparing both optimization strategies, dP/dtmax favored contractility (8 ± 12% vs. 5 ± 10%; p = 0.015), whereas SW optimization improved ventricular-arterial (VA) coupling (45% vs. 32%; p < 0.001). After 6 months, mean LV ejection fraction (LVEF) change was 10 ± 9% with 23 (56%) patients becoming super-responders to CRT (≥10% LVEF improvement). Although acute changes in SW were predictive for long-term CRT response (area under the curve: 0.78; p = 0.002), changes in dP/dtmax were not (area under the curve: 0.65; p = 0.112).

CONCLUSIONS: PV-guided hemodynamic optimization in CRT results in approximately one-third SW improvement on top of conventional CRT, caused by a mechanism of enhanced VA coupling. In contrast, dP/dtmax optimization favored LV contractility. Ultimately, acute changes in SW showed larger predictive value for long-term CRT response compared with dP/dtmax.

Original languageEnglish
Pages (from-to)1013-1025
Number of pages13
JournalJACC: Clinical Electrophysiology
Issue number9
Publication statusPublished - Sep 2019


  • cardiac resynchronization therapy (CRT)
  • dP/dt(max)
  • hemodynamic optimization
  • pressure volume loops
  • quadripolar LV leads
  • stroke work
  • LOAD

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