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Biventricular paced QRS area predicts acute hemodynamic CRT response better than QRS duration or QRS amplitudes

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Abstract
Introduction: Vectorcardiographic (VCG) QRS area of left bundle branch block (LBBB) predicts acute hemodynamic response in cardiac resynchronization therapy (CRT) patients. We hypothesized that changes in QRS area occurring with biventricular pacing (BV) might predict acute hemodynamic CRT response (AHR). Methods and Results: VCGs of 624 BV paced electrocardiograms (25 LBBB patients with 35 different pacing configurations) were calculated according to Frank's orthogonal lead system. Maximum QRS vector amplitudes (X-Ampl, Y-Ampl, Z(Ampl), and 3D(Amp)) and QRS areas (X-Area, Y-Area, Z(Area), and 3D(Area)) in the orthogonal leads (X, Y, and Z) and in 3-dimensional projection were measured. Volume of the 3D vector loop and global QRS duration (QRSD) on the surface electrocardiogram were assessed. Differences (Delta) in VCG parameters between BV paced and LBBB QRS complexes were calculated. An increase of 10% in dP/dt max was considered as AHR. LBBB conduction is characterized by a large Z(Area) (109 mu Vs, interquartile range [ IQR]: 75; 135), significantly larger than X-Area (22 mu Vs, IQR: 10; 57) and Y-Area (44 mu Vs, IQR: 32; 62, P< 0.001). Overall, QRS duration, amplitudes, and areas decrease significantly with BV pacing (P <0.001). Of all VCG parameters, 3D(Ampl), Delta 3D(Ampl), ZArea, Delta ZArea, Delta 3DArea, and Delta QRSD differentiate AHR response from nonresponse (P < 0.05). Delta Z(Area) predicted best positive AHR (area under the curve = 0.813) and outperformed any other VCG parameter or QRSD measurement. Conclusion: Of all VCG parameters, reduction in QRS area, calculated in Frank's Z lead, predicts acute hemodynamic response best. This method might be an easy, noninvasive tool to guide CRT implantation and optimization.
Keywords
biventricular pacing, cardiac resynchronization therapy, QRS area, vectorcardiography, CARDIAC RESYNCHRONIZATION THERAPY, BUNDLE-BRANCH BLOCK, HEART-FAILURE, TASK-FORCE, VECTORCARDIOGRAPHY, ELECTROCARDIOGRAM, MORPHOLOGY, OPTIMIZATION, CANDIDATES, GUIDELINES

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Chicago
De Pooter, Jan, Milad El Haddad, Marc De Buyzere, Hernandez Alfonso Aranda, Richard Cornelussen, Berthold Stegemann, Christopher A Rinaldi, et al. 2017. “Biventricular Paced QRS Area Predicts Acute Hemodynamic CRT Response Better Than QRS Duration or QRS Amplitudes.” Journal of Cardiovascular Electrophysiology 28 (2): 192–200.
APA
De Pooter, J., El Haddad, M., De Buyzere, M., Aranda, H. A., Cornelussen, R., Stegemann, B., Rinaldi, C. A., et al. (2017). Biventricular paced QRS area predicts acute hemodynamic CRT response better than QRS duration or QRS amplitudes. JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, 28(2), 192–200.
Vancouver
1.
De Pooter J, El Haddad M, De Buyzere M, Aranda HA, Cornelussen R, Stegemann B, et al. Biventricular paced QRS area predicts acute hemodynamic CRT response better than QRS duration or QRS amplitudes. JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY. 2017;28(2):192–200.
MLA
De Pooter, Jan, Milad El Haddad, Marc De Buyzere, et al. “Biventricular Paced QRS Area Predicts Acute Hemodynamic CRT Response Better Than QRS Duration or QRS Amplitudes.” JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY 28.2 (2017): 192–200. Print.
@article{8514313,
  abstract     = {Introduction: Vectorcardiographic (VCG) QRS area of left bundle branch block (LBBB) predicts acute hemodynamic response in cardiac resynchronization therapy (CRT) patients. We hypothesized that changes in QRS area occurring with biventricular pacing (BV) might predict acute hemodynamic CRT response (AHR). 
Methods and Results: VCGs of 624 BV paced electrocardiograms (25 LBBB patients with 35 different pacing configurations) were calculated according to Frank's orthogonal lead system. Maximum QRS vector amplitudes (X-Ampl, Y-Ampl, Z(Ampl), and 3D(Amp)) and QRS areas (X-Area, Y-Area, Z(Area), and 3D(Area)) in the orthogonal leads (X, Y, and Z) and in 3-dimensional projection were measured. Volume of the 3D vector loop and global QRS duration (QRSD) on the surface electrocardiogram were assessed. Differences (Delta) in VCG parameters between BV paced and LBBB QRS complexes were calculated. An increase of 10\% in dP/dt max was considered as AHR. LBBB conduction is characterized by a large Z(Area) (109 mu Vs, interquartile range [ IQR]: 75; 135), significantly larger than X-Area (22 mu Vs, IQR: 10; 57) and Y-Area (44 mu Vs, IQR: 32; 62, P{\textlangle} 0.001). Overall, QRS duration, amplitudes, and areas decrease significantly with BV pacing (P {\textlangle}0.001). Of all VCG parameters, 3D(Ampl), Delta 3D(Ampl), ZArea, Delta ZArea, Delta 3DArea, and Delta QRSD differentiate AHR response from nonresponse (P {\textlangle} 0.05). Delta Z(Area) predicted best positive AHR (area under the curve = 0.813) and outperformed any other VCG parameter or QRSD measurement. 
Conclusion: Of all VCG parameters, reduction in QRS area, calculated in Frank's Z lead, predicts acute hemodynamic response best. This method might be an easy, noninvasive tool to guide CRT implantation and optimization.},
  author       = {De Pooter, Jan and El Haddad, Milad and De Buyzere, Marc and Aranda, Hernandez Alfonso and Cornelussen, Richard and Stegemann, Berthold and Rinaldi, Christopher A and Sterlinski, Maciej and Sokal, Adam and Francis, Darrel P and Jordaens, Luc and Stroobandt, Roland and Van Heuverswyn, Frederic and Timmermans, Frank},
  issn         = {1045-3873},
  journal      = {JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY},
  language     = {eng},
  number       = {2},
  pages        = {192--200},
  title        = {Biventricular paced QRS area predicts acute hemodynamic CRT response better than QRS duration or QRS amplitudes},
  url          = {http://dx.doi.org/10.1111/jce.13132},
  volume       = {28},
  year         = {2017},
}

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