Comparison of different invasive hemodynamic methods for AV delay optimization in patients with cardiac resynchronization therapy: Implications for clinical.

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Comparison of different invasive hemodynamic methods for AV delay optimization in patients with cardiac resynchronization therapy: Implications for clinical trial design and clinical practice Zachary I. Whinnett, Darrel P. Francis, Arnaud Denis, Keith Willson, Patrizio Pascale, Irene van Geldorp, Maxime De Guillebon, Sylvain Ploux, Kenneth Ellenbogen, Michel Haïssaguerre, Philippe Ritter, Pierre Bordachar International Journal of Cardiology Volume 168, Issue 3, Pages 2228-2237 (October 2013) DOI: 10.1016/j.ijcard.2013.01.216 Copyright © 2013 Elsevier Ireland Ltd Terms and Conditions

Fig. 1 Description of the four tested protocols for processing the dp/dtmax signal for AV delay optimization. (a) Immediate absolute LV dp/dtmax protocol: mean of a 10second recording commenced immediately after a transition to the tested AV delay (not compared to a reference setting). (b) Delayed absolute LV dp/dtmax protocol: mean of a 10second recording commenced after a 30second stabilisation period following the transition to the tested AV delay. (c) Single relative LV dp/dtmax protocol: the relative change in LV dp/dtmax measured with a single transition between a reference AV delay (120ms) and the tested AV delay. (4) Multiple relative LV dp/dtmax: the mean relative change in LV dp/dtmax calculated from a total of six transitions to and from the tested AV delay (three forward transitions to the tested AV delay and three back transitions to the reference AV delay, reversing the sign for the back transitions). International Journal of Cardiology 2013 168, 2228-2237DOI: (10.1016/j.ijcard.2013.01.216) Copyright © 2013 Elsevier Ireland Ltd Terms and Conditions

Fig. 2 Method for calculating scatter and curvature which are the biological determinants of the reproducibility of the optimum AV delay. Data from one patient is shown in order to describe how Scatter and Curvature can be calculated. Scatter is the spontaneous variability in measurements and is calculated as the standard deviation of the repeated measurements (shown in panel a). Curvature expresses how quickly the underlying measurement declines with distance away from the optimum. It is approximately parabolic and it is possible to calculate the underlying curvature by measuring the change in the acute hemodynamic parameter occurring over a known change in AV delay (panel b). The scatter:curvature ratio is calculated for each tested hemodynamic parameter in order to compare precision when used for AVD optimisation. The ratio between scatter and curvature is the biological determinant of the test–retest variability of the optimum: higher ratios indicate greater variability (panel c). SD: standard deviation. International Journal of Cardiology 2013 168, 2228-2237DOI: (10.1016/j.ijcard.2013.01.216) Copyright © 2013 Elsevier Ireland Ltd Terms and Conditions

Fig. 3 Same day reproducibility of AV delay optimization, using the four tested protocols for processing left ventricular dp/dtmax. Line of equivalence (dashed line) is displayed. International Journal of Cardiology 2013 168, 2228-2237DOI: (10.1016/j.ijcard.2013.01.216) Copyright © 2013 Elsevier Ireland Ltd Terms and Conditions

Fig. 4 Agreement with each other with regard to AV delay determined as optimal, for the 4 different protocols tested for processing LV dp/dtmax. International Journal of Cardiology 2013 168, 2228-2237DOI: (10.1016/j.ijcard.2013.01.216) Copyright © 2013 Elsevier Ireland Ltd Terms and Conditions

Fig. 5 Test–retest agreement with regard to the AV delay determined as optimal for three tested invasive hemodynamic measures. We used the multiple relative protocol to process the hemodynamic signals. International Journal of Cardiology 2013 168, 2228-2237DOI: (10.1016/j.ijcard.2013.01.216) Copyright © 2013 Elsevier Ireland Ltd Terms and Conditions

Fig. 6 Hemodynamic consequence of progressively programming the AV delay longer or shorter than optimal. In order to minimise bias we used separate measurements to identify the optimal AV delay from those used to measure the hemodynamic consequences of programming a longer or shorter AV delay. International Journal of Cardiology 2013 168, 2228-2237DOI: (10.1016/j.ijcard.2013.01.216) Copyright © 2013 Elsevier Ireland Ltd Terms and Conditions