0. Optimization of AV and VV Delays
Lumax 540 CRM Training and Education
Optimization of AV and VV Delays

1. Optimization of BiV Pacing
A-V Delay
V-V Delay

2. AV Delay Optimization Goals Ensure BiV pacing
Improve diastolic filling
Reduce mitral regurgitation
Cardiac Output 

3. AV Delay Optimization AV too long Close to intrinsic PR (fusion)
Loss of CRT
AV too short
Premature mitral valve closure
Hemodynamic compromise

4. AV Delay Optimization Methods Empirical Calculation Echocardiography
Pulse pressure

5. AV Delay Optimization Aortic Pressure in percent LV dP/dtmaxRV LV
BiV
Aortic Pressure
in percent
LV dP/dtmax
in percent 16 24 12 18 8 12 4 6 PR
- 30 ms PR
- 30 ms -4 -6
-12 -8
A-V Delay
A-V Delay
Auricchio et al., Circulation 1999

6. AV Delay Optimization Calculation (PR interval) - 30 ms AVopt = 2
Example for As-Vs = 220 ms AVopt = (220-30)/2 = 95 ms
Auricchio et al., Circulation 1999

7. AV Delay Optimization Limitations of Calculation Methods
LV lead in anterior vein
RBBB
Intrinsic PR > 300 ms
AV block II°/III°

8. AV Delay Optimization Doppler Echocardiography
Flow Velocity at Mitral Valve
Aortic Velocity Time Integral

9. Echocardiography
4 Chamber View
Apical Position

10. Apical 4-Chamber View

11. Doppler-Echocardiography
Fd = Doppler frequency
f0 = Ultrasound frequency (e.g., 2.4 MHz)
V = Blood flow velocity
 = Angle between sound beam and direction of blood flow
c = Speed of sound in human tissue (1,530 m/s)
2 V cos 
Fd = f0 c

12. Doppler-Echocardiography
Blood flow velocity
Spectral analysis
1.5
1.0
0.5

13. Mitral Valve Doppler Echo
LV Ejection
Filling
ECG
Doppler
Sample
Volume

14. Pulsed Wave Doppler Echo
4 Chamber View
E/A Ratio
Mitral Valve

15. Pulsed Wave Doppler Echo
ECG E A
Velocity
(cm/s)
Time (50mm/s)

16. AV Delay Optimization Doppler Echo
Transmitral Flow Velocity  LV filling pressure
E wave Early diastolic passive filling of the left ventricle
A wave Late diastolic active filling of the left ventricle  atrial contribution

17. Normal Heart Cycle R P T P P Q S A A A E IVC IVR E IVC IVR E Aortic
Flow
Aortic
Flow
Isovolumic
Contraction
Isovolumic
Relaxation
LVFT
Left Ventricular
Filling Time

18. Left Bundle Branch Block
R1 R2
R1 R2 P Q T T A A A A E

19. LBBB: Late MV Closure R1 R2 R1 R2 P Q T P P Mitral Valve Closure MVC A
IVC*
IVC*
Aortic Valve Opening
AVO
* IVC = Isovolumic Contraction

20. LBBB: Late End of LV Systole
R1 R2
R1 R2 P Q T P P
MVC
MVC A A A
IVC
IVC
Aortic
Flow
Aortic
Flow
AVO
Aortic Valve Closure
Ejection
LV Systole

21. LBBB: Late Start of LV Filling
R1 R2
R1 R2 P Q T P Q T P
MVC
MVO* A A A
IVC
IVR*
Aortic
Flow
Aortic
Flow
AVO
AVC
* MVO = Mitral Valve Opening
** IVR = Isovolumic Relaxation

22. LBBB: Fusion of E and A R1 R2 R1 R2 P Q T P Q T P A A A E E E Aortic
Flow
Aortic
Flow
Short LV
Filling
Time
250 ms
at HR 65/min

23. LBBB: Resynchronization
R1 R2
R1 R2 P Q T P Q T P
MVC A A A E
IVC
IVR E E
Aortic
Flow
Aortic
Flow
Pre Ejection Period (PEP)

24. Biventricular Pacing BiV BiV BiV AVD T T P P P MVC MVC A A A E IVC E
Aortic
Flow
Aortic
Flow
Pro- longed
LV Filling
Time
PEP
325 ms
at HR 65/min

25. AV Optimization Short AV Delay Long AV Delay Ritter Formula Forced MVCQA QA
A wave
truncation
Spontaneous
MVC A A E E
Ritter Formula

26. AVopt = AVshort + [(AVlong - AVshort) - (QAshort - QAlong)]
AV Delay Optimization
Ritter Formula
"The Difference of the Differences"
AVopt = AVshort + [(AVlong - AVshort) - (QAshort - QAlong)]
Programmed AV Delays
AVshort = short AV (25% of PR)
AVlong = long AV (75% of PR)
Measured QA Intervals
QAshort = QA at short AV
QAlong = QA at long AV
Ritter et al., PACE 1995

27. Transmitral Flow At short AV delay AVshort = 50 ms QAshort = 128 ms
Begin Q A E
128 ms

28. Transmitral Flow At long A-V delay AVlong = 160 ms QAlong = 48 ms Q A

29. AV Delay Optimization Result Programmed AV Delays AVshort = 50 ms
AVlong = 160 ms
Measured QA Intervals
QAshort = 128 ms
QAlong = 48 ms
"The Difference of the Differences"
AVopt = AVshort + [(AVlong - AVshort) - (QAshort - QAlong)]
AVopt = 50 + [(160-50)-( )]
= 50 + ( )
AVopt = 80 ms

30. AV Delay Optimization
Short AV
Long AV
Optimal AV

31. AV Delay Optimization Doppler Echocardiography
Flow Velocity at Mitral Valve
Aortic Velocity Time Integral

32. Doppler Echo
Apical Five Chamber View

33. Doppler Echo
Aortic Flow Velocity
Kruck, Biamino 1988

34. Aortic Flow Velocity
LBBB A A A
Aortic
Flow
Aortic
Flow
Time
Velocity

35. Aortic Flow Velocity Biventricular Pacing AVD A E Aortic Flow Aortic
Time
Velocity

36. Velocity Time Integral
Integral = Area under the curve
VTI =
AVO
AVC
V * dt
(cm)
Fehske 1988

37. Velocity Time Integral
Ejection time
Time
vmax
vmean
Vmax = 1.58 m/s
Vmean = 1.09 m/s
ET = 288 ms
VTI = Vmean * ET
VTI = 0.31 m
Velocity
(m/s)
ECG

38. AV Delay Optimization Velocity Time Integral VTI = 12.7 cm
Dr. Uhrig, Vivantes Urban Hospital Berlin

39. VTI Method Derived Parameters Stroke Volume SV = VTI * A
VTI = Velocity Time Integral
A = Aortic Valve Area
Cardiac Output
CO = SV * HR
HR = Heart Rate
Fehske 1988

40. VTI Method Objective Identify optimal AV delay at max. VTI Procedure
CW Doppler of aortic outflow tract
Decrement AV delay by 20 ms down to ≥ 80 ms
Limitations
Doppler signal quality
Breathing modulations
Intrinsic error %

41. AV Delay Optimization
30 Pts. after CRT implantation NYHA III-IV, LVEF < 35%, SR
BiV on atrial sensed beats AV optimization on LV dp/dt max
Comparison to Ritter formula, diastolic filling time (DFT), LV VTI, E/A VTI
Jansen et al., Am J Cardiol 2006

42. LV dP/dt max LV Pressure (mmHg) dP/dt (mmHg/s)
Jansen et al., Am J Cardiol 2006

43. Compliance with LV dP/dt max. measurements
Good
Good to reasonable %
Jansen et al., Am J Cardiol 2006

44. AV Delay Optimization Methods Empirical Calculation Echocardiography
Pulse pressure

45. Pulse Pressure Method Objective
Identify AV delay that provides maximal difference between systolic and diastolic blood pressure
Procedure
Arterial line to measure central aortic pressure accurately

46. Pulse Pressure Method Intrinsic Paced Pressure P Vp Time Pressure P R
Aorta LV
PEP
Time
Auricchio et al., PACE 1998

47. Pulse Pressure Method BiV Pacing 110 Aortic Pressure (mmHg) 85 60
LV IEGM
Time (s) 1 2 3 4 5 6 7 8 9

48. AV Delay Optimization Summary Pulse pressure: hemodynamic testing
Calculation: initial programming
Doppler Echo: non-responders

49. Optimization of BiV Pacing
A-V Delay
V-V Delay

50. V-V Delay OptimizationAV AV AV AS AS AS VV VV
LVP
RVP
LVP
RVP
RVP
LVP
VV = 0
LV first
RV first

51. V-V Optimization 41 pts. with CHF after CRT-PM AV delay optimization
RV-/LV pre-activation: 0, 12, 20, 40, 80 ms
Endpoints: Cardiac output, mitral regurgitation from echo
Bordachar et al., JACC 2004

52. V-V Optimization Echocardiographic Parameters
M-mode: septal-to-posterior wall motion delay (SPWMD)
Doppler: Interventricular mechenical delay (IVMD)
Tissue Doppler:
Intra LV delay onset (LV onset)
Intra LV delay peak (LV peak)
SD from 12 segments intra LV delay peak (SD LV peak))
Delayed longitudinal contraction (DLC)
Bordachar et al., JACC 2004

53. V-V Optimization Correlation to Hemodynamics Cardiac Output
Mitral Regurgitation
Parameter
LV peak
SD LV peak
LV onset
DLC
SPWMD
IVMD
-0.67
-0.64
-0.48
-0.41
-0.24
0.68
0.63
0.51
0.24
0.06
Bordachar et al., JACC 2004

54. V-V Optimization 41 CHF pts. with CRT-PM No. of pts. 80 40 20 12 12 2012 20 40 80 ms
LV first
RV first
Bordachar et al., JACC 2004

55. V-V Optimization 166 DCM pts. with CRT (Doppler Echo) No. of pts. 80
At Implant
3 months
No. of pts. 80 40 20 20 40 80 ms
LV first
RV first
Delurgio et al., NASPE 2002

56. V-V Optimization V-V Optimization van Gelder et al., Am J Cardiol 2004AF
SR ischemic
SR non-ischemic
V-V Optimization
van Gelder et al., Am J Cardiol 2004

57. Optimizing BiV Pacing

58. Optimizing BiV Pacing
RV only
LV only
BiV
BiV LV first I V1

59. Optimizing V-V Delay Summary Start with standard setting
VV optimization in patients with persistent dyssynchrony
Trouble shooting option in clinical non-responders

60. Optimization of BiV Pacing
A-V Delay
V-V Delay