Anodal stimulation: An underrecognized cause of nonresponders to cardiac resynchronization therapy

Khalin F. Dendy, Brian D. Powell, Yong-Mei Cha, Raul Emilio Espinosa, Paul Andrew Friedman, Robert F. Rea, David L. Hayes, Margaret May Redfield, Samuel J Asirvatham

Research output: Contribution to journalArticle

19 Citations (Scopus)

Abstract

Objective: The purpose of this study was to determine if anodal stimulation accounts for failure to benefit from cardiac resynchronization therapy (CRT) in some patients. Background: Approximately 30-40% of patients with moderate to severe heart failure do not have symptomatic nor echocardiographic improvement in cardiac function following CRT. Modern CRT devices allow the option of programming left ventricular (LV) lead pacing as LV tip to right ventricular (RV) lead coil to potentially improve pacing thresholds. However, anodal stimulation can result in unintentional RV pacing (anode) instead of LV pacing (cathode). Methods: Patients enrolled in our center's CRT registry had an echocardiogram, 6-minute walk (6MW), and Minnesota Living with HF Questionnaire (MLHFQ) pre-implant and 6 months after CRT. Electrocardiograms (12 lead) during RV, LV, and biventricular (BiV) pacing were obtained at the end of the implant in 102 patients. Anodal stimulation was defined as LV pacing QRS morphology on EKG being identical to RV pacing or consistent with fusion with RV and LV electrode capture. LV end systolic volume (LVESV) was measured by echo biplane Simpson's method and CRT responder was defined as 15% or greater reduction in LVESV. Results: Of the 102 patients, 46 (45.1%) had the final LV lead pacing configuration programmed LV (tip or ring) to RV (coil or ring). 3 of the 46 subjects (6.5%) had EKG findings consistent with anodal stimulation, not corrected intraoperatively. All anodal stimulation patients were nonresponders to CRT by echo criteria (reduction in LVESV 13.3 +/- 0.6%, increase in EF 5.0 +/- 1.4%) compared to 46% responders for those without anodal stimulation, (change in LVESV 18.7 +/- 25.6%, EF 7.6 +/-10.9%). None of the anodal stimulation patients were responders for the 6 minute walk, compared to 32 of 66 (48%) of those without anodal stimulation. Conclusion: Anodal stimulation is a potential underrecognized and ameliorable cause of poor response to CRT.

Original languageEnglish (US)
Pages (from-to)64-72
Number of pages9
JournalIndian Pacing and Electrophysiology Journal
Volume11
Issue number3
StatePublished - May 2011

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Cardiac Resynchronization Therapy
Electrocardiography
Electrodes
Cardiac Resynchronization Therapy Devices
Stroke Volume
Registries
Heart Failure

Keywords

  • Anodal stimulation
  • Biventricular pacemaker
  • Cardiac resynchronization therapy
  • Heart failure

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

@article{31fe31fc71984a74ada9da743da233f6,
title = "Anodal stimulation: An underrecognized cause of nonresponders to cardiac resynchronization therapy",
abstract = "Objective: The purpose of this study was to determine if anodal stimulation accounts for failure to benefit from cardiac resynchronization therapy (CRT) in some patients. Background: Approximately 30-40{\%} of patients with moderate to severe heart failure do not have symptomatic nor echocardiographic improvement in cardiac function following CRT. Modern CRT devices allow the option of programming left ventricular (LV) lead pacing as LV tip to right ventricular (RV) lead coil to potentially improve pacing thresholds. However, anodal stimulation can result in unintentional RV pacing (anode) instead of LV pacing (cathode). Methods: Patients enrolled in our center's CRT registry had an echocardiogram, 6-minute walk (6MW), and Minnesota Living with HF Questionnaire (MLHFQ) pre-implant and 6 months after CRT. Electrocardiograms (12 lead) during RV, LV, and biventricular (BiV) pacing were obtained at the end of the implant in 102 patients. Anodal stimulation was defined as LV pacing QRS morphology on EKG being identical to RV pacing or consistent with fusion with RV and LV electrode capture. LV end systolic volume (LVESV) was measured by echo biplane Simpson's method and CRT responder was defined as 15{\%} or greater reduction in LVESV. Results: Of the 102 patients, 46 (45.1{\%}) had the final LV lead pacing configuration programmed LV (tip or ring) to RV (coil or ring). 3 of the 46 subjects (6.5{\%}) had EKG findings consistent with anodal stimulation, not corrected intraoperatively. All anodal stimulation patients were nonresponders to CRT by echo criteria (reduction in LVESV 13.3 +/- 0.6{\%}, increase in EF 5.0 +/- 1.4{\%}) compared to 46{\%} responders for those without anodal stimulation, (change in LVESV 18.7 +/- 25.6{\%}, EF 7.6 +/-10.9{\%}). None of the anodal stimulation patients were responders for the 6 minute walk, compared to 32 of 66 (48{\%}) of those without anodal stimulation. Conclusion: Anodal stimulation is a potential underrecognized and ameliorable cause of poor response to CRT.",
keywords = "Anodal stimulation, Biventricular pacemaker, Cardiac resynchronization therapy, Heart failure",
author = "Dendy, {Khalin F.} and Powell, {Brian D.} and Yong-Mei Cha and Espinosa, {Raul Emilio} and Friedman, {Paul Andrew} and Rea, {Robert F.} and Hayes, {David L.} and Redfield, {Margaret May} and Asirvatham, {Samuel J}",
year = "2011",
month = "5",
language = "English (US)",
volume = "11",
pages = "64--72",
journal = "Indian Pacing and Electrophysiology Journal",
issn = "0972-6292",
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TY - JOUR

T1 - Anodal stimulation

T2 - An underrecognized cause of nonresponders to cardiac resynchronization therapy

AU - Dendy, Khalin F.

AU - Powell, Brian D.

AU - Cha, Yong-Mei

AU - Espinosa, Raul Emilio

AU - Friedman, Paul Andrew

AU - Rea, Robert F.

AU - Hayes, David L.

AU - Redfield, Margaret May

AU - Asirvatham, Samuel J

PY - 2011/5

Y1 - 2011/5

N2 - Objective: The purpose of this study was to determine if anodal stimulation accounts for failure to benefit from cardiac resynchronization therapy (CRT) in some patients. Background: Approximately 30-40% of patients with moderate to severe heart failure do not have symptomatic nor echocardiographic improvement in cardiac function following CRT. Modern CRT devices allow the option of programming left ventricular (LV) lead pacing as LV tip to right ventricular (RV) lead coil to potentially improve pacing thresholds. However, anodal stimulation can result in unintentional RV pacing (anode) instead of LV pacing (cathode). Methods: Patients enrolled in our center's CRT registry had an echocardiogram, 6-minute walk (6MW), and Minnesota Living with HF Questionnaire (MLHFQ) pre-implant and 6 months after CRT. Electrocardiograms (12 lead) during RV, LV, and biventricular (BiV) pacing were obtained at the end of the implant in 102 patients. Anodal stimulation was defined as LV pacing QRS morphology on EKG being identical to RV pacing or consistent with fusion with RV and LV electrode capture. LV end systolic volume (LVESV) was measured by echo biplane Simpson's method and CRT responder was defined as 15% or greater reduction in LVESV. Results: Of the 102 patients, 46 (45.1%) had the final LV lead pacing configuration programmed LV (tip or ring) to RV (coil or ring). 3 of the 46 subjects (6.5%) had EKG findings consistent with anodal stimulation, not corrected intraoperatively. All anodal stimulation patients were nonresponders to CRT by echo criteria (reduction in LVESV 13.3 +/- 0.6%, increase in EF 5.0 +/- 1.4%) compared to 46% responders for those without anodal stimulation, (change in LVESV 18.7 +/- 25.6%, EF 7.6 +/-10.9%). None of the anodal stimulation patients were responders for the 6 minute walk, compared to 32 of 66 (48%) of those without anodal stimulation. Conclusion: Anodal stimulation is a potential underrecognized and ameliorable cause of poor response to CRT.

AB - Objective: The purpose of this study was to determine if anodal stimulation accounts for failure to benefit from cardiac resynchronization therapy (CRT) in some patients. Background: Approximately 30-40% of patients with moderate to severe heart failure do not have symptomatic nor echocardiographic improvement in cardiac function following CRT. Modern CRT devices allow the option of programming left ventricular (LV) lead pacing as LV tip to right ventricular (RV) lead coil to potentially improve pacing thresholds. However, anodal stimulation can result in unintentional RV pacing (anode) instead of LV pacing (cathode). Methods: Patients enrolled in our center's CRT registry had an echocardiogram, 6-minute walk (6MW), and Minnesota Living with HF Questionnaire (MLHFQ) pre-implant and 6 months after CRT. Electrocardiograms (12 lead) during RV, LV, and biventricular (BiV) pacing were obtained at the end of the implant in 102 patients. Anodal stimulation was defined as LV pacing QRS morphology on EKG being identical to RV pacing or consistent with fusion with RV and LV electrode capture. LV end systolic volume (LVESV) was measured by echo biplane Simpson's method and CRT responder was defined as 15% or greater reduction in LVESV. Results: Of the 102 patients, 46 (45.1%) had the final LV lead pacing configuration programmed LV (tip or ring) to RV (coil or ring). 3 of the 46 subjects (6.5%) had EKG findings consistent with anodal stimulation, not corrected intraoperatively. All anodal stimulation patients were nonresponders to CRT by echo criteria (reduction in LVESV 13.3 +/- 0.6%, increase in EF 5.0 +/- 1.4%) compared to 46% responders for those without anodal stimulation, (change in LVESV 18.7 +/- 25.6%, EF 7.6 +/-10.9%). None of the anodal stimulation patients were responders for the 6 minute walk, compared to 32 of 66 (48%) of those without anodal stimulation. Conclusion: Anodal stimulation is a potential underrecognized and ameliorable cause of poor response to CRT.

KW - Anodal stimulation

KW - Biventricular pacemaker

KW - Cardiac resynchronization therapy

KW - Heart failure

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