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An Electrocardiogram-Based Algorithm To Detect Loss of Left Ventricular Capture during Cardiac Resynchronization Therapy

Peter Ammann, MD; Christian Sticherling, MD; Dietrich Kalusche, MD; Jens Eckstein, MD; Alain Bernheim, MD; Beat Schaer, MD; and Stefan Osswald, MD
[+] Article and Author Information

From University Hospital, Basel, and Kantonsspital St. Gallen, St. Gallen, Switzerland; and Herz-Zentrum Bad Krozingen, Bad Krozingen, Germany.


Note: Drs. Ammann and Sticherling contributed equally to this research.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Peter Ammann, MD, Department of Internal Medicine, Division of Cardiology, Kantonsspital St. Gallen, CH-9007 St. Gallen, Switzerland; e-mail, peter.ammann@kssg.ch.

Current Author Addresses: Dr. Ammann: Department of Internal Medicine, Division of Cardiology, Kantonsspital St. Gallen, CH-9007 St. Gallen, Switzerland.

Drs. Sticherling, Eckstein, Bernheim, Schaer, and Osswald: Division of Cardiology, University Hospital, CH-4031 Basel, Switzerland.

Dr. Kalusche: Herz-Zentrum Bad Krozingen, D-79189 Bad Krotzingen, Germany.

Author Contributions: Conception and design: P. Ammann, C. Sticherling, S. Osswald.

Analysis and interpretation of the data: P. Ammann, C. Sticherling, S. Osswald, B. Schaer, A. Bernheim, D. Kalusche, J. Eckstein.

Drafting of the article: P. Ammann, C. Sticherling, S. Osswald, B. Schaer, D. Kalusche.

Critical revision of the article for important intellectual content: P. Ammann, C. Sticherling, S. Osswald, B. Schaer.

Final approval of the article: P. Ammann, C. Sticherling, S. Osswald, B. Schaer, A. Bernheim, D. Kalusche, J. Eckstein.

Provision of study materials or patients: C. Sticherling, S. Osswald, B. Schaer.

Statistical expertise: C. Sticherling, S. Osswald.

Obtaining of funding: S. Osswald.

Administrative, technical, or logistic support: C. Sticherling, S. Osswald, B. Schaer, J. Eckstein.

Collection and assembly of data: P. Ammann, C. Sticherling, S. Osswald, B. Schaer, A. Bernheim, D. Kalusche, J. Eckstein.


Ann Intern Med. 2005;142(12_Part_1):968-973. doi:10.7326/0003-4819-142-12_Part_1-200506210-00006
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We devised an algorithm that reliably detects loss of left ventricular capture in patients with a cardiac resynchronization device and left bundle-branch block. The sensitivity and specificity of the algorithm are high (94% [CI, 88.2% to 97.7%] and 93% [CI, 86.3% to 95.8], respectively).

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Figure 1. ECG = electrocardiogram.
Algorithm to identify biventricular pacing in patients with an implanted cardiac resynchronization device.
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Figure 4. The algorithm assesses electrograms obtained through lead V1, the only chest lead overlying the right ventricle, and lead I. Whenever the left ventricle is activated, the main electrical vector is directed towards lead V1. Since there is always fusion with the concurrent right ventricular apical stimulation, a complete right bundle-branch block pattern in V1 is rare. However, an R–S spike ratio of 1 or greater can reliably detect left ventricular capture. Lead I needs to be assessed only if fusion with right ventricular stimulation is causing a mainly negative deflection in lead V1. In this example, left ventricular stimulation will cause a negative deflection because the main vector is now directed from the left to the right side, pointing away from lead I.
Main QRS axis during biventricular pacing, relative to electrocardiograph leads I and V1.
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Figure 3. Biventricular pacing, which the algorithm identified. Right ventricular pacing only, which the algorithm identified. Biventricular pacing, which the algorithm failed to identify. Right ventricular pacing only, which the algorithm identified.
Coronary sinus electrode placement in the lateral cardiac vein (A and B) and the posterior cardiac vein (C and D) of 2 different patients with an implanted cardiac resynchronization device.A.B.C.D.
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Figure 2. In the upper tracing, the device is programmed in right ventricular pacing mode. In the first tracing ( ), the cardiac resynchronization device is programmed to the right ventricular pacing mode. The remaining 3 tracings show the shift of the V1 and I axes with continuous electrocardiographic resynchronization between the right and left ventricle at 0 ms ( ), −40 ms ( ), and −80 ms ( ) of left ventricular offset.
Electrocardiographic tracings from lead V1 and I in 1 patient with an implanted cardiac resynchronization device.top2nd from top2nd from bottombottom
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Summary for Patients

Using Electrocardiography To Detect Problems with Cardiac Resynchronization Devices

The summary below is from the full report titled “An Electrocardiogram-Based Algorithm To Detect Loss of Left Ventricular Capture during Cardiac Resynchronization Therapy.” It is in the 21 June 2005 issue of Annals of Internal Medicine (volume 142, pages 968-973). The authors are P. Ammann, C. Sticherling, D. Kalusche, J. Eckstein, A. Bernheim, B. Schaer, and S. Osswald.

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