Comparison of chronic biventricular pacing between epicardial and endocardial left ventricular stimulation using Doppler tissue imaging in patients with heart failure

In patients with a wide QRS, drug-resistant heart failure, and a coronary sinus that is unsuitable for transvenous biventricular pacing (BVP), a transseptal approach from the right to left atrium can allow endocardial left ventricular (LV) pacing (with permanent anticoagulant therapy) instead of epicardial pacing via the coronary sinus branches. We sought to compare the effects of endocardial pacing with those of epicardial LV pacing on regional LV electromechanical delay (EMD) and contractility. Twenty-three patients (68 ± 8 years) with severe heart failure and QRS ≥130 ms received a pacemaker for BVP. Fifteen patients underwent epicardial LV pacing, and 8 underwent endocardial LV pacing because of an unsuitable coronary sinus. All LV leads were placed at the anterolateral LV wall. Six months after implant, echocardiography and Doppler tissue imaging were performed. LV wall velocities and regional EMDs (time interval between the onset of the QRS and local ventricular systolic motion) were calculated for the 4 LV walls and compared for each patient between right ventricular (RV) and BVP. The amplitude of regional LV contractility was also assessed. Epicardial BVP reduced the septal wall EMD by 11% versus RV pacing (p = 0.05) and the lateral wall EMD by 41% versus RV pacing (p <0.01). With endocardial BVP, the septal and lateral EMDs were 21.3% and 54%, respectively (p <0.01, compared with epicardial BVP). The mitral time-velocity integral increased by 40% with endocardial BVP versus 2% with epicardial BVP (p <0.01). The amplitude of the lateral LV wall systolic motion increased by 14% with epicardial BVP versus 31% with endocardial BVP (p = 0.01). This resulted in a LV shorterning fraction increase of 25% in patients with endocardial BVP (p = 0.05). However, all patients were clinically improved at the end of follow-up. Thus, in heart failure patients with BVP, endocardial BVP provides more homogenous intraventricular resynchronization than epicardial BVP and is associated with better LV filling and systolic performance.