P262Cardiac resynchronization therapy beyond nominal settings: an IEGM based approach for atrioventricular delay optimization in daily clinical practice

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Introduction: Individual optimization of the atrioventricular (AV) delay has been part of standard protocol in several landmark cardiac resynchronization therapy (CRT) trials. However, in daily clinical practice optimization of the AV delay is often not performed while it seems unlikely that nominal, out-of-the-box, settings are a ‘’once size fits all’’ solution. This might be even more important in patients needing atrial pacing. Purpose: A simpler method may increase routine AV optimization. The aim of the present study was to study optimal AV delays and investigate a new, simple intracardiac electrogram (IEGM)-based optimization approach in patients undergoing CRT optimization in a real world clinical setting. Methods: In our single-center observational study we included 417 consecutive CRT patients without permanent atrial fibrillation. In 328 patients paired IEGM and echocardiography optimization data were available. Reasons for an incomplete dataset were sinus arrest (N=7), atrioventricular block (N=63), or supraventricular arrhythmias during optimization (N=19) preventing paired data collection. Sensed (sAV) and paced (pAV) AV delays were optimized by one experienced cardiologist using the iterative echocardiography method. The offset between sAV and pAV delays was also calculated using the IEGM method on a later time and without knowledge of the programmed delays during optimization. Results: Age of the population was 66±12 years; 66% of patients were male, 46% had ischemic heart disease and mean ejection fraction was 26±9%. During echocardiography median sAV delay was 75±26 ms, and median pAV delay was 148±32 ms, leading to an offset of 73±18 ms. These values differ substantially from the nominal AV settings of five major manufacturers. As can be seen in Figure 1A, 67.7% of patients had an offset that exceeded nominal settings. The calculated optimal offset was 75±25 based on IEGM values. Using Bland-Altman plot analysis the clinically acceptable correlation between echocardiography- and IEGM-generated AV offset delays showed good agreement. In 93% of patients differences in mean’s variations were less than 30 ms and within ±2 standard deviations of the mean. Furthermore, the optimal offset between sAV and pAV delays, obtained during echocardiography and from IEGM calculations, showed a good correlation (R2=0.62, P<0.001) (Figure 1B). Conclusion: Optimal AV delays are patient specific and differ from nominal device settings. Offset between sAV and pAV delay can be calculated using a new, simple IEGM based approach. In daily clinical practice this means that after sAV delay optimization, pAV delay can easily be calculated and subsequently programmed, reducing the time consuming nature of AV optimization. Abstract P262 Figure. AV offset delays

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