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\begin{document}

\title{Is Multipoint Pacing Superior to Optimized Single-Point Pacing?}



\author[1]{Rodolfo San Antonio}%
\author[2]{Jose Maria Tolosana}%
\author[3]{Luis Mont Girbau}%
\affil[1]{Teknon Medical Centre}%
\affil[2]{Hospital Clinic, Universitat de Barcelona; }%
\affil[3]{Hospital Clinic de Barcelona}%


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  \date{May 23, 2024}


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\textbf{Is Multipoint Pacing Superior to Optimized Single-Point Pacing?}

Rodolfo San Antonio\textsuperscript{1}, MD; Jose Mar\selectlanguage{ngerman}ía
Tolosana\textsuperscript{2}, MD, PhD; Lluís Mont\textsuperscript{2}, MD,
PhD.

\textsuperscript{1}Heart Institute, Teknon Medical Center, Barcelona,
Spain; University of Barcelona, Spain

\textsuperscript{2}Institut Clínic Cardio-Vascular, Hospital Clínic,
University of Barcelona, Spain; Institut d'Investigacions Biomèdiques
August Pi I Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación
Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.

\textbf{Word count:} 434

\textbf{*Corresponding Author:}

Dr. Lluís Mont

Institut Clínic Cardio-Vascular, Hospital Clinic, Villarroel 170, 08036
Barcelona, Catalonia, Spain. Tel: +34 93 227 55 51.

Email: \emph{lmont@clinic.cat}

\section*{Funding: None}

{\label{funding-none}}

\textbf{Disclosures:}

LM declares consulting services, and advisory boards to St. Jude Medical
(Now Abbott), Medtronic, Biotronik, Boston Scientific, Livanova and
Johnson\&Johnson. JMT declares consulting services, and advisory boards
to St. Jude Medical (Now Abbott), Medtronic, Biotronik and Boston
Scientific. RS declares no conflicts of interest with the subject matter
discussed in the manuscript.

\textbf{Is Multipoint Pacing Superior to Optimized Single-Point Pacing?}

In this article, Mehta et al.\textsuperscript{1} add interesting data
about the role of multipoint pacing (MPP) in cardiac resynchronization
therapy (CRT). Despite the promising initial results, the largest
randomized studies have failed to show a clear benefit of MPP in CRT.
Therefore, the authors conclude that it is difficult to justify the
widespread use of MPP in CRT.

Indeed, most MPP studies have focused on correcting intra-left
ventricular dyssynchrony, recruiting more ventricular muscle than
single-point pacing (SPP). However, these studies have neglected the
potential role of fusion-based optimization with intrinsic conduction.
In a recent study, we assessed the potential role of MPP in CRT by
comparing MPP with SPP optimized by the fusion-optimized intervals (FOI)
method.\textsuperscript{2} This method consists of achieving fusion
between the paced rhythm and intrinsic conduction by modifying the
atrioventricular (AV) and interventricular delays. We compared a
single-point left ventricular pacing strategy optimized by FOI (SPP-FOI)
with MPP programmed with a fixed AV interval of 130 ms. The SPP-FOI
strategy resulted in greater QRS shortening than the MPP strategy (-56
ms vs. -42 ms; P \textless{} 0.001). On the other hand, when FOI was
added to MPP (MPP-FOI), there was no further shortening. Similarly,
O'Donnell et al.\textsuperscript{3} observed that SPP with automatic AV
delay optimization using the SyncAV algorithm resulted in a significant
shortening of the QRS duration compared to non-optimized modes (SPP and
MPP). Furthermore, they did not find a significant difference in QRS
shortening when comparing SPP and MPP.

These two recent studies, not included in the previous review by Mehta
et al., further reinforce the concept that most patients achieve their
narrowest QRS when the AV interval is optimized to obtain fusion with
intrinsic conduction, regardless of the use of MPP.

In summary, multipoint pacing was not superior to single-point pacing
optimized with SyncAV or manual FOI, and MPP also resulted in higher
battery drainage than SPP. It is possible to test individually whether
MPP may be useful in specific cases by measuring the QRS duration with
different options.

\begin{enumerate}
\tightlist
\item
  Mehta VS, Elliott MK, Sidhu BS, et al. Multipoint pacing for cardiac
  resynchronisation therapy in patients with heart failure: A systematic
  review and meta-analysis. J Cardiovasc Electrophysiol. 2021 Aug 11.
  doi: 10.1111/jce.15199.
\item
  San Antonio R, Guasch E, González-Ascaso A, et al. Optimized
  single-point left ventricular pacing leads to improved
  resynchronization compared with multipoint pacing. Pacing Clin
  Electrophysiol. 2021 Mar;44(3):519-527. doi: 10.1111/pace.14185.
\item
  O'Donnell D, Wisnoskey B, Badie N, et al. Electrical synchronization
  achieved by multipoint pacing combined with dynamic atrioventricular
  delay. J Interv Card Electrophysiol. 2021 Sep;61(3):453-460. doi:
  10.1007/s10840-020-00842-7.
\end{enumerate}

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