Table 1.
Comparison of the advantages and disadvantages of MPP and BVP
| Feature | BVP | MPP |
|---|---|---|
| Clearly defined target population | Several landmark trials have established the DyssHF population that may benefit from CRT in its classical BVP mode-however there is no certainty that these patients will benefit. | Although still unresolved, it appears that DyssHF patients with extensive, non-specific intraventricular conduction abnormalities benefit more from multiple LV pulses which shorten LV activation time. |
| Of note, CRT devices from all major manufacturers are MPP-capable (not with the same options), allowing for easy transition if deemed necessary. | ||
| Complexity of implantation | Identical. | |
| Presence of suitable dipoles | Almost always achievable (quadripolar leads). | Usually achievable. |
| Due to constraints regarding dipole combination, although multiple BVP-suitable dipoles may be present, their serial use may be unfeasible. | ||
| Also, rates of MPP loss of up to 20% have been reported. | ||
| Ease of programming | A basic setting has emerged that is often followed in practice-LV/RV pulses either simultaneous (nominal setting) of with up to 30 msec LV precedence. | There is no consensus regarding a basic setting that could be subsequently be improved upon. |
| However, regarding reaping maximal benefit, programming becomes exponentially more laborious/complex (see text for details). | This notwithstanding, most relevant trials have suggested opting for dipoles allowing for maximizing left ventricular myocardial mass capture, thus exploiting the innate advantage over BVP, and using minimal delay between LV pulses. | |
| Moreover, achieving optimal settings is quite cumbersome and resource-intensive (see text). | ||
| Acute effects | In most studies with direct BVP-MPP comparison, the latter outperformed the former regarding acute hemodynamic effects, at least when basic settings (see above) were used. | |
| Long-term effects | Firmly established survival benefits, at least compared to pharmacotherapy. | Encouraging findings regarding reduced cardiovascular mortality and performance status compared to BVP, even in their respective optimized modes (non-randomized studies and meta-analyses). |
| Pairing with additional modalities (LV-only pacing, QRS fusion, magnetic resonance guidance) | Identical. | |
| However, MPP offers more versatility and can better adapt to the suggestions of advanced LV output optimization approaches. | ||
In general, MPP could be considered an enhanced version of conventional BVP, offering more options, especially when non-response remains an issue. Admittedly, the core issue of whether MPP should be pursued in patients with satisfactory response to BVP cannot be resolved, inasmuch as there are randomized long-term trials of the two modalities.