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Background   QRS  narrowing following cardiac resynchronization therapy with biventricular (BiV) or left ventricular (LV) pacing is likely affected by patient‐specific conduction characteristics ( PR , qLV,  LV ‐paced propagation interval), making a universal programming strategy likely ineffective. We tested these factors using a novel, device‐based algorithm (Sync AV ) that automatically adjusts paced atrioventricular delay (default or programmable offset) according to intrinsic atrioventricular conduction.    Methods and Results  Seventy‐five patients undergoing cardiac resynchronization therapy (age 66±11 years; 65% male; 32% with ischemic cardiomyopathy; LV ejection fraction 28±8%;  QRS  duration 162±16 ms) with intact atrioventricular conduction (PR interval 194±34, range 128–300 ms), left bundle branch block, and optimized  LV  lead position were studied at implant.  QRS  duration ( QRS d) reduction was compared for the following pacing configurations: nominal simultaneous BiV (Mode I: paced/sensed atrioventricular delay=140/110 ms), BiV+Sync AV  with 50 ms offset (Mode  II ), BiV+Sync AV  with offset that minimized  QRS d (Mode  III ), or  LV ‐only pacing+Sync AV  with 50 ms offset (Mode  IV ). The intrinsic  QRS d (162±16 ms) was reduced to 142±17 ms (−11.8%) by Mode I, 136±14 ms (−15.6%) by Mode  IV , and 132±13 ms (−17.8%) by Mode  II . Mode  III  yielded the shortest overall  QRS d (123±12 ms, −23.9% [ P <0.001 versus all modes]) and was the only configuration without  QRS d prolongation in any patient.  QRS  narrowing occurred regardless of  QRS d,  PR , or  LV ‐paced intervals, or underlying ischemic disease.    Conclusions  Post‐implant electrical optimization in already well‐selected patients with left bundle branch block and optimized  LV  lead position is facilitated by patient‐tailored BiV pacing adjusted to intrinsic atrioventricular timing using an automatic device–based algorithm.

Programming Cardiac Resynchronization Therapy for Electrical Synchrony: Reaching Beyond Left Bundle Branch Block and Left Ventricular Activation Delay