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Malcolmson JW, Hughes RK, Husselbury T, Khan K, Learoyd AE, Lees M, Wicks EC, Smith J, Simms AD, Moon JC, Lopes LR, O'Mahony C, Sekhri N, Elliott PM, Petersen SE, Dhinoja MB, Mohiddin SA. Distal Ventricular Pacing for Drug-Refractory Mid-Cavity Obstructive Hypertrophic Cardiomyopathy: A Randomized, Placebo-Controlled Trial of Personalized Pacing. Circ Arrhythm Electrophysiol 2024; 17:e012570. [PMID: 39012930 DOI: 10.1161/circep.123.012570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 05/14/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND Patients with refractory, symptomatic left ventricular (LV) mid-cavity obstructive (LVMCO) hypertrophic cardiomyopathy have few therapeutic options. Right ventricular pacing is associated with modest hemodynamic and symptomatic improvement, and LV pacing pilot data suggest therapeutic potential. We hypothesized that site-specific pacing would reduce LVMCO gradients and improve symptoms. METHODS Patients with symptomatic-drug-refractory LVMCO were recruited for a randomized, blinded trial of personalized prescription of pacing (PPoP). Multiple LV and apical right ventricular pacing sites were assessed during an invasive hemodynamic study of multisite pacing. Patient-specific pacing-site and atrioventricular delays, defining PPoP, were selected on the basis of LVMCO gradient reduction and acceptable pacing parameters. Patients were randomized to 6 months of active PPoP or backup pacing in a crossover design. The primary outcome examined invasive gradient change with best-site pacing. Secondary outcomes assessed quality of life and exercise following randomization to PPoP. RESULTS A total of 17 patients were recruited; 16 of whom met primary end points. Baseline New York Heart Association was 3±0.6, despite optimal medical therapy. Hemodynamic effects were assessed during pacing at the right ventricular apex and at a mean of 8 LV sites. The gradients in all 16 patients fell with pacing, with maximum gradient reduction achieved via LV pacing in 14 (88%) patients and right ventricular apex in 2. The mean baseline gradient of 80±29 mm Hg fell to 31±21 mm Hg with best-site pacing, a 60% reduction (P<0.0001). One cardiac vein perforation occurred in 1 case, and 15 subjects entered crossover; 2 withdrawals occurred during crossover. Of the 13 completing crossover, 9 (69%) chose active pacing in PPoP configuration as preferred setting. PPoP was associated with improved 6-minute walking test performance (328.5±99.9 versus 285.8±105.5 m; P=0.018); other outcome measures also indicated benefit with PPoP. CONCLUSIONS In a randomized placebo-controlled trial, PPoP reduces obstruction and improves exercise performance in severely symptomatic patients with LVMCO. REGISTRATION URL: https://clinicaltrials.gov/study; Unique Identifier: NCT03450252.
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Affiliation(s)
- James W Malcolmson
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, United Kingdom (J.W.M., K.K., A.E.L., S.E.P., S.A.M.)
| | - Rebecca K Hughes
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
- Institute of Cardiovascular Science, University College London, United Kingdom (R.K.H., E.C.W., J.C.M., L.R.L., C.O.M., P.M.E.)
| | - Tim Husselbury
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
| | - Kamran Khan
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, United Kingdom (J.W.M., K.K., A.E.L., S.E.P., S.A.M.)
| | - Annastazia E Learoyd
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, United Kingdom (J.W.M., K.K., A.E.L., S.E.P., S.A.M.)
| | - Martin Lees
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
| | - Eleanor C Wicks
- Institute of Cardiovascular Science, University College London, United Kingdom (R.K.H., E.C.W., J.C.M., L.R.L., C.O.M., P.M.E.)
- Inherited Cardiovascular Diseases Unit, John Radcliffe Hospital, London, United Kingdom (E.C.W.)
| | - Jamie Smith
- Raigmore Hospital, NHS Highland, Inverness, United Kingdom (J.S.)
| | - Alexander D Simms
- Yorkshire Heart Centre, Leeds Teaching Hospital NHS Trust, Leeds, United Kingdom (A.D.S.)
| | - James C Moon
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
- Institute of Cardiovascular Science, University College London, United Kingdom (R.K.H., E.C.W., J.C.M., L.R.L., C.O.M., P.M.E.)
| | - Luis R Lopes
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
- Institute of Cardiovascular Science, University College London, United Kingdom (R.K.H., E.C.W., J.C.M., L.R.L., C.O.M., P.M.E.)
| | - Constantinos O'Mahony
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
- Institute of Cardiovascular Science, University College London, United Kingdom (R.K.H., E.C.W., J.C.M., L.R.L., C.O.M., P.M.E.)
| | - Neha Sekhri
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
| | - Perry M Elliott
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
- Institute of Cardiovascular Science, University College London, United Kingdom (R.K.H., E.C.W., J.C.M., L.R.L., C.O.M., P.M.E.)
| | - Steffen E Petersen
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, United Kingdom (J.W.M., K.K., A.E.L., S.E.P., S.A.M.)
- Health Data Research UK, London (S.E.P.)
| | - Mehul B Dhinoja
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
| | - Saidi A Mohiddin
- Barts Heart Center, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (J.W.M., R.K.H., T.H., M.L., J.C.M., L.R.L., C.O.M., N.S., P.M.E., S.E.P., M.B.D., S.A.M.)
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, United Kingdom (J.W.M., K.K., A.E.L., S.E.P., S.A.M.)
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Nie C, Zhu C, Xiao M, Yang Q, Meng Y, Wu R, Wang S. Mid-ventricular obstruction is associated with non-sustained ventricular tachycardia in patients with hypertrophic obstructive cardiomyopathy. Clin Cardiol 2021; 44:555-562. [PMID: 33626191 PMCID: PMC8027587 DOI: 10.1002/clc.23575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/08/2021] [Accepted: 02/09/2021] [Indexed: 12/12/2022] Open
Abstract
Background Mid‐ventricular obstruction (MVO) is a rare subtype of hypertrophic cardiomyopathy (HCM) but it is associated with ventricular arrhythmia. The relationship between MVO and non‐sustained ventricular tachycardia (NSVT) in HCM patients is unknown. Hypothesis The severity of MVO increases the incidence of NSVT in patients with hypertrophic obstructive cardiomyopathy (HOCM). Methods Five hundred and seventy‐two consecutive patients diagnosed with HOCM in Fuwai Hospital between January 2015 and December 2017 were enrolled in this study. Holter electrocardiographic and clinical parameters were compared between HOCM patients with and without MVO. Results Seventy‐six (13.3%) of 572 patients were diagnosed with MVO. Compared to patients without MVO, those with MVO were much younger, and had a higher incidence of syncope, greater left ventricular (LV) posterior wall thickness, a higher percentage of LV late gadolinium enhancement, and higher prevalence of NSVT. Furthermore, the prevalence of NSVT increased with the severity of MVO (without, mild, moderate or severe: 11.1%, 18.2%, 25.6%, respectively, p for trend < .01). Similarly, the prevalence of NSVT differed among patients with isolated LV outflow tract (LVOTO), both MVO and LVOTO, and isolated MVO (11.1%, 21.3%, 26.6%, respectively, p for trend = .018). In addition to age, diabetes, left atrial diameter, and maximal wall thickness, multivariate analysis revealed the presence of MVO as an independent risk factor for NSVT (Odds ratio 2.69; 95% confidence interval 1.41 to 5.13, p = .003). Conclusions The presence and severity of MVO was associated with higher incidence of NSVT in HOCM patients.
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Affiliation(s)
- Changrong Nie
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Changsheng Zhu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Minghu Xiao
- Department of Ultrasound, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiulan Yang
- Department of Intensive Care Unit, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanhai Meng
- Department of Intensive Care Unit, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rong Wu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuiyun Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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