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Bertelli M, Ziacchi M, van Slochteren F, Rondanina E, Lazzeri M, Carecci A, Biffi M. LV cathode position in CRT recipients: How can we benefit from CMR? Int J Cardiol 2024; 412:132321. [PMID: 38977225 DOI: 10.1016/j.ijcard.2024.132321] [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: 05/09/2024] [Revised: 06/24/2024] [Accepted: 07/01/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Left ventricular lead positioning represents a key step in CRT optimization. However, evidence for its guidance based on specific topographical factors and related imaging techniques is sparse. OBJECTIVE To analyze reverse remodeling (RR) and clinical events in CRT recipients based on LV cathode (LVC) position relative to latest mechanical activation (LMA) and scar as determined by cardiac magnetic resonance (CMR). METHODS This is a retrospective single-center study of 68 consecutive Q-LV-guided CRT-D and CRT-P recipients. Through CMR-based 3D reconstructions overlayed on fluoroscopy images, LVCs were stratified as concordant, adjacent, or discordant to LMA (3 segments with latest and greatest radial strain) and scar (segments with >50% scar transmurality). The primary endpoint of RR (expressed as percentage ESV change) and secondary composite endpoint of HF hospitalizations, LVAD/heart transplant, or cardiovascular death were compared across categories. RESULTS LVC proximity to LMA was associated with a progressive increase in RR (percentage ESV change: concordant -47.0 ± 5.9%, adjacent -31.4 ± 3.1%, discordant +0.4 ± 3.7%), while proximity to scar was associated with sharply decreasing RR (concordant +10.7 ± 12.9%, adjacent +0.3 ± 5.3%, discordant -31.3 ± 4.4%, no scar -35.4 ± 4.8%). 4 integrated classes of LVC position demonstrated a significant positive RR gradient the more optimal the category (class I -47.0 ± 5.9%, class II -34.9 ± 2.8%, class III -5.5 ± 4.3%, class IV + 3.4 ± 5.2%). Freedom from composite secondary endpoint of HF hospitalization, LVAD/heart transplant, or cardiovascular death confirmed these trends demonstrating significant differences across both integrated as well as individual LMA and scar categories. CONCLUSION Integrated CMR-determined LVC position relative to LMA and scar stratifies response to CRT.
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Affiliation(s)
- Michele Bertelli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Cardiology, 40122 Bologna, Italy.
| | - Matteo Ziacchi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Cardiology, 40122 Bologna, Italy
| | | | | | - Mirco Lazzeri
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Cardiology, 40122 Bologna, Italy
| | - Alessandro Carecci
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Cardiology, 40122 Bologna, Italy
| | - Mauro Biffi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Cardiology, 40122 Bologna, Italy
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2
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Komamura K, Iwase M. Clinical outcomes of the AdaptResponse trial. Lancet 2024; 403:2484. [PMID: 38851282 DOI: 10.1016/s0140-6736(24)00867-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 04/22/2024] [Indexed: 06/10/2024]
Affiliation(s)
- Kazuo Komamura
- Toyota Memorial Hospital, 1-1, Heiwa-cho, Toyota, Aichi 471-8513, Japan.
| | - Mitsunori Iwase
- Toyota Memorial Hospital, 1-1, Heiwa-cho, Toyota, Aichi 471-8513, Japan
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3
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Si H, He Z, Malhotra S, Zhang X, Zou F, Xue S, Qian Z, Wang Y, Hou X, Zhou W, Zou J. A novel method combining gated SPECT and vectorcardiography to guide left ventricular lead placement to improve response to cardiac resynchronization therapy: A proof of concept study. J Nucl Cardiol 2024; 36:101867. [PMID: 38697386 DOI: 10.1016/j.nuclcard.2024.101867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/08/2024] [Accepted: 04/15/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND The segment of the latest mechanical contraction (LMC) does not always overlap with the site of the latest electrical activation (LEA). By integrating both mechanical and electrical dyssynchrony, this proof-of-concept study aimed to propose a new method for recommending left ventricular (LV) lead placements, with the goal of enhancing response to cardiac resynchronization therapy (CRT). METHODS The LMC segment was determined by single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI) phase analysis. The LEA site was detected by vectorcardiogram. The recommended segments for LV lead placement were as follows: (1) the LMC viable segments that overlapped with the LEA site; (2) the LMC viable segments adjacent to the LEA site; (3) If no segment met either of the above, the LV lateral wall was recommended. The response was defined as ≥15% reduction in left ventricular end-systolic volume (LVESV) 6-months after CRT. Patients with LV lead located in the recommended site were assigned to the recommended group, and those located in the non-recommended site were assigned to the non-recommended group. RESULTS The cohort comprised of 76 patients, including 54 (71.1%) in the recommended group and 22 (28.9%) in the non-recommended group. Among the recommended group, 74.1% of the patients responded to CRT, while 36.4% in the non-recommended group were responders (P = .002). Compared to pacing at the non-recommended segments, pacing at the recommended segments showed an independent association with an increased response by univariate and multivariable analysis (odds ratio 5.00, 95% confidence interval 1.73-14.44, P = .003; odds ratio 7.33, 95% confidence interval 1.53-35.14, P = .013). Kaplan-Meier curves showed that pacing at the recommended LV lead position demonstrated a better long-term prognosis. CONCLUSION Our findings indicate that pacing at the recommended segments, by integrating of mechanical and electrical dyssynchrony, is significantly associated with an improved CRT response and better long-term prognosis.
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Affiliation(s)
- Hongjin Si
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China; Department of Cardiology, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, Jiangsu, China
| | - Zhuo He
- Department of Applied Computing, Michigan Technological University, Houghton, MI, USA
| | - Saurabh Malhotra
- Division of Cardiology, Cook County Health and Hospitals System, Chicago, IL, USA; Division of Cardiology, Rush Medical College, Chicago, IL, USA
| | - Xinwei Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Fengwei Zou
- Department of Cardiology, Montefiore Medical Center, 111 E 210th St, Bronx, NY, 10467, USA
| | - Siyuan Xue
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhiyong Qian
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yao Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiaofeng Hou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Weihua Zhou
- Department of Applied Computing, Michigan Technological University, Houghton, MI, USA; Center for Biocomputing and Digital Health, Institute of Computing and Cybersystems, and Health Research Institute, Michigan Technological University, Houghton, MI, USA
| | - Jiangang Zou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.
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4
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Kodama N, Nakagawa M, Ishii Y, Yufu K, Yamauchi S, Yamamoto E, Miyoshi M, Abe I, Kondo H, Fukui A, Satoh H, Akiyoshi K, Fukuda T, Shinohara T, Teshima Y, Takahashi N. R-R' interval in the left bundle branch block predicts long-term outcomes after cardiac resynchronization therapy by estimating greater mechanical dyssynchrony and viable myocardium. Heart Rhythm 2024; 21:436-444. [PMID: 38154602 DOI: 10.1016/j.hrthm.2023.12.014] [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: 08/08/2023] [Revised: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Typical left bundle branch block (LBBB) shows 2 peaks of the R wave, which reflect activation reaching the interventricular septum (R) and posterolateral wall (R') sequentially. OBJECTIVE The purpose of this study was to investigate the relationship among R-R' interval (RR'), mechanical dyssynchrony, extent of viable myocardium, and long-term outcomes in cardiac resynchronization therapy (CRT) candidates. METHODS The study enrolled 49 patients (34 men; mean age: 69 ± 11 years) with LBBB who received CRT. The LBBB definition used requires the presence of mid-QRS notching in leads V1, V2, V5, V6, I, and aVL. Baseline evaluations were QRS duration (QRSd) and RR' measured from the 12-lead electrocardiogram; eyeball dyssynchrony (apical rocking and septal flash) and opposing-wall delay by speckle tracking from echocardiography, and extent of viable myocardium assessed by thallium-201 single-photon emission computed tomography. Primary outcomes included the combination of all-cause death and heart failure-related hospitalization. RESULTS RR' predicted volumetric response better than QRSd (area under the curve 0.73 vs 0.67, respectively). The long RR' group (≥48 ms) revealed more frequent eyeball dyssynchrony and significantly greater radial (SL) and circumferential dyssynchrony (AP and SL) and %viable segment than the short RR' group. In multivariate regression analysis, only RR' ≥48 ms was independently associated with higher event-free survival rates following CRT (hazard ratio 0.21; P = .014). CONCLUSION These findings suggest that RR' in complete LBBB was associated with mechanical dyssynchrony, extent of viable myocardium, and long-term outcomes following CRT.
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Affiliation(s)
- Nozomi Kodama
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Mikiko Nakagawa
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan.
| | - Yumi Ishii
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Kunio Yufu
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Syuichiro Yamauchi
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Ena Yamamoto
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Miho Miyoshi
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Ichitaro Abe
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Hidekazu Kondo
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Akira Fukui
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Hideki Satoh
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Kumiko Akiyoshi
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Tomoko Fukuda
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Tetsuji Shinohara
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Yasushi Teshima
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
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5
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Nguyên UC, Prinzen FW, Vernooy K. Left ventricular lead placement in cardiac resynchronization therapy: Current data and potential explanations for the lack of benefit. Heart Rhythm 2024; 21:197-205. [PMID: 37806647 DOI: 10.1016/j.hrthm.2023.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/22/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Abstract
The present article reviews the literature on image-guided cardiac resynchronization therapy (CRT) studies. Improved outcome to CRT has been associated with the placement of a left ventricular (LV) lead in the latest activated segment free from scar. The majority of randomized controlled trials investigating guided LV lead implantation did not show superiority over conventional implantation approaches. Several factors may contribute to this paradoxical observation, including inclusion criteria favoring patients with left bundle branch block who already respond well to conventional anatomical LV lead implantation, differences in activation wavefronts during simultaneous right ventricular and LV pacing, incorrect definition of target regions, and limitations in coronary venous anatomy that prevent access to target regions that are detected by imaging. It is imperative that exclusion of patients lacking access to target regions from these studies would lead to larger benefit of image-guided CRT.
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Affiliation(s)
- Uyên Châu Nguyên
- Department of Physiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands; Department of Cardiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.
| | - Frits W Prinzen
- Department of Physiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
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Chousou PA, Chattopadhyay RK, Matthews GDK, Vassiliou VS, Pugh PJ. Location, Location, Location: A Pilot Study to Compare Electrical with Echocardiographic-Guided Targeting of Left Ventricular Lead Placement in Cardiac Resynchronisation Therapy. Diagnostics (Basel) 2024; 14:299. [PMID: 38337816 PMCID: PMC10855693 DOI: 10.3390/diagnostics14030299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/21/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
Introduction: Cardiac resynchronisation therapy is ineffective in 30-40% of patients with heart failure with reduced ejection fraction. Targeting non-scarred myocardium by selecting the site of latest mechanical activation using echocardiography has been suggested to improve outcomes but at the cost of increased resource utilisation. The interval between the beginning of the QRS complex and the local LV lead electrogram (QLV) might represent an alternative electrical marker. Aims: To determine whether the site of latest myocardial electrical and mechanical activation are concordant. Methods: This was a single-centre, prospective pilot study, enrolling patients between March 2019 and June 2021. Patients underwent speckle-tracking echocardiography (STE) prior to CRT implantation. Intra-procedural QLV measurement and R-wave amplitude were performed in a blinded fashion at all accessible coronary sinus branches. Pearson's correlation coefficient and Cohen's Kappa coefficient were utilised for the comparison of electrical and echocardiographic parameters. Results: A total of 20 subjects had complete data sets. In 15, there was a concordance at the optimal site between the electrically targeted region and the mechanically targeted region; in four, the regions were adjacent (within one segment). There was discordance (≥2 segments away) in only one case between the two methods of targeting. There was a statistically significant increase in procedure time and fluoroscopy duration using the intraprocedural QLV strategy. There was no statistical correlation between the quantitative electrical and echocardiographic data. Conclusions: A QLV-guided approach to targeting LV lead placement appears to be a potential alternative to the established echocardiographic-guided technique. However, it is associated with prolonged fluoroscopy and overall procedure time.
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Affiliation(s)
- Panagiota A. Chousou
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
- Department of Cardiology, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Rahul K. Chattopadhyay
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
- Department of Cardiology, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | | | | | - Peter J. Pugh
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
- Department of Cardiology, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
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7
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Sisti N, Cardona A, Baldi E, Sciaccaluga C, Notaristefano F, Santoro A, Mandoli GE, Cameli M. Multimodality Imaging for Selecting Candidates for CRT: Do We Have a Single Alley to Increase Responders? Curr Probl Cardiol 2024; 49:102150. [PMID: 37863462 DOI: 10.1016/j.cpcardiol.2023.102150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/14/2023] [Indexed: 10/22/2023]
Abstract
Cardiac resynchronization therapy has evolved in recent years to provide a reduction of morbidity and mortality for many patients with heart failure. Its application and optimization is an evolving field and its use requires a multidisciplinary approach for patient and device selection, technical preprocedural planning, and optimization. While echocardiography has always been considered the first line for the evaluation of patients, additional imaging techniques have gained increasing evidence in recent years. Today different details about heart anatomy, function, dissynchrony can be investigated by magnetic resonance, cardiac computed tomography, nuclear imaging, and more, with the aim of obtaining clues to reach a maximal response from the electrical therapy. The purpose of this review is to provide a practical analysis of the single and combined use of different imaging techniques in the preoperative and perioperative phases of cardiac resynchronization therapy, underlining their main advantages, limitations, and information provided.
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Affiliation(s)
- Nicolò Sisti
- Department of Cardiology, Hospital of Gubbio, Gubbio, Italy.
| | - Andrea Cardona
- Division of Advanced Cardiovascular Diagnostics, Regional Healthcare Unit, Todi Hospital, Todi, Italy
| | - Enrico Baldi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Carlotta Sciaccaluga
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | | | - Amato Santoro
- Division of Cardiology, Cardio Thoracic and Vascular Department, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
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8
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Cundari G, Alkadhi H, Eberhard M. The role of CT in arrhythmia management-treatment planning and post-procedural imaging surveillance. Br J Radiol 2023; 96:20230028. [PMID: 37191058 PMCID: PMC10607403 DOI: 10.1259/bjr.20230028] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/21/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023] Open
Abstract
Several interventional treatment options exist in patients with atrial and ventricular arrhythmia. Cardiac CT is routinely performed prior to occlusion of the left atrial appendage, pulmonary vein isolation, and cardiac device implantation. Besides the evaluation of coronary artery disease, cardiac CT provides isotropic, high-resolution CT images of the cardiac anatomy with the possibility of multiplanar reformations and three-dimensional reconstructions which are helpful to guide interventional treatment. In addition, cardiac CT is increasingly used to rapidly evaluate periprocedural complications and for the routine post-procedural imaging surveillance in patients after interventions. This review article will discuss current applications of pre- and post-interventional CT imaging in patients with arrhythmia.
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Affiliation(s)
| | - Hatem Alkadhi
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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9
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Kronborg MB, Frausing MHJP, Svendsen JH, Johansen JB, Riahi S, Haarbo J, Poulsen SH, Eiskjær H, Køber L, Øvrehus K, Sommer AM, Schou M, Nørgaard BL, Risum N, Poulsen MK, Søgaard P, Sandgaard N, Kofoed KF, Hansen TF, Graff C, Pedersen SS, Skals RG, Nielsen JC. Does targeted positioning of the left ventricular pacing lead towards the latest local electrical activation in cardiac resynchronization therapy reduce the incidence of death or hospitalization for heart failure? Am Heart J 2023; 263:112-122. [PMID: 37220821 DOI: 10.1016/j.ahj.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 05/04/2023] [Accepted: 05/15/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) improves symptoms, health-related quality of life and long-term survival in patients with systolic heart failure (HF) and shortens QRS duration. However, up to one third of patients attain no measurable clinical benefit from CRT. An important determinant of clinical response is optimal choice in left ventricular (LV) pacing site. Observational data have shown that achieving an LV lead position at a site of late electrical activation is associated with better clinical and echocardiographic outcomes compared to standard placement, but mapping-guided LV lead placement towards the site of latest electrical activation has never been investigated in a randomized controlled trial (RCT). The purpose of this study was to evaluate the effect of targeted positioning of the LV lead towards the latest electrically activated area. We hypothesize that this strategy is superior to standard LV lead placement. METHODS The DANISH-CRT trial is a national, double-blinded RCT (ClinicalTrials.gov NCT03280862). A total of 1,000 patients referred for a de novo CRT implantation or an upgrade to CRT from right ventricular pacing will be randomized 1:1 to receive conventional LV lead positioning preferably in a nonapical posterolateral branch of the coronary sinus (CS) (control group) or targeted positioning of the LV lead to the CS branch with the latest local electrical LV activation (intervention group). In the intervention group, late activation will be determined using electrical mapping of the CS. The primary endpoint is a composite of death and nonplanned HF hospitalization. Patients are followed for a minimum of 2 years and until 264 primary endpoints occurred. Analyses will be conducted according to the intention-to-treat principle. Enrollment for this trial began in March 2018, and per April 2023, a total of 823 patients have been included. Enrollment is expected to be complete by mid-2024. CONCLUSIONS The DANISH-CRT trial will clarify whether mapping-guided positioning of the LV lead according to the latest local electrical activation in the CS is beneficial for patients in terms of reducing the composite endpoint of death or nonplanned hospitalization for heart failure. Results from this trial are expected to impact future guidelines on CRT. CLINICALTRIALS GOV IDENTIFIER NCT03280862.
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Affiliation(s)
- Mads Brix Kronborg
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Maria Hee Jung Park Frausing
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Sam Riahi
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jens Haarbo
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Steen Hvitfeldt Poulsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Kristian Øvrehus
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | | | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Bjarne Linde Nørgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Niels Risum
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | | | - Peter Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Niels Sandgaard
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Klaus F Kofoed
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Radiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Fritz Hansen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Susanne S Pedersen
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Department of Psychology, University of Southern Denmark, Odense, Denmark
| | | | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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10
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Fyenbo DB, Bjerre HL, Frausing MHJP, Stephansen C, Sommer A, Borgquist R, Bakos Z, Glikson M, Milman A, Beinart R, Kockova R, Sedlacek K, Wichterle D, Saba S, Jain S, Shalaby A, Kronborg MB, Nielsen JC. Targeted left ventricular lead positioning to the site of latest activation in cardiac resynchronization therapy: a systematic review and meta-analysis. Europace 2023; 25:euad267. [PMID: 37695316 PMCID: PMC10507669 DOI: 10.1093/europace/euad267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 09/06/2023] [Indexed: 09/12/2023] Open
Abstract
AIMS Several studies have evaluated the use of electrically- or imaging-guided left ventricular (LV) lead placement in cardiac resynchronization therapy (CRT) recipients. We aimed to assess evidence for a guided strategy that targets LV lead position to the site of latest LV activation. METHODS AND RESULTS A systematic review and meta-analysis was performed for randomized controlled trials (RCTs) until March 2023 that evaluated electrically- or imaging-guided LV lead positioning on clinical and echocardiographic outcomes. The primary endpoint was a composite of all-cause mortality and heart failure hospitalization, and secondary endpoints were quality of life, 6-min walk test (6MWT), QRS duration, LV end-systolic volume, and LV ejection fraction. We included eight RCTs that comprised 1323 patients. Six RCTs compared guided strategy (n = 638) to routine (n = 468), and two RCTs compared different guiding strategies head-to-head: electrically- (n = 111) vs. imaging-guided (n = 106). Compared to routine, a guided strategy did not significantly reduce the risk of the primary endpoint after 12-24 (RR 0.83, 95% CI 0.52-1.33) months. A guided strategy was associated with slight improvement in 6MWT distance after 6 months of follow-up of absolute 18 (95% CI 6-30) m between groups, but not in remaining secondary endpoints. None of the secondary endpoints differed between the guided strategies. CONCLUSION In this study, a CRT implantation strategy that targets the latest LV activation did not improve survival or reduce heart failure hospitalizations.
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Affiliation(s)
- Daniel Benjamin Fyenbo
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 11, 8200 Aarhus N, Denmark
- Diagnostic Center, Silkeborg Regional Hospital, Falkevej 1A, 8600 Silkeborg, Denmark
| | - Henrik Laurits Bjerre
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 11, 8200 Aarhus N, Denmark
| | - Maria Hee Jung Park Frausing
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 11, 8200 Aarhus N, Denmark
| | - Charlotte Stephansen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Anders Sommer
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Zoltan Bakos
- Department of Cardiology, Kristianstad Hospital, Kristianstad, Sweden
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Anat Milman
- Leviev Heart Institute, The Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roy Beinart
- Leviev Heart Institute, The Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Radka Kockova
- Department of Cardiac Surgery, Na Homolce Hospital, Prague, Czech Republic
| | - Kamil Sedlacek
- 1st Department of Internal Medicine—Cardiology and Angiology, University Hospital, Hradec Králové, Czech Republic
- Faculty of Medicine, Charles University, Hradec Králové, Czech Republic
| | - Dan Wichterle
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Samir Saba
- Heart and Vascular Institute, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sandeep Jain
- Heart and Vascular Institute, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alaa Shalaby
- Heart and Vascular Institute, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mads Brix Kronborg
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 11, 8200 Aarhus N, Denmark
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 11, 8200 Aarhus N, Denmark
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11
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Dokuchaev A, Chumarnaya T, Bazhutina A, Khamzin S, Lebedeva V, Lyubimtseva T, Zubarev S, Lebedev D, Solovyova O. Combination of personalized computational modeling and machine learning for optimization of left ventricular pacing site in cardiac resynchronization therapy. Front Physiol 2023; 14:1162520. [PMID: 37497440 PMCID: PMC10367108 DOI: 10.3389/fphys.2023.1162520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/26/2023] [Indexed: 07/28/2023] Open
Abstract
Introduction: The 30-50% non-response rate to cardiac resynchronization therapy (CRT) calls for improved patient selection and optimized pacing lead placement. The study aimed to develop a novel technique using patient-specific cardiac models and machine learning (ML) to predict an optimal left ventricular (LV) pacing site (ML-PS) that maximizes the likelihood of LV ejection fraction (LVEF) improvement in a given CRT candidate. To validate the approach, we evaluated whether the distance DPS between the clinical LV pacing site (ref-PS) and ML-PS is associated with improved response rate and magnitude. Materials and methods: We reviewed retrospective data for 57 CRT recipients. A positive response was defined as a more than 10% LVEF improvement. Personalized models of ventricular activation and ECG were created from MRI and CT images. The characteristics of ventricular activation during intrinsic rhythm and biventricular (BiV) pacing with ref-PS were derived from the models and used in combination with clinical data to train supervised ML classifiers. The best logistic regression model classified CRT responders with a high accuracy of 0.77 (ROC AUC = 0.84). The LR classifier, model simulations and Bayesian optimization with Gaussian process regression were combined to identify an optimal ML-PS that maximizes the ML-score of CRT response over the LV surface in each patient. Results: The optimal ML-PS improved the ML-score by 17 ± 14% over the ref-PS. Twenty percent of the non-responders were reclassified as positive at ML-PS. Selection of positive patients with a max ML-score >0.5 demonstrated an improved clinical response rate. The distance DPS was shorter in the responders. The max ML-score and DPS were found to be strong predictors of CRT response (ROC AUC = 0.85). In the group with max ML-score > 0.5 and DPS< 30 mm, the response rate was 83% compared to 14% in the rest of the cohort. LVEF improvement in this group was higher than in the other patients (16 ± 8% vs. 7 ± 8%). Conclusion: A new technique combining clinical data, personalized heart modelling and supervised ML demonstrates the potential for use in clinical practice to assist in optimizing patient selection and predicting optimal LV pacing lead position in HF candidates for CRT.
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Affiliation(s)
- Arsenii Dokuchaev
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Sciences, Ekaterinburg, Russia
| | - Tatiana Chumarnaya
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Sciences, Ekaterinburg, Russia
- Laboratory of Mathematical Modeling in Physiology and Medicine Based on Supercomputers, Ural Federal University, Ekaterinburg, Russia
| | - Anastasia Bazhutina
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Sciences, Ekaterinburg, Russia
- Laboratory of Mathematical Modeling in Physiology and Medicine Based on Supercomputers, Ural Federal University, Ekaterinburg, Russia
| | - Svyatoslav Khamzin
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Sciences, Ekaterinburg, Russia
| | | | - Tamara Lyubimtseva
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Sciences, Ekaterinburg, Russia
- Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - Stepan Zubarev
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Sciences, Ekaterinburg, Russia
- Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - Dmitry Lebedev
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Sciences, Ekaterinburg, Russia
- Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - Olga Solovyova
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Sciences, Ekaterinburg, Russia
- Laboratory of Mathematical Modeling in Physiology and Medicine Based on Supercomputers, Ural Federal University, Ekaterinburg, Russia
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12
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Frausing MHJP, Johansen JB, Afonso D, Jørgensen OD, Olsen T, Gerdes C, Johansen ML, Wolff C, Mealing S, Nielsen JC, Kronborg MB. Cost-effectiveness of an antibacterial envelope for infection prevention in patients undergoing cardiac resynchronization therapy reoperations in Denmark. Europace 2023; 25:euad159. [PMID: 37345858 PMCID: PMC10286568 DOI: 10.1093/europace/euad159] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 06/03/2023] [Indexed: 06/23/2023] Open
Abstract
AIMS Use of an absorbable antibacterial envelope during implantation prevents cardiac implantable electronic device infections in patients with a moderate-to-high infection risk. Previous studies demonstrated that an envelope is cost-effective in high-risk patients within German, Italian, and English healthcare systems, but these analyses were based on limited data and may not be generalizable to other healthcare settings. METHODS AND RESULTS A previously published decision-tree-based cost-effectiveness model was used to compare the costs per quality-adjusted life year (QALY) associated with adjunctive use of an antibacterial envelope for infection prevention compared to standard-of-care intravenous antibiotics. The model was adapted using data from a Danish observational two-centre cohort study that investigated infection-risk patients undergoing cardiac resynchronization therapy (CRT) reoperations with and without an antibacterial envelope (n = 1943). We assumed a cost-effectiveness threshold of €34 125/QALY gained, based on the upper threshold used by the National Institute for Health and Care Excellence (£30 000). An antibacterial envelope was associated with an incremental cost-effectiveness ratio (ICER) of €12 022 per QALY in patients undergoing CRT reoperations, thus indicating that the envelope is cost-effective when compared with standard of care. A separate analysis stratified by device type showed ICERS of €6227 (CRT defibrillator) and €29 177 (CRT pacemaker) per QALY gained. CONCLUSIONS Cost-effectiveness ratios were favourable for patients undergoing CRT reoperations in the Danish healthcare system, and thus are in line with previous studies. Results from this study can contribute to making the technology available to Danish patients and align preventive efforts in the pacemaker and ICD area.
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Affiliation(s)
- Maria Hee Jung Park Frausing
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Bvld. 99, 8200 Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Bvld. 82, 8200 Aarhus, Denmark
| | - Jens Brock Johansen
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Daniela Afonso
- York Health Economics Consortium, Enterprise House, Innovation Way, University of York, York Y0105NQ, United Kingdom
| | - Ole Dan Jørgensen
- Department of Cardiac-, Thoracic-, and Vascular Surgery, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Thomas Olsen
- York Health Economics Consortium, Enterprise House, Innovation Way, University of York, York Y0105NQ, United Kingdom
| | - Christian Gerdes
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Bvld. 99, 8200 Aarhus, Denmark
| | | | - Claudia Wolff
- Medtronic International Trading Sarl, Route du Molliau 31, CH-1131 Tolochenaz, Switzerland
| | - Stuart Mealing
- York Health Economics Consortium, Enterprise House, Innovation Way, University of York, York Y0105NQ, United Kingdom
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Bvld. 99, 8200 Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Bvld. 82, 8200 Aarhus, Denmark
| | - Mads Brix Kronborg
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Bvld. 99, 8200 Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Bvld. 82, 8200 Aarhus, Denmark
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13
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Guillem MS, Pujol-López M, Sanchez-Arciniegas J, Mont L. In silico experiments explain the non-consistent benefit of conduction system pacing over cardiac resynchronization therapy. The need to personalize therapy. J Cardiovasc Electrophysiol 2023; 34:994-996. [PMID: 36852911 DOI: 10.1111/jce.15871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 03/01/2023]
Affiliation(s)
- María S Guillem
- ITACA Institute, Universitat Politècnica de València, Valencia, Spain
| | - Margarida Pujol-López
- Secció d'Arrítmies, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain.,Institut de Recerca Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | | | - Lluís Mont
- Secció d'Arrítmies, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain.,Institut de Recerca Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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14
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Left Ventricular "Longitudinal Rotation" and Conduction Abnormalities-A New Outlook on Dyssynchrony. J Clin Med 2023; 12:jcm12030745. [PMID: 36769391 PMCID: PMC9917432 DOI: 10.3390/jcm12030745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/24/2022] [Accepted: 01/12/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The complete left bundle branch block (CLBBB) results in ventricular dyssynchrony and a reduction in systolic and diastolic efficiency. We noticed a distinct clockwise rotation of the left ventricle (LV) in patients with CLBBB ("longitudinal rotation"). AIM The aim of this study was to quantify the "longitudinal rotation" of the LV in patients with CLBBB in comparison to patients with normal conduction or complete right bundle branch block (CRBBB). METHODS Sixty consecutive patients with normal QRS, CRBBB, or CLBBB were included. Stored raw data DICOM 2D apical-4 chambers view images cine clips were analyzed using EchoPac plugin version 203 (GE Vingmed Ultrasound AS, Horten, Norway). In EchoPac-Q-Analysis, 2D strain application was selected. Instead of apical view algorithms, the SAX-MV (short axis-mitral valve level) algorithm was selected for analysis. A closed loop endocardial contour was drawn to initiate the analysis. The "posterior" segment (representing the mitral valve) was excluded before finalizing the analysis. Longitudinal rotation direction, peak angle, and time-to-peak rotation were recorded. RESULTS All patients with CLBBB (n = 21) had clockwise longitudinal rotation with mean four chamber peak rotation angle of -3.9 ± 2.4°. This rotation is significantly larger than in patients with normal QRS (-1.4 ± 3°, p = 0.005) and CRBBB (0.1 ± 2.2°, p = 0.00001). Clockwise rotation was found to be correlated to QRS duration in patients with the non-RBBB pattern. The angle of rotation was not associated with a lower ejection fraction or the presence of regional wall abnormalities. CONCLUSIONS Significant clockwise longitudinal rotation was found in CLBBB patients compared to normal QRS or CRBBB patients using speckle-tracking echocardiography.
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15
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Borgquist R, Mörtsell D, Chaudhry U, Brandt J, Farouq M, Wang L. Repositioning and optimization of left ventricular lead position in nonresponders to cardiac resynchronization therapy is associated with improved ejection fraction, lower NT-proBNP values, and fewer heart failure symptoms. Heart Rhythm O2 2022; 3:457-463. [PMID: 36340500 PMCID: PMC9626901 DOI: 10.1016/j.hroo.2022.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 06/27/2022] [Accepted: 06/27/2022] [Indexed: 01/26/2023] Open
Abstract
Background Observational data suggest that an anterior or apical left ventricular (LV) position in cardiac resynchronization therapy (CRT) is associated with worse outcome and higher likelihood of "nonresponse." It is not known whether the benefits of optimizing LV lead position in a second procedure outweighs the procedural risks. Objective To evaluate the clinical effects of LV lead repositioning. Methods During the period 2015-2020, we identified all patients in whom the indication for the procedure was LV lead repositioning owing to "nonresponse" in combination with suboptimal LV lead position. All patients were followed with a structured visit 6 months post LV lead revision. Heart failure hospitalization and mortality data were gathered from the medical records and cross-checked with the population registry. Results A total of 25 patients were identified who fulfilled the inclusion criteria. All procedures were successful in establishing LV lead pacing in a lateral mid or basal location. Median follow-up was 2.5 years [1.1-3.7]. There were improvements in NYHA class (mean -0.5 ± 0.5 class, P < .001), LV ejection fraction (+5 [interquartile range 2-11] absolute %, P = .01), QRS duration (-36 [-44 to -8], P < .001) and N-terminal pro-brain natriuretic peptide (NT-proBNP) (-615 [-2837 to +121] ng/L, P = .03). Clinical outcome was similar to a reference population with CRT (P = ns). Conclusion In nonresponders to CRT with either an anterior or inferior LV lead position, it was feasible to perform LV lead repositioning in all cases, with a low complication rate. Changing the LV lead position was associated with improved LV ejection fraction, larger QRS reduction, and larger NT-proBNP reduction.
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Affiliation(s)
- Rasmus Borgquist
- Cardiology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - David Mörtsell
- Cardiology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Uzma Chaudhry
- Cardiology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Johan Brandt
- Cardiology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Maiwand Farouq
- Cardiology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Lingwei Wang
- Cardiology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
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16
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Melgaard J, van Dam PM, Sommer A, Fruelund P, Nielsen JC, Riahi S, Graff C. Non-invasive estimation of QLV from the standard 12-lead ECG in patients with left bundle branch block. Front Physiol 2022; 13:939240. [PMID: 36213226 PMCID: PMC9532835 DOI: 10.3389/fphys.2022.939240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Cardiac resynchronization therapy (CRT) is a treatment for patients with heart failure and electrical dyssynchrony, i.e., left bundle branch block (LBBB) ECG pattern. CRT resynchronizes ventricular contraction with a right ventricle (RV) and a left ventricle (LV) pacemaker lead. Positioning the LV lead in the latest electrically activated region (measured from Q wave onset in the ECG to LV sensing by the left pacemaker electrode [QLV]) is associated with favorable outcome. However, optimal LV lead placement is limited by coronary venous anatomy and the inability to measure QLV non-invasively before implantation. We propose a novel non-invasive method for estimating QLV in sinus-rhythm from the standard 12-lead ECG.Methods: We obtained 12-lead ECG, LV electrograms and LV lead position in a standard LV 17-segment model from procedural recordings from 135 standard CRT recipients. QLV duration was measured post-operatively. Using a generic heart geometry and corresponding forward model for ECG computation, the electrical activation pattern of the heart was fitted to best match the 12-lead ECG in an iterative optimization procedure. This procedure initialized six activation sites associated with the His-Purkinje system. The initial timing of each site was based on the directions of the vectorcardiogram (VCG). Timing and position of the sites were then changed iteratively to improve the match between simulated and measured ECG. Noninvasive estimation of QLV was done by calculating the time difference between Q-onset on the computed ECG and the activation time corresponding to centroidal epicardial activation time of the segment where the LV electrode is positioned. The estimated QLV was compared to the measured QLV. Further, the distance between the actual LV position and the estimated LV position was computed from the generic ventricular model.Results: On average there was no difference between QLV measured from procedural recordings and non-invasive estimation of QLV (ΔQLV=−3.0±22.5 ms, p=0.12). Median distance between actual LV pacing site and the estimated pacing site was 18.6 mm (IQR 17.3 mm).Conclusion: Using the standard 12-lead ECG and a generic heart model it is possible to accurately estimate QLV. This method may potentially be used to support patient selection, optimize implant procedures, and to simulate optimal stimulation parameters prior to pacemaker implantation.
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Affiliation(s)
- Jacob Melgaard
- CardioTech Research Group, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- *Correspondence: Jacob Melgaard,
| | - Peter M. van Dam
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
- Peacs BV, Nieuwerbrug Aan Den Rijn, Netherlands
| | - Anders Sommer
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Patricia Fruelund
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Sam Riahi
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Claus Graff
- CardioTech Research Group, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
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17
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The role of cardiac magnetic resonance in identifying appropriate candidates for cardiac resynchronization therapy - a systematic review of the literature. Heart Fail Rev 2022; 27:2095-2118. [PMID: 36045189 DOI: 10.1007/s10741-022-10263-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 11/04/2022]
Abstract
Despite the strict indications for cardiac resynchronization therapy (CRT) implantation, a significant proportion of patients will fail to adequately respond to the treatment. This systematic review aims to present the existing evidence about the role of cardiac magnetic resonance (CMR) in identifying patients who are likely to respond better to the CRT. A systematic search in the MedLine database and Cochrane Library from their inception to August 2021 was performed, without any limitations, by two independent investigators. We considered eligible observational studies or randomized clinical trials (RCTs) that enrolled patients > 18 years old with heart failure (HF) of ischaemic or non-ischaemic aetiology and provided data about the association of baseline CMR variables with clinical or echocardiographic response to CRT for at least 3 months. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA Statement). Following our search strategy, 47 studies were finally included in our review. CMR appears to have an additive role in identifying the subgroup of patients who will respond better to CRT. Specifically, the presence and the extent of myocardial scar were associated with increased non-response rates, while those with no scar respond better. Furthermore, existing data show that scar location can be associated with CRT response rates. CMR-derived markers of mechanical desynchrony can also be used as predictors of CRT response. CMR data can be used to optimize the position of the left ventricular lead during the CRT implantation procedure. Specifically, positioning the left ventricular lead in a branch of the coronary sinus that feeds an area with transmural scar was associated with poorer response to CRT. CMR can be used as a non-invasive optimization tool to identify patients who are more likely to achieve better clinical and echocardiographic response following CRT implantation.
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18
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Lehmann HI, Tsao L, Singh JP. Treatment of cardiac resynchronization therapy non-responders: current approaches and new frontiers. Expert Rev Med Devices 2022; 19:539-547. [PMID: 35997539 DOI: 10.1080/17434440.2022.2117031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Cardiac resynchronization therapy (CRT) has developed into a very effective technology for patients with decreased systolic function and has substantially improved patients' clinical course. However, non-responsiveness to CRT, described as lack of reverse cardiac chamber remodeling, leading to lack to improve symptoms, heart failure hospitalizations or mortality, is common, rather unpredictable, and not fully understood. AREAS COVERED This article aims to discuss key factors that are impacting CRT response; from patient selection to LV lead position, to structured follow-up in CRT clinics. Secondly, common causes and interventions for CRT non-responsiveness are discussed. Next, insight is given into technologies representing new and feasible interventions as well as pacing strategies in this group of patients that remain challenging to treat. Finally, an outlook is given into future scientific development. EXPERT OPINION Despite the progress that has been made, CRT non-response remains a significant and complex problem. Patient management in interdisciplinary teams including heart failure, imaging, and cardiac arrhythmia experts appears critical as complexity is increasing and CRT non-response often is a multifactorial problem. This will allow optimization of medical therapy, the use of new integrated sensor technologies and telemedicine to ultimately optimize outcomes for all patients in need of CRT.
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Affiliation(s)
- H Immo Lehmann
- Cardiology Division, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Lana Tsao
- Cardiology Division, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Jagmeet P Singh
- Cardiology Division, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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19
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Manohar A, Colvert GM, Yang J, Chen Z, Ledesma-Carbayo MJ, Kronborg MB, Sommer A, Nørgaard BL, Nielsen JC, McVeigh ER. Prediction of Cardiac Resynchronization Therapy Response Using a Lead Placement Score Derived From 4-Dimensional Computed Tomography. Circ Cardiovasc Imaging 2022; 15:e014165. [PMID: 35973012 PMCID: PMC9558060 DOI: 10.1161/circimaging.122.014165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/19/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is an effective treatment for patients with heart failure; however, 30% of patients do not respond to the treatment. We sought to derive patient-specific left ventricle maps of lead placement scores (LPS) that highlight target pacing lead sites for achieving a higher probability of CRT response. METHODS Eighty-two subjects recruited for the ImagingCRT trial (Empiric Versus Imaging Guided Left Ventricular Lead Placement in Cardiac Resynchronization Therapy) were retrospectively analyzed. All 82 subjects had 2 contrast-enhanced full cardiac cycle 4-dimensional computed tomography scans: a baseline and a 6-month follow-up scan. CRT response was defined as a reduction in computed tomography-derived end-systolic volume ≥15%. Eight left ventricle features derived from the baseline scans were used to train a support vector machine via a bagging approach. An LPS map over the left ventricle was created for each subject as a linear combination of the support vector machine feature weights and the subject's own feature vector. Performance for distinguishing responders was performed on the original 82 subjects. RESULTS Fifty-two (63%) subjects were responders. Subjects with an LPS≤Q1 (lower-quartile) had a posttest probability of responding of 14% (3/21), while subjects with an LPS≥ Q3 (upper-quartile) had a posttest probability of responding of 90% (19/21). Subjects with Q1 CONCLUSIONS An LPS map was defined using 4-dimensional computed tomography-derived features of left ventricular mechanics. The LPS correlated with CRT response, reclassifying 25% of the subjects into low probability of response, 25% into high probability of response, and 50% unchanged. These encouraging results highlight the potential utility of 4-dimensional computed tomography in guiding patient selection for CRT. The present findings need verification in larger independent data sets and prospective trials.
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Affiliation(s)
- Ashish Manohar
- Department of Mechanical and Aerospace Engineering, University of California San Diego, La Jolla, California, USA
| | - Gabrielle M. Colvert
- Department of Bioengineering, University of California San Diego, La Jolla, California, USA
| | - James Yang
- Department of Bioengineering, University of California San Diego, La Jolla, California, USA
| | - Zhennong Chen
- Department of Bioengineering, University of California San Diego, La Jolla, California, USA
| | - Maria J. Ledesma-Carbayo
- Biomedical Image Technologies Laboratory, ETSI Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
- Biomedical Research Networking Centre in Bioengineering, Biomaterials and Nanomedicine, Madrid, Spain
| | | | - Anders Sommer
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Elliot R. McVeigh
- Department of Bioengineering, University of California San Diego, La Jolla, California, USA
- Department of Radiology, University of California San Diego, La Jolla, California, USA
- Department of Medicine, Cardiovascular Division, University of California San Diego, La Jolla, California, USA
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20
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Allen LaPointe NM, Ali-Ahmed F, Dalgaard F, Kosinski AS, Sanders Schmidler G, Al-Khatib SM. Cardiac resynchronization therapy outcomes with left ventricular lead concordant with latest mechanical activation: A meta-analysis. Pacing Clin Electrophysiol 2022; 45:930-939. [PMID: 35687711 PMCID: PMC10752256 DOI: 10.1111/pace.14549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/11/2022] [Accepted: 06/05/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND For cardiac resynchronization therapy (CRT), image-guided approaches targeting left ventricular (LV) lead placement at the site of latest mechanical activation had inconsistent outcomes. We examined evidence for improved CRT outcomes when LV lead placement concordant with latest mechanical activation occurred. METHODS A review of EMBASE and PubMed was performed for randomized controlled trials or prospective observational studies from October 2008 through October 2020 comparing outcomes with concordant versus discordant LV lead placement. Meta-analyses were performed to assess the association between concordance and death, death or heart failure (HF) hospitalization, ≥ 15% reduction in LV end systolic volume (LVESV), and changes in LVESV or ejection fraction (LVEF). RESULTS From 5897 citations, nine publications (eight studies) with 1355 patients were selected; 975 with a concordant LV lead and 380 with a discordant lead. Mean age was 66-68 years, 82% were male, and 64% had ischemic cardiomyopathy. Meta-analyses demonstrated a statistically significant reduction in death/HF hospitalization at 2 years (OR 0.38; 95% CI 0.16, 0.92) and LVESV at 6 months (mean difference [MD] -13.4%; 95% CI -6.7%, -20.0%), and an increase in LVEF (MD 4.03; 95% CI 0.77, 7.30) with the concordant LV lead. There were trends toward decreased death at 2 years (OR 0.49; 95% CI 0.19, 1.23) and ≥ 15% reduction in LVESV at 6 months (OR 3.81; 95% CI 0.24, 61.24) with concordant LV lead placement. CONCLUSION A concordant LV lead was associated with better CRT outcomes. Further study of feasible methods to achieve LV lead concordance is needed.
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Affiliation(s)
- Nancy M. Allen LaPointe
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Fatima Ali-Ahmed
- Department of Cardiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Frederik Dalgaard
- Department of Cardiology, Herlev and Gentofte Hospital, Hellerup, Denmark
| | - Andrzej S. Kosinski
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Gillian Sanders Schmidler
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sana M. Al-Khatib
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
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21
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Mehta VS, Ayis S, Elliott MK, Widjesuriya N, Kardaman N, Gould J, Behar JM, Chiribiri A, Razavi R, Niederer S, Rinaldi CA. The role of guidance in delivering cardiac resynchronization therapy: A systematic review and network meta-analysis. Heart Rhythm O2 2022; 3:482-492. [PMID: 36340494 PMCID: PMC9626880 DOI: 10.1016/j.hroo.2022.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/12/2022] [Accepted: 07/15/2022] [Indexed: 11/28/2022] Open
Abstract
Background Positioning the left ventricular lead at the optimal myocardial segment has been proposed to improve cardiac resynchronization therapy (CRT) response. Objectives We performed a systematic review and network meta-analysis evaluating echocardiographic and clinical response delivered with different guidance modalities compared to conventional fluoroscopic positioning. Methods Randomized trials with ≥6 months follow-up comparing any combination of imaging, electrical, hemodynamic, or fluoroscopic guidance were included. Imaging modalities were split whether one modality was used: cardiac magnetic resonance (CMR), speckle-tracking echocardiography (STE), single-photon emission computed tomography, cardiac computed tomography (CT), or a combination of these, defined as “multimodality imaging.” Results Twelve studies were included (n = 1864). Pair-wise meta-analysis resulted in significant odds of reduction in left ventricular end-systolic volume (LVESV) >15% (odds ratio [OR] 1.50, 95% confidence interval [CI] 1.05–2.13, P = .025) and absolute reduction in LVESV (standardized mean difference [SMD] -0.25, 95% CI -0.43 to -0.08, P = .005) with guidance. CMR (OR 55.3, 95% CI 4.7–656.9, P = .002), electrical (OR 17.0, 95% CI 2.9–100, P = .002), multimodality imaging (OR 4.47, 95% CI 1.36–14.7, P = .014), and hemodynamic guidance (OR 1.29–28.0, P = .02) were significant in reducing LVESV >15%. Only STE demonstrated a significant reduction in absolute LVESV (SMD -0.38, 95% CI -0.68 to -0.09, P = .011]. CMR had the highest probability of improving clinical response (OR 17.9, 95% CI 5.14–62.5, P < .001). Conclusion Overall, guidance improves CRT outcomes. STE and multimodality imaging provided the most reliable evidence of efficacy. Wide CIs observed for results of CMR guidance suggest more powered studies are required before a clear ranking is possible.
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Affiliation(s)
- Vishal S. Mehta
- Cardiology Department, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Address reprint requests and correspondence: Dr Vishal S. Mehta, School of Biomedical Engineering and Imaging Sciences, St Thomas’ Hospital, London, SE1 7EH, UK.
| | - Salma Ayis
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom
| | - Mark K. Elliott
- Cardiology Department, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Nadeev Widjesuriya
- Cardiology Department, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Nuha Kardaman
- Cardiology Department, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Justin Gould
- Cardiology Department, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Jonathan M. Behar
- Cardiology Department, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Amedeo Chiribiri
- Cardiology Department, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Reza Razavi
- Cardiology Department, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Christopher A. Rinaldi
- Cardiology Department, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
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22
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Gosling RC, Al-Mohammad A. The Role of Cardiac Imaging in Heart Failure with Reduced Ejection Fraction. Card Fail Rev 2022; 8:e22. [PMID: 35815258 PMCID: PMC9253963 DOI: 10.15420/cfr.2021.33] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 03/21/2022] [Indexed: 11/30/2022] Open
Abstract
Heart failure (HF) is a major health burden associated with significant morbidity and mortality. Approximately half of all HF patients have reduced ejection fraction (left ventricular ejection fraction <40%) at rest (HF with reduced ejection fraction). The aetiology of HF is complex, and encompasses a wide range of cardiac conditions, hereditary defects and systemic diseases. Early identification of aetiology is important to allow personalised treatment and prognostication. Cardiac imaging has a major role in the assessment of patients with HF with reduced ejection fraction, and typically incorporates multiple imaging modalities, each with unique but complimentary roles. In this review, the comprehensive role of cardiac imaging in the diagnosis, assessment of aetiology, treatment planning and prognostication of HF with reduced ejection fraction is discussed.
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Affiliation(s)
- Rebecca C Gosling
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Abdallah Al-Mohammad
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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23
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Green PG, Herring N, Betts TR. What Have We Learned in the Last 20 Years About CRT Non-Responders? Card Electrophysiol Clin 2022; 14:283-296. [PMID: 35715086 DOI: 10.1016/j.ccep.2021.12.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Although cardiac resynchronization therapy (CRT) has become well established in the treatment of heart failure, the management of patients who do not respond after CRT remains a key challenge. This review will summarize what we have learned about non-responders over the last 20 years and discuss methods for optimizing response, including the introduction of novel therapies.
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Affiliation(s)
- Peregrine G Green
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK; Oxford Centre for Clinical Magnetic Resonance Research (OCMR), University of Oxford, Level 0 John Radcliffe Hospital, Oxford, OX3 9DU, UK; Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Neil Herring
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK; Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Timothy R Betts
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK; Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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24
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Allen LaPointe NM, Ali-Ahmed F, Dalgaard F, Kosinski AS, Schmidler GS, Al-Khatib SM. Outcomes of Cardiac Resynchronization Therapy with Image-Guided Left Ventricular Lead Placement at the Site of Latest Mechanical Activation: A Systematic Review and Meta-Analysis. J Interv Cardiol 2022; 2022:6285894. [PMID: 35655661 PMCID: PMC9146808 DOI: 10.1155/2022/6285894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/22/2022] [Indexed: 12/07/2022] Open
Abstract
Aim To assess evidence for an image-guided approach for cardiac resynchronization therapy (CRT) that targets left ventricular (LV) lead placement at the segment of latest mechanical activation. Methods A systematic review of EMBASE and PubMed was performed for randomized controlled trials (RCTs) and prospective observational studies from October 2008 through October 2020 that compared an image-guided CRT approach with a non-image-guided approach for LV lead placement. Meta-analyses were performed to assess the association between the image-guided approach and NYHA class improvement or changes in end-systolic volume (LVESV), end-diastolic volume (LVEDV), and ejection fraction (LVEF). Results From 5897 citations, 5 RCTs including 818 patients (426 image-guided and 392 non-image-guided) were identified. The mean age ranged from 66 to 71 years, 76% were male, and 53% had ischemic cardiomyopathy. Speckle tracking echocardiography was the primary image-guided method in all studies. LV lead placement within the segment of the latest mechanical activation (concordant) was achieved in the image-guided arm in 45% of the evaluable patients. There was a statistically significant improvement in the NYHA class at 6 months (odds ratio 1.66; 95% confidence interval (CI) [1.02, 2.69]) with the image-guided approach, but no statistically significant change in LVESV (MD -7.1%; 95% CI [-16.0, 1.8]), LVEDV (MD -5.2%; 95% CI [-15.8, 5.4]), or LVEF (MD 0.68; 95% CI [-4.36, 5.73]) versus the non-image-guided approach. Conclusion The image-guided CRT approach was associated with improvement in the NYHA class but not echocardiographic measures, possibly due to the small sample size and a low rate of concordant LV lead placement despite using the image-guided approach. Therefore, our meta-analysis was not able to identify consistent improvement in CRT outcomes with an image-guided approach.
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Affiliation(s)
- Nancy M. Allen LaPointe
- Department of Medicine, Duke University School of Medicine, Durham, NC 27710, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC 27708, USA
| | | | - Frederik Dalgaard
- Department of Cardiology, Herlev and Gentofte Hospital, Hellerup, Denmark
| | - Andrzej S. Kosinski
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC 27710, USA
- Duke Clinical Research Institute, Durham, NC 27710, USA
| | - Gillian Sanders Schmidler
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC 27708, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC 27710, USA
| | - Sana M. Al-Khatib
- Department of Medicine, Duke University School of Medicine, Durham, NC 27710, USA
- Duke Clinical Research Institute, Durham, NC 27710, USA
- Division of Cardiology, Duke University Medical Center, Durham, NC 27710, USA
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25
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The Role of Cardiac Computed Tomography in Heart Failure. Curr Heart Fail Rep 2022; 19:213-222. [PMID: 35588344 DOI: 10.1007/s11897-022-00553-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE OF REVIEW Cardiac computed tomography (CT) is becoming a more widely applied tool in the diagnosis and management of a variety of cardiovascular conditions, including heart failure. The aim of this narrative review is to examine the role of cardiac CT in patients with heart failure. RECENT FINDINGS Coronary computed tomographic angiography has robust diagnostic accuracy for ruling out coronary artery disease. These data are reflected in updated guidelines from major cardiology organizations. New roles for cardiac CT in myocardial imaging, perfusion scanning, and periprocedural planning, execution, and monitoring are being implemented. Cardiac CT is useful in ruling out coronary artery disease its diagnostic accuracy, accessibility, and safety. It is also intricately linked to invasive cardiac procedures that patients with heart failure routinely undergo.
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26
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Johansen JB, Nielsen JC, Kristensen J, Sandgaard NC. Troubleshooting the difficult left ventricular lead placement in cardiac resynchronization therapy: current status and future perspectives. Expert Rev Med Devices 2022; 19:341-352. [PMID: 35536115 DOI: 10.1080/17434440.2022.2075728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Cardiac resynchronization therapy (CRT) is an important option in modern cardiac implantable electronic device (CIED) treatment. Techniques for left ventricular (LV) lead placement in the coronary sinus and its tributaries are neither well described nor studied systematically, despite attention regarding where to place the LV lead. AREAS COVERED This review presents specialized tools and techniques to overcome some of the most common problems encountered in LV lead placement in CRT. These tools and techniques are termed Interventional-CRT (I-CRT), as they share technology with other interventional procedures. The main principle in I-CRT, compared to the traditional Over-The-Wire technique, is to add better support for delivery of the LV lead through dedicated inner catheters that also allows more flexibility with use of more guidewires and better imaging with direct venography in the target vein. EXPERT OPINION Even though CRT is an established therapeutic option, there are still many challenges in the implementation of the therapy. The cornerstone should be an ease of delivering the CRT and specifically implantation of the LV lead. Therefore, knowledge of the principles in I-CRT, as I-CRT could make implantation simpler in general and easier to reach the optimal LV pacing site.
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Affiliation(s)
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Kristensen
- Department of Cardiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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27
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Borgquist R, Barrington WR, Bakos Z, Werther-Evaldsson A, Saba S. Targeting the latest site of left ventricular mechanical activation is associated with improved long-term outcomes for recipients of Cardiac Resynchronization Therapy. Heart Rhythm O2 2022; 3:377-384. [PMID: 36097466 PMCID: PMC9463689 DOI: 10.1016/j.hroo.2022.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Previous studies have suggested that targeting the site of latest mechanical activation of the left ventricle (LV) results in improved cardiac resynchronization therapy (CRT) outcomes. It is not known whether these benefits are sustained over medium-term follow-up. Objective To assess the clinical outcome of imaging-guided LV lead position. Methods We sought to assess the medium-term clinical outcome by performing a patient-level meta-analysis of 2 previously published randomized controlled trials (the “STARTER” trial and the “CRT Clinic” trial). These 2 trials compared imaging-guided LV lead placement in the latest activated scar-free segment (intervention group) to standard of care (control). Mortality and heart failure hospitalization outcomes over extended follow-up were gathered from the medical records and merged. Results were stratified for native electrocardiogram (ECG) morphology. Results A total of 289 patients were followed for a median of 6.3 years. Seven years post implant, 47 (28%) in the intervention group had died, vs 47 (38%) in the control group (P = .13); 49 (30%) vs 53 (42%) had been hospitalized for heart failure (P = .035); and 47% vs 59% (P = .057) had reached the combined endpoint. In Kaplan-Meier analysis, patients in the intervention group had better survival free of heart failure hospitalization (P = .045) and lower risk of heart failure hospitalization (P = .019). Conclusion Targeting the latest mechanically activated segment in CRT results in better medium-term clinical outcome, mainly driven by a reduced risk of hospitalization for heart failure. The effect was seen regardless of native ECG morphology.
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Affiliation(s)
- Rasmus Borgquist
- Arrhythmia Section, Department of Cardiology, Lund University, Skane University Hospital, Lund, Sweden
- Address reprint requests and correspondence: Dr Rasmus Borgquist, Arrhythmia Section, Skane University Hospital, 221 85, Lund, Sweden.
| | - William R. Barrington
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Zoltan Bakos
- Department of Cardiology, Kristianstad Hospital, Kristianstad, Sweden
| | - Anna Werther-Evaldsson
- Heart Failure and Transplant Section, Department of Cardiology, Lund University, Skane University Hospital, Lund, Sweden
| | - Samir Saba
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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28
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2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Translation of the document prepared by the Czech Society of Cardiology. COR ET VASA 2022. [DOI: 10.33678/cor.2022.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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29
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Cardiac computed tomography-verified right ventricular lead position and outcomes in cardiac resynchronization therapy. J Interv Card Electrophysiol 2022; 64:783-792. [DOI: 10.1007/s10840-022-01193-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 03/20/2022] [Indexed: 10/18/2022]
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30
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJ, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM. Grupo de trabajo sobre estimulación cardiaca y terapia de resincronización cardiaca de la Sociedad Europea de Cardiología (ESC). Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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31
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Fyenbo DB, Sommer A, Nørgaard BL, Kronborg MB, Kristensen J, Gerdes C, Jensen HK, Jensen JM, Nielsen JC. Long-term outcomes in a randomized controlled trial of multimodality imaging-guided left ventricular lead placement in cardiac resynchronization therapy. Europace 2022; 24:828-834. [PMID: 35041000 DOI: 10.1093/europace/euab314] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 12/08/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS This study aims to investigate the long-term occurrence of the composite endpoint of heart failure (HF) hospitalization or all-cause death (primary endpoint) in patients randomized to cardiac resynchronization therapy (CRT) using individualized multimodality imaging-guided left ventricular (LV) lead placement compared with a routine fluoroscopic approach. Furthermore, this study aims to evaluate whether inter-lead electrical delay (IED) is associated with improved response rate of this endpoint. METHODS AND RESULTS We reviewed follow-up data until November 2020 for all 182 patients included in the ImagingCRT trial for the occurrence of HF hospitalization and all-cause death. During median (inter-quartile range) time to primary endpoint/censuring of 6.7 (3.3-7.9) years, the rate of the primary endpoint was 60% (n = 53) in the imaging group compared with 52% (n = 48) in the control group [hazard ratio (HR) 1.22, 95% confidence interval (CI) 0.83-1.81, P = 0.31]. Neither the risk of HF hospitalization (HR 1.11, 95% CI 0.62-1.99, P = 0.72) nor of all-cause death differed between treatment groups (HR 1.23, 95% CI 0.82-1.85, P = 0.32). The risk of the primary endpoint was significantly reduced among those with IED ≥100 ms when compared with those with IED <100 ms (HR 0.62, 95% CI 0.39-0.98, P = 0.04). CONCLUSIONS In this study, an individualized multimodality imaging-guided strategy targeting LV lead placement towards the latest mechanically activated non-scarred myocardial segment during CRT implantation did not reduce HF hospitalization or all-cause death when compared with routine LV lead placement during long-term follow-up. Targeting the latest electrical activation should be studied as an alternative individualized strategy for optimizing LV lead placement in CRT recipients.
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Affiliation(s)
- Daniel Benjamin Fyenbo
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anders Sommer
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Bjarne Linde Nørgaard
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Mads Brix Kronborg
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Kristensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Christian Gerdes
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Henrik Kjærulf Jensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jesper Møller Jensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM, Leyva F, Linde C, Abdelhamid M, Aboyans V, Arbelo E, Asteggiano R, Barón-Esquivias G, Bauersachs J, Biffi M, Birgersdotter-Green U, Bongiorni MG, Borger MA, Čelutkienė J, Cikes M, Daubert JC, Drossart I, Ellenbogen K, Elliott PM, Fabritz L, Falk V, Fauchier L, Fernández-Avilés F, Foldager D, Gadler F, De Vinuesa PGG, Gorenek B, Guerra JM, Hermann Haugaa K, Hendriks J, Kahan T, Katus HA, Konradi A, Koskinas KC, Law H, Lewis BS, Linker NJ, Løchen ML, Lumens J, Mascherbauer J, Mullens W, Nagy KV, Prescott E, Raatikainen P, Rakisheva A, Reichlin T, Ricci RP, Shlyakhto E, Sitges M, Sousa-Uva M, Sutton R, Suwalski P, Svendsen JH, Touyz RM, Van Gelder IC, Vernooy K, Waltenberger J, Whinnett Z, Witte KK. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Europace 2022; 24:71-164. [PMID: 34455427 DOI: 10.1093/europace/euab232] [Citation(s) in RCA: 140] [Impact Index Per Article: 70.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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New Perspectives in the Treatment of Acute and Chronic Heart Failure with Reduced Ejection Fraction. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2021. [DOI: 10.2478/jce-2021-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
ABSTRACT
Acute and chronic heart failure with reduced ejection fraction (HFrEF) is a major public health problem, studies showing a 25% survival rate at 5 years after hospitalization. If left untreated, it is a common and potentially fatal disease. In recent years, the medical and device therapies of patients with HFrEF have significantly improved. The aim of our review is to provide an evidence-based update on new therapeutic strategies in acute and chronic settings, to prevent hospitalization and death in patients with HFrEF. We performed a systematic literature search on PubMed, EMBASE, and the Cochrane Database of Systemic Reviews, and we included a number of 23 randomized controlled trials published in the last 30 years. The benefit of beta-blockers and renin-angiotensin-aldosterone system inhibitors in patients with HFrEF is well known. Recent developments, such as sodium-glucose cotransporter 2 inhibitors, vericiguat, transcatheter mitral valve repair, wireless pulmonary artery pressure monitor and cardiac contractility modulation, have also proven effective in improving prognosis. In addition, other new therapeutic agents showed encouraging results, but they are currently being studied. The implementation of personalized disease management programs that directly target the cause of HFrEF is crucial in order to improve prognosis and quality of life for these patients.
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Glikson M, Beinart R, Golovchiner G, Sheshet AB, Swissa M, Bolous M, Rosso R, Medina A, Haim M, Friedman P, Khalamaizer V, Benzvi S, Ito S, Goldenberg I, Klempfner R, Vaturi O, Oh JK. Radial strain imaging-guided lead placement for improving response to cardiac resynchronization therapy in patients with ischaemic cardiomyopathy: the raise cardiac resynchronization therapy trial. Europace 2021; 24:835-844. [PMID: 34734227 DOI: 10.1093/europace/euab253] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS To evaluate the benefit of speckle tracking radial strain imaging (STRSI)-guided left ventricular (LV) lead (LVL) positioning in cardiac resynchronization therapy (CRT) in patients (pts) with ischaemic cardiomyopathy with CRT indication. METHODS AND RESULTS We conducted a prospective randomized controlled trial. Patients were enrolled in nine centres with 2:1 randomization into two groups (guided vs. control). Patients underwent STRSI to identify the optimal LV position from six LV segments at midventricular level. Implantation via STRSI was attempted for recommended segment in the guided group only. Follow-up included echocardiography (6 months) and clinical evaluation (6 and 12 months). The primary endpoint was comparison % reduction in LV end-systolic volume at 6 months with baseline. Secondary endpoints included hospitalizations for heart failure and death, and improvement in additional echocardiographic measurements and quality of life score. A total of 172 patients (115 guided vs. 57 control) were enrolled. In the guided group, 60% of the implanted LV leads were adjudicated to be successfully located at the recommended segment, whereas in the control group 44% reached the best STRSI determined segment. There was no difference between the groups in any of the primary or secondary endpoints at 6 and 12 months. CONCLUSION Our findings suggest that echo-guided implantation of an LV lead using STRSI does not improve the clinical or echocardiographic response compared with conventional implantation.
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Affiliation(s)
- Michael Glikson
- Integrated Heart Centre, Shaare Zedek Medical Centre, Hebrew University, Jerusalem, Israel.,Arrhythmia center, Sheba Medical Centre, Tel Aviv University, Tel Hashomer, Israel
| | - Roy Beinart
- Arrhythmia center, Sheba Medical Centre, Tel Aviv University, Tel Hashomer, Israel
| | - Gregory Golovchiner
- Department of cardiology, Rabin MC, Tel Aviv University, Petah Tikva, Israel
| | - Alon Bar Sheshet
- Department of cardiology, Rabin MC, Tel Aviv University, Petah Tikva, Israel
| | - Moshe Swissa
- Department of cardiology, Kaplan MC, Hebrew University, Rehovot, Israel
| | - Munther Bolous
- Department of cardiology, Rambam MC, Technion Institute, Haifa, Israel
| | - Raphael Rosso
- Department of cardiology, Tel Aviv Souraski MC, Tel Aviv University, Tel Aviv, Israel
| | - Aharon Medina
- Integrated Heart Centre, Shaare Zedek Medical Centre, Hebrew University, Jerusalem, Israel
| | - Moti Haim
- Department of cardiology, Soroka MC, Ben Gurion University, Beer Sheba, Israel
| | - Paul Friedman
- Department of cardiovascular medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Shlomit Benzvi
- Israeli Centre for Cardiovascular Research, Tel Hashomer, Israel
| | - Saki Ito
- Department of cardiovascular medicine, Mayo Clinic, Rochester, MN, USA
| | - Ilan Goldenberg
- Israeli Centre for Cardiovascular Research, Tel Hashomer, Israel.,University of Rochester, Rochester, NY, USA
| | - Robert Klempfner
- Israeli Centre for Cardiovascular Research, Tel Hashomer, Israel
| | - Ori Vaturi
- Arrhythmia center, Sheba Medical Centre, Tel Aviv University, Tel Hashomer, Israel
| | - Jae K Oh
- Department of cardiovascular medicine, Mayo Clinic, Rochester, MN, USA
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Östenson B, Ostenfeld E, Werther-Evaldsson A, Roijer A, Bakos Z, Kanski M, Heiberg E, Arheden H, Borgquist R, Carlsson M. Regional contributions to left ventricular stroke volume determined by cardiac magnetic resonance imaging in cardiac resynchronization therapy. BMC Cardiovasc Disord 2021; 21:519. [PMID: 34702172 PMCID: PMC8549254 DOI: 10.1186/s12872-021-02325-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) restores ventricular synchrony and induces left ventricular (LV) reverse remodeling in patients with heart failure (HF) and dyssynchrony. However, 30% of treated patients are non-responders despite all efforts. Cardiac magnetic resonance imaging (CMR) can be used to quantify regional contributions to stroke volume (SV) as potential CRT predictors. The aim of this study was to determine if LV longitudinal (SVlong%), lateral (SVlat%), and septal (SVsept%) contributions to SV differ from healthy controls and investigate if these parameters can predict CRT response. METHODS Sixty-five patients (19 women, 67 ± 9 years) with symptomatic HF (LVEF ≤ 35%) and broadened QRS (≥ 120 ms) underwent CMR. SVlong% was calculated as the volume encompassed by the atrioventricular plane displacement (AVPD) from end diastole (ED) to end systole (ES) divided by total SV. SVlat%, and SVsept% were calculated as the volume encompassed by radial contraction from ED to ES. Twenty age- and sex-matched healthy volunteers were used as controls. The regional measures were compared to outcome response defined as ≥ 15% decrease in echocardiographic LV end-systolic volume (LVESV) from pre- to 6-months post CRT (delta, Δ). RESULTS AVPD and SVlong% were lower in patients compared to controls (8.3 ± 3.2 mm vs 15.3 ± 1.6 mm, P < 0.001; and 53 ± 18% vs 64 ± 8%, P < 0.01). SVsept% was lower (0 ± 15% vs 10 ± 4%, P < 0.01) with a higher SVlat% in the patient group (42 ± 16% vs 29 ± 7%, P < 0.01). There were no differences between responders and non-responders in neither SVlong% (P = 0.87), SVlat% (P = 0.09), nor SVsept% (P = 0.65). In patients with septal net motion towards the right ventricle (n = 28) ΔLVESV was - 18 ± 22% and with septal net motion towards the LV (n = 37) ΔLVESV was - 19 ± 23% (P = 0.96). CONCLUSIONS Longitudinal function, expressed as AVPD and longitudinal contribution to SV, is decreased in patients with HF scheduled for CRT. A larger lateral contribution to SV compensates for the abnormal septal systolic net movement. However, LV reverse remodeling could not be predicted by these regional contributors to SV.
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Affiliation(s)
- Björn Östenson
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Ellen Ostenfeld
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Anna Werther-Evaldsson
- Section for Heart Failure and Valvular Disease, Department of Clinical Sciences Lund, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Anders Roijer
- Section for Heart Failure and Valvular Disease, Department of Clinical Sciences Lund, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Zoltan Bakos
- Section of Arrhythmia, Department of Clinical Sciences Lund, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Mikael Kanski
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Department of Radiology, New York University School of Medicine, New York, NY, USA
| | - Einar Heiberg
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
| | - Håkan Arheden
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Rasmus Borgquist
- Section of Arrhythmia, Department of Clinical Sciences Lund, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marcus Carlsson
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden.
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36
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J 2021; 42:3427-3520. [PMID: 34455430 DOI: 10.1093/eurheartj/ehab364] [Citation(s) in RCA: 893] [Impact Index Per Article: 297.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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37
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Butter C, Georgi C, Stockburger M. Optimal CRT Implantation-Where and How To Place the Left-Ventricular Lead? Curr Heart Fail Rep 2021; 18:329-344. [PMID: 34495452 PMCID: PMC8484220 DOI: 10.1007/s11897-021-00528-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 12/28/2022]
Abstract
Purpose of Review Cardiac resynchronization therapy (CRT) represents a well-established and effective non-pharmaceutical heart failure (HF) treatment in selected patients. Still, a significant number of patients remain CRT non-responders. An optimal placement of the left ventricular (LV) lead appears crucial for the intended hemodynamic and hence clinical improvement. A well-localized target area and tools that help to achieve successful lead implantation seem to be of utmost importance to reach an optimal CRT effect. Recent Findings Recent studies suggest previous multimodal imaging (CT/cMRI/ECG torso) to guide intraprocedural LV lead placement. Relevant benefit compared to empirical lead optimization is still a matter of debate. Technical improvements in leads and algorithms (e.g., multipoint pacing (MPP), adaptive algorithms) promise higher procedural success. Recently emerging alternatives for ventricular synchronization such as conduction system pacing (CSP), LV endocardial pacing, or leadless pacing challenge classical biventricular pacing. Summary This article reviews current strategies for a successful planning, implementation, and validation of the optimal CRT implantation. Pre-implant imaging modalities offer promising assistance for complex cases; empirical lead positioning and intraoperative testing remain the cornerstone in most cases and ensure a successful CRT effect.
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Affiliation(s)
- Christian Butter
- Department of Cardiology, Heart Center Brandenburg, University Hospital Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany
| | - Christian Georgi
- Department of Cardiology, Heart Center Brandenburg, University Hospital Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany
| | - Martin Stockburger
- Department of Internal Medicine/Cardiology, Havelland Kliniken GmbH, Nauen, Germany
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38
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Kheiri B, Przybylowicz R, Simpson TF, Merrill M, Osman M, Dalouk K, Rahmouni H, Stecker E, Nazer B, Henrikson CA. Imaging-guided cardiac resynchronization therapy: A meta-analysis of randomized controlled trials. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1570-1576. [PMID: 34255376 DOI: 10.1111/pace.14316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/07/2021] [Accepted: 07/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Among patients with heart failure and left ventricular (LV) dysfunction despite guideline directed medical therapy, cardiac resynchronization (CRT) is an effective technology to reverse LV remodeling. Given that a large portion of patients are non-responders, alternatives to traditional LV-lead placement have been explored. A promising alternative is image targeted placement of an LV-lead to latest mechanically activated segment without scar. METHODS Electronic database search for randomized controlled trials (RCTs) that evaluated the imaging-guided LV-lead placement on clinical, echocardiographic, and functional outcomes. The primary outcome was a composite of mortality and heart failure hospitalization. The secondary outcomes included CRT responders, New York Heart Association (NYHA), 6-minute walk test, Minnesota Living with Heart Failure Questionnaire (MLHFQ), and ejection fraction (EF) changes. RESULTS Analysis included 4 RCTs of 691 patients with an average follow-up of 2 years (age 69.5 ± 10.3 years, 76% males, 54% ischemic cardiomyopathy, 81% with NYHA classes III/IV, and EF of 24.4% ± 8). The most common site for LV-lead paced segment was the anterolateral segment (45%) and at mid-LV (49%). Compared with the control, imaging-guided LV-lead placement was associated with a significant reduction of the primary outcome (hazard ratio [HR] = 0.60; 95% CI = 0.40-0.88; p = .01), higher CRT responders (odd ratio [OR] = 2.10; p < .01), more NYHA improvements by ≥1 (OR = 1.89; p = .01), increased 6MWT (mean difference [MD] = 25.78 feet; p < .01), and lower MLHFQ (MD = -4.04; p = .04), without significant differences in the LVEF (p = .08). CONCLUSIONS In patients undergoing CRT, imaging-guided LV-lead placement was associated with improved clinical, echocardiographic, and functional status.
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Affiliation(s)
- Babikir Kheiri
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Ryle Przybylowicz
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Timothy F Simpson
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Miranda Merrill
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Mohammed Osman
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA.,Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Khidir Dalouk
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Hind Rahmouni
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Eric Stecker
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Babak Nazer
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Charles A Henrikson
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
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Marques P, Nunes-Ferreira A, Silvério António P, Aguiar-Ricardo I, Rodrigues T, Badie N, Marcos I, Bernardes A, Pinto FJ, de Sousa J. Clinical impact of MultiPoint pacing in responders to cardiac resynchronization therapy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1577-1584. [PMID: 34255874 DOI: 10.1111/pace.14319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 06/08/2021] [Accepted: 07/11/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy demonstrated benefits in heart failure. However, only 60-70% are responders and only 22% are super-responders. MultiPoint pacing (MPP) improves structural remodeling, but data in responder patients is scarce. METHODS A prospective, randomized study of the efficacy of MPP was conducted in patients who were CRT responders after 6 months of bi-ventricular (BiV) therapy. At 6 months, responder patients (LV end-systolic volume [LVESV] reduction ≥15%) were randomized to either continued BiV therapy or to MPP programmed with wide anatomical separation ≥30 mm, and followed until 12 months. Efficacy was determined by 6-12 month changes in LVESV and LV ejection fraction (LVEF). Evaluations of super-responder rate (LVESV reduction ≥30%) and quality of life (NYHA, EQ-5D, MLHFQ) were also performed. RESULTS From February 2017 to February 2019, 73 CRTs with Quartet LV leads were implanted (42.9% female, 65.7 ± 10.8 years old, 79.5% dilated cardiomyopathy). At 6 months, 74.2% responded to BiV and were randomized to BiV (n = 25) or MPP (n = 24). MPP versus BiV delivered greater LVESV improvement (8.3% decrease in MPP vs. 10.3% increase in BiV patients, p = .047), greater increase in LVEF (7.7% vs. 1.8%, p = .008), and higher 0-12 month super-responder rate (86.4% vs. 56.0%, p = .027). More MPP vs. BiV patients experienced an improvement in NYHA (84.6% vs. 50.0%, p = .047) and EQ-5D (94.4% vs. 54.0%, p = .006). CONCLUSIONS MPP with wide anatomical spacing in CRT responder patients resulted in improved LV reverse remodeling with higher rates of super-responders, and better quality of life metrics.
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Affiliation(s)
- Pedro Marques
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal.,CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisboa, Portugal
| | - Afonso Nunes-Ferreira
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal.,CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisboa, Portugal
| | - Pedro Silvério António
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal.,CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisboa, Portugal
| | - Inês Aguiar-Ricardo
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal.,CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisboa, Portugal
| | - Tiago Rodrigues
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal.,CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisboa, Portugal
| | | | - Ivo Marcos
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Ana Bernardes
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Fausto J Pinto
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal.,CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisboa, Portugal
| | - João de Sousa
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal.,CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisboa, Portugal
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Atabekov TA, Batalov RE, Sazonova SI, Krivolapov SN, Khlynin MS, Mishkina AI, Zavadovsky KV, Curnis A, Popov SV. How to get the optimal defibrillation lead parameters using myocardial perfusion scintigraphy in patients with coronary artery disease. Int J Cardiovasc Imaging 2021; 37:3323-3333. [PMID: 34100141 DOI: 10.1007/s10554-021-02308-x] [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: 05/03/2021] [Accepted: 06/01/2021] [Indexed: 11/26/2022]
Abstract
The conventional criteria for a defibrillation lead (DL) implantation don't take into account presence of scar or deep ischemia in the myocardium. This may impair a proper functioning of the DL. We sought to optimize the DL implantation placement using rest myocardial perfusion scintigraphy (MPS), which allow detecting areas of myocardial hypoperfusion (MH). To study the influence of MH and scarring, detected by MPS, on the DL parameters in patients with coronary artery disease (CAD). 69 patients (male-65, age 64.8 ± 7.7 years) with CAD and indications for ICD implantation were enrolled. Two days before ICD implantation all patients underwent MPS at rest. Then patients were divided in 2 groups. In the 1st group DL was implanted considering MPS results: to the septal position, if the most significant MH were detected in the apical segments, and to the apical position, if MH were in the septal segments. In the 2nd group DL was implanted using the conventional approach without considering MPS results. Clinical 12 months follow-up was performed with ICD interrogation. Patients of both groups were comparable by clinical and scintigraphic parameters. In the same time, in the 1st group pacing threshold was lower (p < 0.0001) and ventricle signal amplitude was higher (p < 0.0001) comparing with the 2nd group at all control points. The presence of MH detected by MPS in the area of the DL placement worsens its parameters. The results of MPS in patients with CAD can be useful for optimization of DL placement.
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Affiliation(s)
- Tariel A Atabekov
- Department of Surgical Arrhythmology and Cardiac Pacing, Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Kievskaya st., 111a, Tomsk, Russian Federation, 634012.
| | - Roman E Batalov
- Department of Surgical Arrhythmology and Cardiac Pacing, Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Kievskaya st., 111a, Tomsk, Russian Federation, 634012
| | - Svetlana I Sazonova
- Nuclear Medicine Department, Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Kievskaya street, 111a, Tomsk, Russian Federation
| | - Sergey N Krivolapov
- Department of Surgical Arrhythmology and Cardiac Pacing, Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Kievskaya st., 111a, Tomsk, Russian Federation, 634012
| | - Mikhail S Khlynin
- Department of Surgical Arrhythmology and Cardiac Pacing, Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Kievskaya st., 111a, Tomsk, Russian Federation, 634012
| | - Anna I Mishkina
- Nuclear Medicine Department, Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Kievskaya street, 111a, Tomsk, Russian Federation
| | - Konstantin V Zavadovsky
- Nuclear Medicine Department, Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Kievskaya street, 111a, Tomsk, Russian Federation
| | - Antonio Curnis
- Department of Clinical and Experimental Sciences, Università Degli Studi di Brescia, via san Faustino 74b, 25122, Brescia, Italy
| | - Sergey V Popov
- Department of Surgical Arrhythmology and Cardiac Pacing, Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Kievskaya st., 111a, Tomsk, Russian Federation, 634012
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Laczay B, Patel D, Grimm R, Xu B. State-of-the-art narrative review: multimodality imaging in electrophysiology and cardiac device therapies. Cardiovasc Diagn Ther 2021; 11:881-895. [PMID: 34295711 DOI: 10.21037/cdt-20-724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/30/2020] [Indexed: 12/07/2022]
Abstract
Cardiac electrophysiology procedures have evolved to provide improvement in morbidity and mortality for many patients. Cardiac resynchronization therapy (CRT), implantable cardioverter/defibrillator (ICD) placement and lead extraction procedures are proven procedures, associated with significant reductions in patient morbidity and mortality as well as improved quality of life. The applications and optimization of these therapies are an evolving field. The optimal use and outcomes of cardiac electrophysiology procedures require a multidisciplinary approach to patient selection, device selection, and procedural planning. Cardiac imaging using echocardiography plays a key role in selection of patients for CRT therapy, for guidance of left ventricular (LV) lead placement, and for optimization of atrioventricular pacing delays in patients with CRT. Cardiac computed tomography (CT) is an important tool in assessment of lead perforation, as well as assessing risk of lead extraction and procedural planning. Cardiac magnetic resonance imaging (MRI) is an important adjunct to transthoracic echocardiography for patient selection and risk stratification for defibrillator therapy for multiple disease states including ischemic cardiomyopathy, hypertrophic cardiomyopathy, cardiac sarcoidosis, and arrhythmogenic right ventricular cardiomyopathy (ARVC). Cardiac positron emission tomography (PET) is a useful adjunct to the diagnosis of device infections as well as inflammatory conditions including cardiac sarcoidosis. Our review attempts to summarize the contemporary roles of multimodality imaging in CRT therapy, ICD therapy and lead extraction therapy.
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Affiliation(s)
- Balint Laczay
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Divyang Patel
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Richard Grimm
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bo Xu
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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42
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Wang C, Shi J, Ge J, Tang H, He Z, Liu Y, Zhao Z, Li C, Gu K, Hou X, Chen M, Zou J, Zhou L, Garcia EV, Li D, Zhou W. Left ventricular systolic and diastolic dyssynchrony to improve cardiac resynchronization therapy response in heart failure patients with dilated cardiomyopathy. J Nucl Cardiol 2021; 28:1023-1036. [PMID: 32405991 PMCID: PMC10961703 DOI: 10.1007/s12350-020-02132-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 03/28/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The systolic and diastolic dyssynchrony is physiologically related, but measure different left ventricular mechanisms. Left ventricular systolic mechanical dyssynchrony (systolic LVMD) has shown significant clinical values in improving cardiac resynchronization therapy (CRT) response in the heart failure patients with dilated cardiomyopathy (DCM). Our recent study demonstrated that LV diastolic dyssynchrony (diastolic LVMD) parameters have important prognostic values for DCM patients. However, there are a limited number of studies about the clinical value of diastolic LVMD for CRT. This study aims to explore the predictive values of both systolic LVMD and diastolic LVMD for CRT in DCM patients. METHODS Eighty-four consecutive CRT patients with both DCM and complete left bundle branch block (CLBBB) who received gated resting SPECT MPI at baseline were included in the present study. The phase analysis technique was applied on resting gated short-axis SPECT MPI images to measure systolic LVMD and diastolic LVMD, characterized by phase standard deviation (PSD) and phase histogram bandwidth (PBW). CRT response was defined as ≥ 5% improvement of LVEF at 6-month follow-up. Variables with P < 0.10 in the univariate analysis were included in the multivariate cox analysis. RESULTS During the follow-up period, 59.5% (50 of 84) patients were CRT responders. The univariate cox regression analysis showed that at baseline QRS duration, non-sustained ventricular tachycardia (NS-VT), systolic PSD, systolic PBW, diastolic PSD, diastolic PBW, scar burden and LV lead in the scarred myocardium were statistically significantly associated with CRT response. The multivariate cox regression analysis showed that QRS duration, NS-VT, systolic PSD, systolic PBW, diastolic PSD, and diastolic PBW were independent predictive factors for CRT response. Furthermore, the rate of CRT response was 94.4% (17 of 18) in patients whose LV lead was in the segments with both the first three late contraction and the first three late relaxation; by contrast, the rate of CRT response was only 6.7% (1 of 15, P < 0.000) in patients whose LV lead was in the segments with neither the first three late contraction nor the first three late relaxation. CONCLUSION Both systolic LVMD and diastolic LVMD from gated SPECT MPI have important predictive values for CRT response in DCM patients. Pacing at LV segments with both late contraction and late relaxation has potential to increase the CRT response.
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Affiliation(s)
- Cheng Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jianzhou Shi
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jiacheng Ge
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Haipeng Tang
- School of Computing, University of Southern Mississippi, Hattiesburg, USA
| | - Zhuo He
- College of Computing, Michigan Technological University, 1400 Townsend Dr, Houghton, MI, 49931, USA
| | - Yanyun Liu
- School of Computer and Communication Engineering, Zhengzhou University of Light Industry, Zhengzhou, Henan, China
| | - Zhongqiang Zhao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Chunxiang Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Kai Gu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Xiaofeng Hou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jiangang Zou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Lei Zhou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
| | - Ernest V Garcia
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Dianfu Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
| | - Weihua Zhou
- College of Computing, Michigan Technological University, 1400 Townsend Dr, Houghton, MI, 49931, USA.
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Hu X, Xu H, Hassea SRA, Qian Z, Wang Y, Zhang X, Hou X, Zou J. Comparative efficacy of image-guided techniques in cardiac resynchronization therapy: a meta-analysis. BMC Cardiovasc Disord 2021; 21:255. [PMID: 34024286 PMCID: PMC8142495 DOI: 10.1186/s12872-021-02061-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 05/11/2021] [Indexed: 01/06/2023] Open
Abstract
Background Several studies have illustrated the use of echocardiography, magnetic resonance imaging, and nuclear imaging to optimize left ventricular (LV) lead placement to enhance the response of cardiac resynchronization therapy (CRT) in heart failure patients. We aimed to conduct a meta-analysis to determine the incremental efficacy of image-guided CRT over standard CRT. Methods We searched PubMed, Cochrane library, and EMBASE to identify relevant studies. The outcome measures of cardiac function and clinical outcomes were CRT response, concordance of the LV lead to the latest sites of contraction (concordance of LV), heart failure (HF) hospitalization, mortality rates, changes of left ventricular ejection fraction (LVEF), and left ventricular end-systolic volume (LVESV). Results The study population comprised 1075 patients from eight studies. 544 patients underwent image-guided CRT implantation and 531 underwent routine implantation without imaging guidance. The image-guided group had a significantly higher CRT response and more on-target LV lead placement than the control group (RR, 1.33 [95% CI, 1.21 to 1.47]; p < 0.01 and RR, 1.39 [95% CI, 1.01 to 1.92]; p < 0.05, respectively). The reduction of LVESV in the image-guided group was significantly greater than that in the control group (weighted mean difference, − 12.46 [95% CI, − 18.89 to − 6.03]; p < 0.01). The improvement in LVEF was significantly higher in the image-guided group (weighted mean difference, 3.25 [95% CI, 1.80 to 4.70]; p < 0.01). Pooled data demonstrated no significant difference in HF hospitalization and mortality rates between two groups (RR, 0.89 [95% CI, 0.16 to 5.08]; p = 0.90, RR, 0.69 [95% CI, 0.37 to 1.29]; p = 0.24, respectively). Conclusions This meta-analysis indicates that image-guided CRT is correlated with improved CRT volumetric response and cardiac function in heart failure patients but not with lower hospitalization or mortality rate. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02061-y.
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Affiliation(s)
- Xiao Hu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Road, Nanjing, 210029, China.,Department of Cardiology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huaian, Jiangsu, China
| | - Hai Xu
- Department of Cardiology, Staten Island University Hospital / Northwell Health, 475 Seaview Drive, Staten Island, NY, 10305, USA
| | - Shameer Raaj Avishkar Hassea
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Road, Nanjing, 210029, China
| | - Zhiyong Qian
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Road, Nanjing, 210029, China
| | - Yao Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Road, Nanjing, 210029, China
| | - Xinwei Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Road, Nanjing, 210029, China
| | - Xiaofeng Hou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Road, Nanjing, 210029, China
| | - Jiangang Zou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Road, Nanjing, 210029, China.
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Zhang X, Qian Z, Tang H, Hua W, Su Y, Xu G, Liu X, Xue X, Fan J, Cai L, Zhu L, Wang Y, Hou X, Garcia EV, Zhou W, Zou J. A new method to recommend left ventricular lead positions for improved CRT volumetric response and long-term prognosis. J Nucl Cardiol 2021; 28:672-684. [PMID: 31111449 PMCID: PMC10959571 DOI: 10.1007/s12350-019-01735-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/06/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Using ECG-gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), we sought to develop and validate a new method to recommend left ventricular (LV) lead positions in order to improve volumetric response and long-term prognosis after cardiac resynchronization therapy (CRT). METHODS Seventy-nine patients received gated SPECT MPI at baseline, and echocardiography at baseline and follow-up. The volumetric response referred to a reduction of ≥ 15% in LV end-systolic volume 6 months after CRT. After excluding apical, septal, and scarred segments, there were three levels of recommended segments: (1) the optimal recommendation: the latest contracting viable segment; (2) the 2nd recommendation: the late contracting viable segments whose contraction delays were within 10° of the optimal recommendation; and (3) the 3rd recommendation: the viable segments adjacent to the optimal recommendation when there was no late contracting viable segment. RESULTS After excluding 11 patients whose LV lead was placed in apical or scarred segments, 75.6% of the patients concordant to recommended LV segments (n = 41) responded to CRT while 51.9% of those with non-recommended LV lead locations (n = 27) were responders (P = .043). Response rates were 76.9%, 76.9% , and 73.3% (P = .967), respectively, when LV lead was implanted in the optimal recommendation (n = 13), the 2nd recommendation (n = 13), and the 3rd recommendation (n = 15). LV leads placed at recommended segments reduced composite events of all-cause mortality or heart failure (HF) rehospitalization compared with pacing at non-recommended segments (log-rank χ2 = 5.623, P = .018). CONCLUSIONS Pacing in the recommended LV lead segments identified on gated SPECT MPI was associated with improved volumetric response to CRT and long-term prognosis.
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Affiliation(s)
- Xinwei Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, Nanjing, 210029, Jiangsu, China
| | - Zhiyong Qian
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, Nanjing, 210029, Jiangsu, China
| | - Haipeng Tang
- School of Computing, University of Southern Mississippi, 730 Beach Blvd E, Long Beach, MS, 39560, USA
| | - Wei Hua
- Arrhythmia Center, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yangang Su
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Geng Xu
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xingbin Liu
- Department of Cardiology, Westeastern Hospital, Sichuan University, Chengdu, China
| | - Xiaolin Xue
- Department of Cardiology, Affiliated Hospital, Xian Jiaotong University, Xi'an, China
| | - Jie Fan
- Department of Cardiology, Yunnan Province Hospital, Kunming, China
| | - Lin Cai
- Department of Cardiology, Chengdu Third Hospital, Chengdu, China
| | - Li Zhu
- Department of Cardiology, Taizhou People's Hospital, Taizhou, People's Republic of China
| | - Yao Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, Nanjing, 210029, Jiangsu, China
| | - Xiaofeng Hou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, Nanjing, 210029, Jiangsu, China
| | - Ernest V Garcia
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Weihua Zhou
- School of Computing, University of Southern Mississippi, 730 Beach Blvd E, Long Beach, MS, 39560, USA.
| | - Jiangang Zou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, Nanjing, 210029, Jiangsu, China.
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Cardiac Resynchronization Therapy in Non-Ischemic Cardiomyopathy: Role of Multimodality Imaging. Diagnostics (Basel) 2021; 11:diagnostics11040625. [PMID: 33808474 PMCID: PMC8066641 DOI: 10.3390/diagnostics11040625] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 03/26/2021] [Accepted: 03/28/2021] [Indexed: 12/28/2022] Open
Abstract
Non-ischemic cardiomyopathy encompasses a heterogeneous group of diseases, with a generally unfavorable long-term prognosis. Cardiac resynchronization therapy (CRT) is a useful therapeutic option for patients with symptomatic heart failure, currently recommended by all available guidelines, with outstanding benefits, especially in non-ischemic dilated cardiomyopathy. Still, in spite of clear indications based on identifying a dyssynchronous pattern on the electrocardiogram (ECG,) a great proportion of patients are non-responders. The idea that multimodality cardiac imaging can play a role in refining the selection criteria and the implant technique and help with subsequent system optimization is promising. In this regard, predictors of CRT response, such as apical rocking and septal flash have been identified. Promising new data come from studies using cardiac magnetic resonance and nuclear imaging for showcasing myocardial dyssynchrony. Still, to date, no single imaging predictor has been included in the guidelines, probably due to lack of validation in large, multicenter cohorts. This review provides an up-to-date synthesis of the latest evidence of CRT use in non-ischemic cardiomyopathy and highlights the potential additional value of multimodality imaging for improving CRT response in this population. By incorporating all these findings into our clinical practice, we can aim toward obtaining a higher proportion of responders and improve the success rate of CRT.
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Gould J, Sidhu BS, Sieniewicz BJ, Porter B, Lee AWC, Razeghi O, Behar JM, Mehta V, Elliott MK, Toth D, Haberland U, Razavi R, Rajani R, Niederer S, Rinaldi CA. Feasibility of intraprocedural integration of cardiac CT to guide left ventricular lead implantation for CRT upgrades. J Cardiovasc Electrophysiol 2021; 32:802-812. [PMID: 33484216 PMCID: PMC8647921 DOI: 10.1111/jce.14896] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/19/2020] [Accepted: 01/17/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Optimal positioning of the left ventricular (LV) lead is an important determinant of cardiac resynchronization therapy (CRT) response. OBJECTIVE Evaluate the feasibility of intraprocedural integration of cardiac computed tomography (CT) to guide LV lead implantation for CRT upgrades. METHODS Patients undergoing LV lead upgrade underwent ECG-gated cardiac CT dyssynchrony and LV scar assessment. Target American Heart Association segment selection was determined using latest non-scarred mechanically activating segments overlaid onto real-time fluoroscopy with image co-registration to guide optimal LV lead implantation. Hemodynamic validation was performed using a pressure wire in the LV cavity (dP/dtmax) ). RESULTS 18 patients (male 94%, 55.6% ischemic cardiomyopathy) with RV pacing burden 60.0 ± 43.7% and mean QRS duration 154 ± 30 ms underwent cardiac CT. 10/10 ischemic patients had CT evidence of scar and these segments were excluded as targets. Seventeen out of 18 (94%) patients underwent successful LV lead implantation with delivery to the CT target segment in 15 out of 18 (83%) of patients. Acute hemodynamic response (dP/dtmax ≥ 10%) was superior with LV stimulation in CT target versus nontarget segments (83.3% vs. 25.0%; p = .012). Reverse remodeling at 6 months (LV end-systolic volume improvement ≥15%) occurred in 60% of subjects (4/8 [50.0%] ischemic cardiomyopathy vs. 5/7 [71.4%] nonischemic cardiomyopathy, p = .608). CONCLUSION Intraprocedural integration of cardiac CT to guide optimal LV lead placement is feasible with superior hemodynamics when pacing in CT target segments and favorable volumetric response rates, despite a high proportion of patients with ischemic cardiomyopathy. Multicentre, randomized controlled studies are needed to evaluate whether intraprocedural integration of cardiac CT is superior to standard care.
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Affiliation(s)
- Justin Gould
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
- School of Biomedical Engineering and Imaging SciencesKing's CollegeLondonUK
| | - Baldeep S. Sidhu
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
- School of Biomedical Engineering and Imaging SciencesKing's CollegeLondonUK
| | - Benjamin J. Sieniewicz
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
- School of Biomedical Engineering and Imaging SciencesKing's CollegeLondonUK
| | - Bradley Porter
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
- School of Biomedical Engineering and Imaging SciencesKing's CollegeLondonUK
| | - Angela W. C. Lee
- School of Biomedical Engineering and Imaging SciencesKing's CollegeLondonUK
| | - Orod Razeghi
- School of Biomedical Engineering and Imaging SciencesKing's CollegeLondonUK
| | - Jonathan M. Behar
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
- School of Biomedical Engineering and Imaging SciencesKing's CollegeLondonUK
| | - Vishal Mehta
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
- School of Biomedical Engineering and Imaging SciencesKing's CollegeLondonUK
| | - Mark K. Elliott
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
- School of Biomedical Engineering and Imaging SciencesKing's CollegeLondonUK
| | - Daniel Toth
- School of Biomedical Engineering and Imaging SciencesKing's CollegeLondonUK
| | - Ulrike Haberland
- Medical Imaging TechnologiesSiemens HealthineersMalvernPennsylvaniaUSA
| | - Reza Razavi
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
- School of Biomedical Engineering and Imaging SciencesKing's CollegeLondonUK
| | - Ronak Rajani
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
- School of Biomedical Engineering and Imaging SciencesKing's CollegeLondonUK
| | - Steven Niederer
- School of Biomedical Engineering and Imaging SciencesKing's CollegeLondonUK
| | - Christopher A. Rinaldi
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
- School of Biomedical Engineering and Imaging SciencesKing's CollegeLondonUK
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Wouters PC, Vernooy K, Cramer MJ, Prinzen FW, Meine M. Optimizing lead placement for pacing in dyssynchronous heart failure: The patient in the lead. Heart Rhythm 2021; 18:1024-1032. [PMID: 33601035 DOI: 10.1016/j.hrthm.2021.02.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 10/22/2022]
Abstract
Cardiac resynchronization therapy (CRT) greatly reduces morbidity and mortality in patients with dyssynchronous heart failure. However, despite tremendous efforts, response has been variable and can be further improved. Although optimizing left ventricular lead placement (LVLP) is arguably the cornerstone of CRT, the procedure of LVLP using the transvenous approach has remained largely unchanged for more than 2 decades. Improvements have been developed using scar location and electrical and/or mechanical mapping, and interest in conduction system pacing as an alternative to biventricular pacing has emerged recently. Conduction system pacing is promising but may not be suitable for all patients with dyssynchronous heart failure. This review underscores the importance of a patient-tailored approach and discusses the potential applications of both conduction system pacing and targeted biventricular CRT.
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Affiliation(s)
- Philippe C Wouters
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maarten J Cramer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, The Netherlands
| | - Mathias Meine
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
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Non-infective left ventricular lead complications requiring re-intervention following cardiac resynchronization therapy: prevalence, causes and outcomes. J Interv Card Electrophysiol 2021; 63:69-75. [PMID: 33523328 DOI: 10.1007/s10840-021-00947-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Left ventricular (LV) lead complications in cardiac resynchronization therapy are challenging and poorly reported. We aimed to establish prevalence, causes and outcomes of LV lead complications requiring re-intervention. METHODS We analysed the rate of complications in 2551 consecutive patients who received a transvenous de novo LV lead as part of a cardiac resynchronization therapy device between 2000 and 2018. LV lead complications requiring re-intervention were identified; those due to infection were excluded. Patient, procedural and device characteristics, and outcomes were examined for non-infective LV lead complications requiring re-intervention. RESULTS During a median of 4.7 years, 142 (5.6%) patients required re-intervention for non-infective LV lead complications with a decrease from 10.7% between 2000 and 2004, 8.7% between 2005 and 2009, 3.2% between 2010 and 2014 to 3.2% after 2014. The most common complications were LV lead displacement (50%), high pacing threshold (28%) and phrenic nerve stimulation (15%). Of the complications, 79 (56%) occurred within 90 days post-implant and 63 (44%) later. At the end of the study period, 132/142 patients (93%) had a functional LV lead. Lead re-intervention was associated with higher risk of complications (20%), but no increase in mortality (P = 0.19). Quadripolar leads had longer longevity and lower risk of complications compared with unipolar and bipolar LV leads. CONCLUSIONS A small but significant proportion of patients required LV lead re-intervention for complications following de novo implant. Lead displacement accounted for half of the re-interventions. Re-intervention was associated with a higher complication rate, but 92% of these patients had functional LV leads at the end of follow-up.
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Zweerink A, Nijveldt R, Braams NJ, Maass AH, Vernooy K, de Lange FJ, Meine M, Geelhoed B, Rienstra M, van Gelder IC, Vos MA, van Rossum AC, Allaart CP. Segment length in cine (SLICE) strain analysis: a practical approach to estimate potential benefit from cardiac resynchronization therapy. J Cardiovasc Magn Reson 2021; 23:4. [PMID: 33423681 PMCID: PMC7798189 DOI: 10.1186/s12968-020-00701-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 08/24/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Segment length in cine (SLICE) strain analysis on standard cardiovascular magnetic resonance (CMR) cine images was recently validated against gold standard myocardial tagging. The present study aims to explore predictive value of SLICE for cardiac resynchronization therapy (CRT) response. METHODS AND RESULTS Fifty-seven patients with heart failure and left bundle branch block (LBBB) were prospectively enrolled in this multi-center study and underwent CMR examination before CRT implantation. Circumferential strains of the septal and lateral wall were measured by SLICE on short-axis cine images. In addition, timing and strain pattern parameters were assessed. After twelve months, CRT response was quantified by the echocardiographic change in left ventricular (LV) end-systolic volume (LVESV). In contrast to timing parameters, strain pattern parameters being systolic rebound stretch of the septum (SRSsep), systolic stretch index (SSIsep-lat), and internal stretch factor (ISFsep-lat) all correlated significantly with LVESV change (R - 0.56; R - 0.53; and R - 0.58, respectively). Of all strain parameters, end-systolic septal strain (ESSsep) showed strongest correlation with LVESV change (R - 0.63). Multivariable analysis showed ESSsep to be independently related to LVESV change together with age and QRSAREA. CONCLUSION The practicable SLICE strain technique may help the clinician to estimate potential benefit from CRT by analyzing standard CMR cine images without the need for commercial software. Of all strain parameters, end-systolic septal strain (ESSsep) demonstrates the strongest correlation with reverse remodeling after CRT. This parameter may be of special interest in patients with non-strict LBBB morphology for whom CRT benefit is doubted.
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Affiliation(s)
- Alwin Zweerink
- Department of Cardiology, Amsterdam Cardiovascular Sciences (ACS), Amsterdam University Medical Centers (AUMC), Location VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - Robin Nijveldt
- Department of Cardiology, Amsterdam Cardiovascular Sciences (ACS), Amsterdam University Medical Centers (AUMC), Location VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Natalia J. Braams
- Department of Cardiology, Amsterdam Cardiovascular Sciences (ACS), Amsterdam University Medical Centers (AUMC), Location VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - Alexander H. Maass
- Department of Cardiology, Thoraxcentre, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Frederik J. de Lange
- Department of Cardiology, Amsterdam University Medical Centers (AUMC), Location Academic Medical Center, Amsterdam, The Netherlands
| | - Mathias Meine
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Bastiaan Geelhoed
- Department of Cardiology, Thoraxcentre, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, Thoraxcentre, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Isabelle C. van Gelder
- Department of Cardiology, Thoraxcentre, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Marc A. Vos
- Department of Medical Physiology, University of Utrecht, Utrecht, The Netherlands
| | - Albert C. van Rossum
- Department of Cardiology, Amsterdam Cardiovascular Sciences (ACS), Amsterdam University Medical Centers (AUMC), Location VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - Cornelis P. Allaart
- Department of Cardiology, Amsterdam Cardiovascular Sciences (ACS), Amsterdam University Medical Centers (AUMC), Location VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
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Kronborg MB, Stephansen C, Kristensen J, Gerdes C, Nielsen JC. Reproducibility and repeatability of identifying the latest electrical activation during mapping of coronary sinus branches in CRT recipients. J Cardiovasc Electrophysiol 2020; 31:2940-2947. [PMID: 32852869 DOI: 10.1111/jce.14729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/11/2020] [Accepted: 08/19/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Studies have shown an association between the outcome in cardiac resynchronization therapy (CRT) and longer interventricular delay at the site of the left ventricular (LV) lead. Targeted LV lead placement at the latest electrically activated segment increases LV function further as compared with standard treatment. We aimed to determine reproducibility and repeatability of identifying the latest electrically activated segment during mapping of all available coronary sinus (CS) branches in patients receiving CRT. METHODS We included 35 patients who underwent CRT implantation with protocolled mapping guided LV lead implantation aiming for the site of the latest electrical activation. Three different doctors experienced in electrophysiology and implantation of CRT devices independently measured time interval from the local bipolar right ventricular (RV) electrogram (EGM) to the local unipolar LV EGM at all mapped sites (RV-LV). The segment with the latest electrical activation was defined as the target segment (TS) and the CS tributary containing TS was defined as the target vein (TV). Weighted κ statistics with 95% confidence intervals were computed to assess intra- and interobserver agreement for TS and TV. RESULTS We mapped 258 segments within 131 veins. Weighted κ values for repeatability were 0.85 (0.81-0.89) for TS and 0.92 (0.89-0.93) for TV, and weighted κ values of interobserver agreement ranged from 0.70 (0.61-0.73) to 0.80 (0.76-0.83) for TS and 0.73 (0.64-0.78) to 0.86 (0.83-0.89) for TV among all three observers. CONCLUSION The reproducibility and repeatability of identifying the latest electrically activated segment during mapping of all available CS branches in patients receiving CRT range from good to very good.
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Affiliation(s)
- Mads B Kronborg
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Jens Kristensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Gerdes
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens C Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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