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König S, Hilbert S, Bode K. Conduction System Pacing: Hope, Challenges, and the Journey Forward. Curr Cardiol Rep 2024; 26:801-814. [PMID: 38976199 DOI: 10.1007/s11886-024-02085-8] [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] [Accepted: 06/17/2024] [Indexed: 07/09/2024]
Abstract
PURPOSE OF THE REVIEW Cardiac pacing has evolved in recent years currently culminating in the specific stimulation of the cardiac conduction system (conduction system pacing, CSP). This review aims to provide a comprehensive overview of the available literature on CSP, focusing on a critical classification of studies comparing CSP with standard treatment in the two fields of pacing for bradycardia and cardiac resynchronization therapy in patients with heart failure. The article will also elaborate specific benefits and limitations associated with CSP modalities of His bundle pacing (HBP) and left bundle branch area pacing (LBBAP). RECENT FINDINGS Based on a growing number of observational studies for different indications of pacing therapy, both CSP modalities investigated are advantageous over standard treatment in terms of narrowing the paced QRS complex and preserving or improving left ventricular systolic function. Less consistent evidence exists with regard to the improvement of heart failure-related rehospitalization rates or mortality, and effect sizes vary between HBP and LBBAP. LBBAP is superior over HBP in terms of lead measurements and procedural duration. With regard to all reported outcomes, evidence from large scale randomized controlled clinical trials (RCT) is still scarce. CSP has the potential to sustainably improve patient care in cardiac pacing therapy if patients are appropriately selected and limitations are considered. With this review, we offer not only a summary of existing data, but also an outlook on probable future developments in the field, as well as a detailed summary of upcoming RCTs that provide insights into how the journey of CSP continues.
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Affiliation(s)
- S König
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany.
- Helios Health Institute, Real World Evidence and Health Technology Assessment, Berlin, Germany.
| | - S Hilbert
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - K Bode
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
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Postol AS, Neminushchiy NM, Antipov GN, Ivanchenko AV, Lyashenko VV, Kalinin DA, Kotov SN, Vygovsky AB, Shneider YA. Factors that Determined a Positive Response to Resynchronization Therapy in Patients With Chronic Heart Failure and Cardiac Dyssynchrony. One Center Experience. KARDIOLOGIIA 2024; 64:31-39. [PMID: 39102571 DOI: 10.18087/cardio.2024.7.n2627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 01/26/2024] [Indexed: 08/07/2024]
Abstract
AIM To evaluate the efficacy of cardiac resynchronization therapy (CRT) in patients with chronic heart failure (CHF) associated with cardiac dyssynchrony and to identify the factors that influence the CRT efficacy. MATERIAL AND METHODS This retrospective study included 155 patients after implantation of CRT devices. The CRT devices with a built-in cardioverter-defibrillator (CRT-D) and without it (CRT-P) were implanted in 139 (89.7%) and 16 (10.3%) patients, respectively. The follow-up period was 52.37±35.94 months. Based on the study results, two groups of patients were formed depending on the presence of a clinical response to CRT, responders and non-responders. The factors that influenced the clinical response to CRT were studied. The effect of the baseline state of patients on the effect of therapy was assessed. The need for CRT optimization and a possibility of using electrocardiographic criteria for that purpose were studied. Modern devices and leads for CRT, their functional capabilities and their influence on the CRT efficacy were characterized. Statistical analysis was performed with an IBM SPSS Statistics 21.0 (Chicago, USA) package. RESULTS CRT implantation with the left ventricular lead placement according to the traditional technique, through the coronary sinus, was successful in 130 (87.9%) patients. Difficulties with the left ventricular lead placement were noted in 13 (8.3%) patients when other techniques were used. After 6 months, a hemodynamic and clinical response was observed in 112 (72.2%) patients, and no positive response in 43 (27.8%). The increase in left ventricular ejection fraction in the responder group was more than 21.8±3.7%, which was associated with an improvement of the 6-minute walk test results. Th clinical response was significantly influenced by the possibility of stimulation from the basal parts of the heart; the use of more modern devices for CRT and quadripolar left ventricular leads; timely CRT optimization; and persistent dyssynchrony in non-responders. During the follow-up period, 34 (21.9%) patients died. The death rate in the non-responder group was significantly higher than in the responder group, 18 (41.3%) vs. 16 (14.3%), p=0.001. The main cause of death in the group of non-responders was CHF. Heart transplantation was performed in 3 (1.9%) patients. CONCLUSION CRT increases the life span and improves the quality of life in patients with CHF and cardiac dyssynchrony. There was a group of patients with no benefit from CRT in this study. Modern devices allow increasing the number of patients who benefit from CRT. Periodic optimization of CRT is necessary. When optimizing CRT, it is possible to use electrocardiographic criteria of effectiveness: duration of the QRS complex and changes in the position of the electrical axis of the heart.
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Affiliation(s)
- A S Postol
- Federal Center of High Medical Technologies, Kaliningrad
| | | | - G N Antipov
- Federal Center of High Medical Technologies, Kaliningrad
| | - A V Ivanchenko
- Federal Center of High Medical Technologies, Kaliningrad
| | - V V Lyashenko
- Federal Center of High Medical Technologies, Kaliningrad
| | - D A Kalinin
- Federal Center of High Medical Technologies, Kaliningrad
| | - S N Kotov
- Federal Center of High Medical Technologies, Kaliningrad
| | - A B Vygovsky
- Federal Center of High Medical Technologies, Kaliningrad
| | - Yu A Shneider
- Federal Center of High Medical Technologies, Kaliningrad
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Ahmed R, Sivasankaran K, Ahsan A, Mactaggart S, Azzu A, Dulay MS, Ramphul K, Liu A, Okafor J, Dragon M, Kouranos V, Ahmed M, Sharma R. Clinical outcomes with cardiac resynchronization therapy in patients with Cardiac Sarcoidosis: A systematic review and proportional meta-analysis. Curr Probl Cardiol 2024; 49:102747. [PMID: 39009251 DOI: 10.1016/j.cpcardiol.2024.102747] [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: 07/08/2024] [Accepted: 07/10/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Cardiac sarcoidosis (CS) is an inflammatory condition that can present with heart failure (HF). Cardiac resynchronization therapy (CRT) is known to improve clinical outcomes for patients with left bundle branch block in the general HF population. However, data about the outcomes of CRT in CS is limited. METHODS A systematic literature search was conducted using PubMed/Medline, Embase, and the Cochrane Library from inception to February 2024 to identify studies that reported clinical outcomes following the use of CRT in patients with CS. Data for outcomes was extracted, pooled, and analyzed. OpenMetaAnalyst was used for pooling untransformed proportions along with the corresponding 95 % confidence intervals (CIs). RESULTS Five studies with a total of 176 CS patients who received CRT were included. The pooled incidence for all-cause mortality was 7.6 % (95 % CI: -3 % to 18 %), for HF-related hospitalizations 23.2 % (95 % CI: 2 % to 43 %), and for major adverse cerebral and cardiovascular events 27 % (95 % CI: 8 % to 45 %) after a mean follow-up of 60.1 (±48.7) months. The pooled left ventricular ejection fraction (LVEF) was 34.28 % (95 % CI: 29.88 % to 38.68 %) demonstrating an improvement of 3.75 % in LVEF from baseline LVEF of 30.58 % (95 % CI: 24.68 % to 36.48 %). The mean New York Heart Association (NYHA) functional class was 2.16 (95 % CI: 1.47 to 2.84) after CRT as compared to the baseline mean NYHA of 2.58 (95 % CI: 2.29 to 2.86). CONCLUSION Although improvements were observed in LVEF and mean NYHA, mortality was high in CS patients with CRT.
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Affiliation(s)
- Raheel Ahmed
- Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, London, United Kingdom
| | | | - Areeba Ahsan
- Foundation University School of Health Sciences, Islamabad, Pakistan
| | | | | | | | | | | | | | - Margaux Dragon
- Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
| | - Vasilis Kouranos
- Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, London, United Kingdom
| | | | - Rakesh Sharma
- Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, London, United Kingdom; Kings College London, United Kingdom
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Wijesuriya N, Mehta V, De Vere F, Howell S, Niederer SA, Burri H, Sperzel J, Calo L, Thibault B, Lin W, Lee K, Grammatico A, Varma N, Gwechenberger M, Leclercq C, Rinaldi CA. Heart Size Difference Drives Sex-Specific Response to Cardiac Resynchronization Therapy: A Post Hoc Analysis of the MORE-MPP CRT Trial. J Am Heart Assoc 2024; 13:e035279. [PMID: 38879456 PMCID: PMC11255746 DOI: 10.1161/jaha.123.035279] [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: 02/29/2024] [Accepted: 05/10/2024] [Indexed: 06/19/2024]
Abstract
BACKGROUND Studies have reported that female sex predicts superior cardiac resynchronization therapy (CRT) response. One theory is that this association is related to smaller female heart size, thus increased relative dyssynchrony at a given QRS duration (QRSd). Our objective was to investigate the mechanisms of sex-specific CRT response relating to heart size, relative dyssynchrony, cardiomyopathy type, QRS morphology, and other patient characteristics. METHODS AND RESULTS This is a post hoc analysis of the MORE-CRT MPP (More Response on Cardiac Resynchronization Therapy with Multipoint Pacing) trial (n=3739, 28% women), with a subgroup analysis of patients with nonischemic cardiomyopathy and left bundle-branch block (n=1308, 41% women) to control for confounding characteristics. A multivariable analysis examined predictors of response to 6 months of conventional CRT, including sex and relative dyssynchrony, measured by QRSd/left ventricular end-diastolic volume (LVEDV). Women had a higher CRT response rate than men (70.1% versus 56.8%, P<0.0001). In subgroup analysis, regression analysis of the nonischemic cardiomyopathy left bundle-branch block subgroup identified QRSd/LVEDV, but not sex, as a modifier of CRT response (P<0.0039). QRSd/LVEDV was significantly higher in women (0.919) versus men (0.708, P<0.001). CRT response was 78% for female patients with QRSd/LVEDV greater than the median value, compared with 68% with QRSd/LVEDV less than the median value (P=0.012). The association between CRT response and QRSd/LVEDV was strongest at QRSd <150 ms. CONCLUSIONS In the nonischemic cardiomyopathy left bundle-branch block population, increased relative dyssynchrony in women, who have smaller heart sizes than their male counterparts, is a driver of sex-specific CRT response, particularly at QRSd <150 ms. Women may benefit from CRT at a QRSd <130 ms, opening the debate on whether sex-specific QRSd cutoffs or QRS/LVEDV measurement should be incorporated into clinical guidelines.
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Affiliation(s)
- Nadeev Wijesuriya
- King’s College LondonLondonUK
- Guy’s and St Thomas’s NHS Foundation TrustLondonUK
| | - Vishal Mehta
- King’s College LondonLondonUK
- Guy’s and St Thomas’s NHS Foundation TrustLondonUK
| | - Felicity De Vere
- King’s College LondonLondonUK
- Guy’s and St Thomas’s NHS Foundation TrustLondonUK
| | - Sandra Howell
- King’s College LondonLondonUK
- Guy’s and St Thomas’s NHS Foundation TrustLondonUK
| | - Steven A. Niederer
- King’s College LondonLondonUK
- National Heart and Lung InstituteImperial College LondonLondonUK
| | - Haran Burri
- University Hospital of GenevaGenevaSwitzerland
| | | | | | | | | | | | | | | | | | | | - Christopher A. Rinaldi
- King’s College LondonLondonUK
- Guy’s and St Thomas’s NHS Foundation TrustLondonUK
- Cleveland ClinicLondonUK
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5
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Strocchi M, Wijesuriya N, Mehta V, de Vere F, Rinaldi CA, Niederer SA. Computational Modelling Enabling In Silico Trials for Cardiac Physiologic Pacing. J Cardiovasc Transl Res 2024; 17:685-694. [PMID: 37870689 PMCID: PMC11219462 DOI: 10.1007/s12265-023-10453-y] [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: 08/21/2023] [Accepted: 10/10/2023] [Indexed: 10/24/2023]
Abstract
Conduction system pacing (CSP) has the potential to achieve physiological-paced activation by pacing the ventricular conduction system. Before CSP is adopted in standard clinical practice, large, randomised, and multi-centre trials are required to investigate CSP safety and efficacy compared to standard biventricular pacing (BVP). Furthermore, there are unanswered questions about pacing thresholds required to achieve optimal pacing delivery while preventing device battery draining, and about which patient groups are more likely to benefit from CSP rather than BVP. In silico studies have been increasingly used to investigate mechanisms underlying changes in cardiac function in response to pathologies and treatment. In the context of CSP, they have been used to improve our understanding of conduction system capture to optimise CSP delivery and battery life, and noninvasively compare different pacing methods on different patient groups. In this review, we discuss the in silico studies published to date investigating different aspects of CSP delivery.
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Affiliation(s)
- Marina Strocchi
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK.
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.
| | - Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Felicity de Vere
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Steven A Niederer
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- The Alan Turing Institute, London, UK
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Sperlongano S, Benfari G, Ilardi F, Lisi M, Malagoli A, Mandoli GE, Pastore MC, Mele D, Cameli M, D'Andrea A. Role of speckle tracking echocardiography beyond current guidelines in cardiac resynchronization therapy. Int J Cardiol 2024; 402:131885. [PMID: 38382847 DOI: 10.1016/j.ijcard.2024.131885] [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: 07/22/2023] [Revised: 01/11/2024] [Accepted: 02/18/2024] [Indexed: 02/23/2024]
Abstract
Cardiac resynchronization therapy (CRT) is a device-based treatment applied to patients with a specific profile of heart failure. According to current guidelines, indication for CRT is given on the basis of QRS morphology and duration, and traditional transthoracic echocardiography is mainly used to estimate left ventricular (LV) ejection fraction. However, the identification of patients who may benefit from CRT remains challenging, since the application of the above-mentioned guidelines is still associated with a high rate of non-responders. The assessment of various aspects of LV mechanics (including contractile synchrony, coordination and propagation, and myocardial work) performed by conventional and novel ultrasound technologies, first of all speckle tracking echocardiography (STE), may provide additional, useful information for CRT patients' selection, in particular among non-LBBB patients, who generally respond less to CRT. A multiparametric approach, based on the combination of ECG criteria and echocardiographic indices of LV dyssynchrony/discoordination would be desirable to improve the prediction of CRT response.
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Affiliation(s)
- Simona Sperlongano
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy.
| | - Giovanni Benfari
- Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy; Mediterranea Cardiocentro, Naples, Italy
| | - Matteo Lisi
- Department of Cardiovascular Disease - AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Ravenna, Italy
| | - Alessandro Malagoli
- Division of Cardiology, Nephro-Cardiovascular Department, Baggiovara Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Donato Mele
- Department of Cardiac Thoracic Vascular Sciences, University of Padua, Padua, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Antonello D'Andrea
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy; Department of Cardiology, Umberto I Hospital, Nocera Inferiore, Italy
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7
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Xu F, Meng L, Lin H, Xu W, Guo H, Peng F. Systematic review of leadless pacemaker. Acta Cardiol 2024; 79:284-294. [PMID: 37961771 DOI: 10.1080/00015385.2023.2276537] [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: 05/24/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023]
Abstract
Conventional pacing systems consist of a pacemaker and one or more leads threaded from the device pocket through veins into the heart conducting the pacing therapy to the desired pacing site. Although these devices are effective, approximately one in eight patients treated with these traditional pacing systems experiences a complication attributed to the pacemaker pocket or leads. With the technological advances in electronics, leadless pacemakers that small enough to implant within the heart were introduced. Leadless pacemakers have been developed to overcome many of the challenges of transvenous pacing including complications related to leads or pacemaker pockets. This review aims to provide an overview of advantages of leadless pacemaker, complications and limitations of leadless pacemaker, leadless pacemaker candidate, and future directions of this promising technology.
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Affiliation(s)
- Fukang Xu
- Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
| | - Liping Meng
- Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
| | - Hui Lin
- Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
| | - Weiyuan Xu
- Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
| | - Hangyuan Guo
- Shaoxing Wen li Medical College, Shaoxing, China
| | - Fang Peng
- Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
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8
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Kim SS, Park HW. New Insights into Pacing Induced Cardiomyopathy. Rev Cardiovasc Med 2024; 25:118. [PMID: 39076559 PMCID: PMC11263988 DOI: 10.31083/j.rcm2504118] [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: 10/22/2023] [Revised: 11/11/2023] [Accepted: 11/24/2023] [Indexed: 07/31/2024] Open
Abstract
Pacing induced cardiomyopathy (PICM) can occur as a complication due to pacing the right ventricle. Its precise definition varies across different studies, leading to uncertainty as to the best approach for managing this entity. More than 10% of patients who undergo chronic right ventricular pacing develop PICM. Risk factors associated with PICM include reduced left ventricular ejection fraction (LVEF), the proportion of right ventricular pacing, and paced QRS duration. The main approach to treating PICM has been upgrading to biventricular pacing cardiac resynchronization therapy when the LVEF decreases. However, emerging evidence suggest that conduction system pacing might provide an opportunity to manage PICM.
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Affiliation(s)
- Sung Soo Kim
- Department of Cardiovascular Medicine, Chosun University Medical School, 61452 Gwangju, Republic of Korea
| | - Hyung Wook Park
- Department of Cardiovascular Medicine, Chonnam National University Medical School, 61469 Gwangju, Republic of Korea
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9
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Saleem-Talib S, Duineveld MD, Schipper JC, Hauer AD, Ramanna H, de Groot NM, Scheffer MG. Is CRT Optimization Obsolete? A Referral Center's Experience. Rev Cardiovasc Med 2024; 25:63. [PMID: 39077345 PMCID: PMC11263175 DOI: 10.31083/j.rcm2502063] [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: 04/20/2023] [Revised: 11/13/2023] [Accepted: 11/21/2023] [Indexed: 07/31/2024] Open
Abstract
Background Cardiac resynchronization therapy (CRT) is a well-established therapy for patients with heart failure (HF). However, 30% of HF patients do not show any improvement in clinical status after CRT implantation. In this study, we report our echocardiography-based CRT optimization methodology, in daily practice at our CRT referral center. Methods We included 350 ambulatory patients, who were referred to our center for optimization after CRT implantation. A protocol-driven echocardiographic approach for adjusting mechanical dyssynchrony, whereby adjusting for ventriculoventricular (VV) delays with strain and atrioventricular (AV) delays with Doppler echocardiography was performed. We defined changes in left ventricular ejection fraction (LVEF) and New York Heart Association (NYHA) classes as outcome variables in the evaluation of the CRT outcomes. Results Optimization was obtained in 288 (82%) patients. VV and AV timings were adjusted to 61% and 51%, respectively. In 3%, biventricular pacing was turned off and in 3% left ventricular (LV) only pacing was programmed. The LVEF and NYHA class showed significant improvements in all patients who underwent CRT optimization. Conclusions CRT optimization remains valuable in improving LVEF and functional status measured using the NYHA class in all patients receiving CRT devices.
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Affiliation(s)
- Shmaila Saleem-Talib
- Department of Cardiology, Haga Teaching Hospital, 2545 AA The Hague, The Netherlands
| | - Mirjam D. Duineveld
- Department of Cardiology, Haga Teaching Hospital, 2545 AA The Hague, The Netherlands
| | - Jurjan C. Schipper
- Department of Cardiology, Reinier de Graaf Gasthuis, 2625 AD Delft, The Netherlands
| | - Arnaud D. Hauer
- Department of Cardiology, Reinier de Graaf Gasthuis, 2625 AD Delft, The Netherlands
| | - Hemanth Ramanna
- Department of Cardiology, Reinier de Graaf Gasthuis, 2625 AD Delft, The Netherlands
| | - Natasja M.S. de Groot
- Department of Cardiology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Michael G. Scheffer
- Department of Cardiology, Reinier de Graaf Gasthuis, 2625 AD Delft, 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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11
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Yu Y, Ding L, Huang H, Cheng S, Deng Y, Cai C, Gu M, Chen X, Niu H, Hua W. Effect of short-term cardiac function changes after cardiac resynchronization therapy on long-term prognosis in heart failure patients with and without diabetes. Ther Adv Chronic Dis 2024; 15:20406223231223285. [PMID: 38250742 PMCID: PMC10798070 DOI: 10.1177/20406223231223285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 12/12/2023] [Indexed: 01/23/2024] Open
Abstract
Background The relationship between short-term cardiac function changes and long-term outcomes in heart failure (HF) patients undergoing cardiac resynchronization therapy (CRT) remains uncertain, especially when stratified by diabetes status. Objectives This study aims to assess the association between short-term cardiac function changes and outcomes such as all-cause mortality and HF hospitalization in patients undergoing CRT, stratified by diabetes status. Design This is a cohort longitudinal retrospective study. Methods A total of 666 HF patients, treated with CRT between March 2007 and March 2019, were included in this study. Among them, 166 patients (24.9%) were diagnosed with diabetes. Cardiac function was assessed at baseline and again at 6 months, incorporating evaluations of left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), left atrial diameter (LAD), N-terminal prohormone of brain natriuretic peptide (NT-proBNP), and QRS duration. The QRS duration represents the time required for a stimulus to spread through the ventricles (ventricular depolarization). The primary endpoints of the study were all-cause mortality and HF-related hospitalization. Results During a median follow-up of 2.51 years, 172 (25.8%) patients died and 197 (29.6%) were hospitalized for HF. Changes in LVEF, LVEDD, and LAD within 6 months had similar effects on adverse outcomes in both diabetic and nondiabetic patients. However, the presence of diabetes significantly modified the association between changes in NT-proBNP and QRS duration and adverse outcomes. Short-term changes in NT-proBNP and QRS duration were positively associated with all-cause mortality and HF hospitalization in patients without diabetes. However, the relationship between short-term changes in NT-proBNP and QRS duration and adverse outcomes was non-linear in diabetic patients. Conclusion Improvement of cardiac function after CRT implantation can reduce long-term risk of all-cause mortality and HF hospitalization in HF patients. However, the presence of diabetes may affect the association between short-term changes in NT-proBNP and QRS duration and adverse outcomes.
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Affiliation(s)
- Yu Yu
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ligang Ding
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Huang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sijing Cheng
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Deng
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chi Cai
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Min Gu
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuhua Chen
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongxia Niu
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Hua
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Bei Li Shi Road, Xicheng District, Beijing 100037, China
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12
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Ahmed MA, Gercek M, Sommer P, Rudolph V, Dumitrescu D, Faber L, Fox H. Echocardiographic mechanical dyssynchrony predicts long-term mortality in patients with cardiac resynchronisation therapy. Int J Cardiovasc Imaging 2024; 40:35-43. [PMID: 37819382 PMCID: PMC10774169 DOI: 10.1007/s10554-023-02972-1] [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: 01/27/2023] [Accepted: 09/24/2023] [Indexed: 10/13/2023]
Abstract
Cardiac resynchronisation therapy (CRT) is an established treatment for patients with symptomatic heart failure with reduced left ventricular ejection fraction (LVEF ≤ 35%; HFrEF) and conduction disturbances (QRS duration ≥ 130 ms). The presence of mechanical dyssynchrony (MD) on echocardiography has been hypothesised to be of predictive value in determining indication for CRT. This study investigated the impact of MD (apical rocking [AR] and septal flash [SF]) on long-term survival in CRT recipients. HFrEF patients (n = 425; mean age 63.0 ± 10.6 years, 72.3% male, 60.7% non-ischaemic aetiology) with a guideline-derived indication for CRT underwent device implantation. MD markers were determined at baseline and after a mean follow-up of 11.5 ± 8.0 months; long-term survival was also determined. AR and/or SF were present in 307 (72.2%) participants at baseline. During post-CRT follow-up, AR and/or SF disappeared in 256 (83.4%) patients. Overall mean survival was 95.9 ± 52.9 months, longer in women than in men (109.1 ± 52.4 vs. 90.9 ± 52.4 months; p < 0.001) and in younger (< 60 years) versus older patients (110.6 ± 53.7 vs. 88.6 ± 51.1 months; p < 0.001). Patients with versus without MD markers at baseline generally survived for longer (106.2 ± 52.0 vs. 68.9 ± 45.4 months; p < 0.001), and survival was best in patients with resolved versus persisting MD (111.6 ± 51.2 vs. 79.7 ± 47.6 months p < 0.001). Age and MD at baseline were strong predictors of long-term survival in HFrEF patients undergoing CRT on multivariate analysis. Novel echocardiography MD parameters in HFrEF CRT recipients predicted long-term mediated better outcome, and survival improved further when AR and/or SF disappear after CRT implantation.
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Affiliation(s)
- Mohamed Abdelbaset Ahmed
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany
| | - Muhammed Gercek
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany
| | - Volker Rudolph
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany
- Heart Failure Department, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany
| | - Daniel Dumitrescu
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany
- Heart Failure Department, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany
| | - Lothar Faber
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany
| | - Henrik Fox
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany.
- Heart Failure Department, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany.
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13
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Wijesuriya N, Mehta V, De Vere F, Howell S, Niederer SA, Burri H, Sperzel J, Calo L, Thibault B, Lin W, Lee K, Grammatico A, Varma N, Gwechenberger M, Leclercq C, Rinaldi CA. Heart size disparity drives sex-specific response to cardiac resynchronization therapy: a post-hoc analysis of the MORE-MPP CRT trial. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.05.23299532. [PMID: 38106113 PMCID: PMC10723565 DOI: 10.1101/2023.12.05.23299532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Background Studies have reported that female sex predicts superior cardiac resynchronization therapy (CRT) response. One theory is that this association is related to smaller female heart size, thus increased "relative dyssynchrony" at given QRS durations (QRSd). Objective To investigate the mechanisms of sex-specific CRT response relating to heart size, relative dyssynchrony, cardiomyopathy type, QRS morphology, and other patient characteristics. Methods A post-hoc analysis of the MORE-CRT MPP trial (n=3739, 28% female), with a sub-group analysis of patients with non-ischaemic cardiomyopathy (NICM) and left bundle branch block (LBBB) (n=1308, 41% female) to control for confounding characteristics. A multivariable analysis examined predictors of response to 6 months of conventional CRT, including sex and relative dyssynchrony, measured by QRSd/LVEDV (left ventricular end-diastolic volume). Results Females had a higher CRT response rate than males (70.1% vs. 56.8%, p<0.0001). Subgroup analysis: Regression analysis of the NICM LBBB subgroup identified QRSd/LVEDV, but not sex, as a modifier of CRT response (p<0.0039). QRSd/LVEDV was significantly higher in females (0.919) versus males (0.708, p<0.001). CRT response was 78% for female patients with QRSd/LVEDV>median value, compared to 68% < median value (p=0.012). Association between CRT response and QRSd/LVEDV was strongest at QRSd<150ms. Conclusions In the NICM LBBB population, increased relative dyssynchrony in females, who have smaller heart sizes than their male counterparts, is a driver of sex-specific CRT response, particularly at QRSd <150ms. Females may benefit from CRT at a QRSd <130ms, opening the debate on whether sex-specific QRSd cut-offs or QRS/LVEDV measurement should be incorporated into clinical guidelines.
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Affiliation(s)
- Nadeev Wijesuriya
- King’s College London, UK
- Guy’s and St Thomas’s NHS Foundation Trust, London, UK
| | - Vishal Mehta
- King’s College London, UK
- Guy’s and St Thomas’s NHS Foundation Trust, London, UK
| | - Felicity De Vere
- King’s College London, UK
- Guy’s and St Thomas’s NHS Foundation Trust, London, UK
| | - Sandra Howell
- King’s College London, UK
- Guy’s and St Thomas’s NHS Foundation Trust, London, UK
| | - Steven A Niederer
- King’s College London, UK
- National Heart and Lung Institute, Imperial College London, UK
| | - Haran Burri
- University Hospital of Geneva, Geneva, Switzerland
| | | | | | | | | | | | | | | | | | | | - Christopher A Rinaldi
- King’s College London, UK
- Guy’s and St Thomas’s NHS Foundation Trust, London, UK
- Cleveland Clinic, London, UK
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14
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Wijesuriya N, Mehta V, Vere FD, Howell S, Behar JM, Shute A, Lee M, Bosco P, Niederer SA, Rinaldi CA. Cost-effectiveness analysis of leadless cardiac resynchronization therapy. J Cardiovasc Electrophysiol 2023; 34:2590-2598. [PMID: 37814470 PMCID: PMC10946454 DOI: 10.1111/jce.16102] [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: 07/14/2023] [Revised: 09/11/2023] [Accepted: 09/30/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND The Wireless Stimulation Endocardially for CRT (WiSE-CRT) system is a novel technology used to treat patients with dyssynchronous heart failure (HF) by providing leadless cardiac resynchronization therapy (CRT). Observational studies have demonstrated its safety and efficacy profile, however, the treatment cost-effectiveness has not previously been examined. METHODS A cost-effectiveness evaluation of the WiSE-CRT System was performed using a cohort-based economic model adopting a "proportion in state" structure. In addition to the primary analysis, scenario analyses and sensitivity analyses were performed to test for uncertainty in input parameters. Outcomes were quantified in terms of quality-adjusted life year (QALY) differences. RESULTS The primary analysis demonstrated that treatment with the WiSE-CRT system is likely to be cost-effective over a lifetime horizon at a QALY reimbursement threshold of £20 000, with a net monetary benefit (NMB) of £3781 per QALY. Cost-effectiveness declines at time horizons shorter than 10 years. Sensitivity analyses demonstrated that average system battery life had the largest impact on potential cost-effectiveness. CONCLUSION Within the model limitations, these findings support the use of WiSE-CRT in indicated patients from an economic standpoint. However, improving battery technology should be prioritized to maximize cost-effectiveness in times when health services are under significant financial pressures.
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Affiliation(s)
- Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Felicity De Vere
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Sandra Howell
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Jonathan M. Behar
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | | | | | - Paolo Bosco
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Steven A. Niederer
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- National Heart and Lung InstituteImperial CollegeLondonUK
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
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15
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Leclercq C, Burri H, Delnoy PP, Rinaldi CA, Sperzel J, Calò L, Concha JF, Fusco A, Al Samadi F, Lee K, Thibault B. Cardiac resynchronization therapy non-responder to responder conversion rate in the MORE-CRT MPP trial. Europace 2023; 25:euad294. [PMID: 37776313 PMCID: PMC10561537 DOI: 10.1093/europace/euad294] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/26/2023] [Indexed: 10/02/2023] Open
Abstract
AIMS To assess the impact of MultiPoint™ Pacing (MPP) in cardiac resynchronization therapy (CRT) non-responders after 6 months of standard biventricular pacing (BiVP). METHODS AND RESULTS The trial enrolled 5850 patients who planned to receive a CRT device. The echocardiography core laboratory assessed CRT response before implant and after 6 months of BiVP; non-response to BiVP was defined as <15% relative reduction in left ventricular end-systolic volume (LVESV). Echocardiographic non-responders were randomized in a 1:1 ratio to receive MPP (541 patients) or continued BiVP (570 patients) for an additional 6 months and evaluated the conversion rate to the echocardiographic response. The characteristics of both groups at randomization were comparable. The percentage of non-responder patients who became responders to CRT therapy was 29.4% in the MPP arm and 30.4% in the BIVP arm (P = 0.743). In patients with ≥30 mm spacing between the two left ventricular pacing sites (MPP-AS), identified during the first phase as a potential beneficial subgroup, no significant difference in the conversion rate was observed. CONCLUSION Our trial shows that ∼30% of patients, who do not respond to CRT in the first 6 months, experience significant reverse remodelling in the following 6 months. This finding suggests that CRT benefit may be delayed or slowly incremental in a relevant proportion of patients and that the percentage of CRT responders may be higher than what has been described in short-/middle-term studies. MultiPoint™ Pacing does not improve CRT response in non-responders to BiVP, even with MPP-AS.
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Affiliation(s)
- Christophe Leclercq
- Service de Cardiologie et Maladies Vasculaires, Université de Rennes I, CICIT 804, CHU Pontchaillou Rennes, 2, rue Henri le Guilloux 35033 Rennes Cédex 09, Rennes 35033, France
| | - Haran Burri
- Departement of Cardiology, University of Geneva, Geneva, Switzerland
| | - Peter Paul Delnoy
- Isala Hospital, Department of Cardiology, Isala Klinieken, Zwolle, The Netherlands
| | | | - Johannes Sperzel
- The Kerckhoff Heart and Thorax Center, Bad Nauheim, Kerckhoff Klinik, Bad Nauheim, Germany
| | - Leonardo Calò
- Division of Cardiology, Policlinico Casilino, Rome, Italy
| | | | | | | | | | - Bernard Thibault
- Electrophysiology Service Department of Cardiology, Université de Montréal, Montreal, Canada
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16
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Chen M, Shi J, Zhang Y, Ge X, Zhang X, Fan W, Wang S, Guo Z, Guan J, Wu Y, Zhang J. Comparative cost analysis of implanting devices in different cardiac resynchronization therapeutic strategies. Clin Cardiol 2023; 46:1227-1233. [PMID: 37537947 PMCID: PMC10577564 DOI: 10.1002/clc.24107] [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: 06/11/2023] [Revised: 07/14/2023] [Accepted: 07/21/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is an established treatment option for heart failure patients. However, the implementation of triple-chamber pacemakers can be cost-prohibitive. His-Purkinje system pacing (HPSP) can also enable cardiac resynchronization, and it can be achieved with relatively inexpensive conventional pacemakers. HYPOTHESIS This article aims to comparatively evaluate the cost of implanting devices in different CRT strategies to provide meaningful guidance for clinical decision-making by electrophysiologists. METHODS Data was collected on the prices, designed life, and price/designed life of multiple mainstream models of CRT-P, CRT-D, dual-chamber pacemakers, and single-chamber pacemakers that were sold in the Chinese market in 2022. The prices, designed lives, and price/designed life of different pacemaker models were then compared. RESULTS The costs of CRT-P and CRT-D (13008.44 ± 2752.30 USD and 22043.36 ± 3676.25 USD) were significantly higher than those of conventional pacemakers (dual-chamber: 11142.39 ± 4273.85 USD and single-chamber: 5634.28 ± 2032.80 USD) (p < .05). Additionally, the price/designed life of conventional pacemakers (dual-chamber: 839.63 ± 258.62 US dollar/year and single-chamber: 435.86 ± 125.44 US dollar/year) was significantly better than that of CRT-P and CRT-D (1386.91 ± 266.73 and 2585.53 ± 520.27 US dollar/year, respectively) (p < .05). CONCLUSION Conduction system pacing (CSP)-based CRT is more cost-effective than BVP-based CRT. Furthermore, CSP-based CRT can achieve cardiac resynchronization with conventional pacemakers and may be a good option for HF patients who do not need defibrillation.
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Affiliation(s)
- Mengna Chen
- The First Hospital of Tsinghua UniversityBeijingChina
| | - Jing Shi
- The First Hospital of Tsinghua UniversityBeijingChina
| | - Yimin Zhang
- The First Hospital of Tsinghua UniversityBeijingChina
| | - Xiaozhen Ge
- The First Hospital of Tsinghua UniversityBeijingChina
| | - Xu Zhang
- The First Hospital of Tsinghua UniversityBeijingChina
| | - Wenbin Fan
- The First Hospital of Tsinghua UniversityBeijingChina
| | - Shuo Wang
- The First Hospital of Tsinghua UniversityBeijingChina
| | - Zhiqin Guo
- The First Hospital of Tsinghua UniversityBeijingChina
| | - Jian Guan
- The First Hospital of Tsinghua UniversityBeijingChina
| | - Yongquan Wu
- Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Junmeng Zhang
- The First Hospital of Tsinghua UniversityBeijingChina
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17
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Chen X, Li X, Bai Y, Wang J, Qin S, Bai J, Wang W, Liang Y, Chen H, Su Y, Ge J. Electrical Resynchronization and Clinical Outcomes During Long-Term Follow-Up in Intraventricular Conduction Delay Patients Applied Left Bundle Branch Pacing-Optimized Cardiac Resynchronization Therapy. Circ Arrhythm Electrophysiol 2023; 16:e011761. [PMID: 37577815 DOI: 10.1161/circep.122.011761] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 08/03/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Left bundle branch-optimized cardiac resynchronization therapy (LOT-CRT) has shown encouraging results for QRS duration reduction and heart function improvement. However, the feasibility and efficacy of LOT-CRT have not been well established in intraventricular conduction delay patients. This study aims to assess and compare the efficacy and clinical outcome of CRT based on left bundle branch pacing, combined with coronary sinus left ventricular pacing (LOT-CRT) with CRT via biventricular pacing (BiV-CRT) in intraventricular conduction delay patients indicated for CRT. METHODS Consecutive patients with intraventricular conduction delay and CRT indications were assigned nonrandomized to LOT-CRT (n=30) or BiV-CRT (n=55). Addition of the left bundle branch pacing (or coronary venous) lead was at the discretion of the implanting physician guided by suboptimal paced QRS complex and on clinical grounds. Echocardiographic parameters and clinical characteristics were accessed at baseline and during 2-years' follow-up. RESULTS Success rate for LOT-CRT and BiV-CRT was 96.8% and 96.4%. LOT-CRT had greater reduction of QRS duration compared with BiV-CRT (42.7±17.4 ms versus 21.9±21.5 ms; P<0.001). Higher left ventricular ejection fraction was also achieved in LOT-CRT than BiV-CRT at 6-month (36.7±9.8% versus 30.5±6.4%; P<0.05), 12-month (34.8±7.6% versus 30.3±6.2%; P<0.05), 18-month (36.3±7.9% versus 28.1±6.6%; P<0.005), and 24-month follow-up (37±9.5% versus 30.5±7%; P<0.05). Adverse clinical outcomes including heart failure rehospitalization and mortality were lower in LOT-CRT group for 24 months follow-up (hazard ratio, 0.33; P=0.035). CONCLUSIONS LOT-CRT improves ventricular electrical synchrony and may provide greater clinical outcomes as compared with BiV-CRT in intraventricular conduction delay patients. These findings need further evaluation in future randomized controlled trials.
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Affiliation(s)
- Xueying Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Xiao Li
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Yingnan Bai
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Jingfeng Wang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Shengmei Qin
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Jin Bai
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Wei Wang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Yixiu Liang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Haiyan Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Yangang Su
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
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18
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Westphal P, Luo H, Shahmohammadi M, Prinzen FW, Delhaas T, Cornelussen RN. Machine learning-powered, device-embedded heart sound measurement can optimize AV delay in patients with CRT. Heart Rhythm 2023; 20:1316-1324. [PMID: 37247684 DOI: 10.1016/j.hrthm.2023.05.025] [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: 01/30/2023] [Revised: 04/28/2023] [Accepted: 05/17/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Continuous optimization of atrioventricular (AV) delay for cardiac resynchronization therapy (CRT) is mainly performed by electrical means. OBJECTIVE The purpose of this study was to develop an estimation model of cardiac function that uses a piezoelectric microphone embedded in a pulse generator to guide CRT optimization. METHODS Electrocardiogram, left ventricular pressure (LVP), and heart sounds were simultaneously collected during CRT device implantation procedures. A piezoelectric alarm transducer embedded in a modified CRT device facilitated recording of heart sounds in patients undergoing a pacing protocol with different AV delays. Machine learning (ML) was used to produce a decision-tree ensemble model capable of estimating absolute maximal LVP (LVPmax) and maximal rise of LVP (LVdP/dtmax) using 3 heart sound-based features. To gauge the applicability of ML in AV delay optimization, polynomial curves were fitted to measured and estimated values. RESULTS In the data set of ∼30,000 heartbeats, ML indicated S1 amplitude, S2 amplitude, and S1 integral (S1 energy for LVdP/dtmax) as most prominent features for AV delay optimization. ML resulted in single-beat estimation precision for absolute values of LVPmax and LVdP/dtmax of 67% and 64%, respectively. For 20-30 beat averages, cross-correlation between measured and estimated LVPmax and LVdP/dtmax was 0.999 for both. The estimated optimal AV delays were not significantly different from those measured using invasive LVP (difference -5.6 ± 17.1 ms for LVPmax and +5.1 ± 6.7 ms for LVdP/dtmax). The difference in function at estimated and measured optimal AV delays was not statiscally significant (1 ± 3 mm Hg for LVPmax and 9 ± 57 mm Hg/s for LVdP/dtmax). CONCLUSION Heart sound sensors embedded in a CRT device, powered by a ML algorithm, provide a reliable assessment of optimal AV delays and absolute LVPmax and LVdP/dtmax.
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Affiliation(s)
- Philip Westphal
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands; Bakken Research Center, Medtronic, plc, Maastricht, The Netherlands
| | - Hongxing Luo
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Mehrdad Shahmohammadi
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Tammo Delhaas
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Richard N Cornelussen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands; Bakken Research Center, Medtronic, plc, Maastricht, The Netherlands.
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Gin J, Chow CL, Voskoboinik A, Nalliah C, Wong C, Van Gaal W, Farouque O, Mohamed U, Lim HS, Kalman JM, Wong GR. Improved Outcomes of Conduction System Pacing in Heart Failure with Reduced Ejection Fraction - A Systematic Review and Meta-analysis. Heart Rhythm 2023:S1547-5271(23)02226-9. [PMID: 37172670 DOI: 10.1016/j.hrthm.2023.05.010] [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: 03/06/2023] [Revised: 04/25/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023]
Abstract
Conduction system pacing (CSP) - His bundle pacing (HBP) and Left bundle branch area pacing (LBBAP) - are emerging alternatives to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT) in heart failure. However, evidence is largely limited to small and observational studies. We conducted a meta-analysis including a total of 15 randomized control trials (RCTs) and non-RCTs that compare CSP (HBP & LBBAP) with BVP in patients with CRT indications. We assessed the mean differences in QRS duration (QRSd), pacing threshold, left ventricular ejection fraction (LVEF), and New York Heart Association (NYHA) class score. CSP resulted in a pooled mean QRSd improvement of -20.3 ms (95% CI -26.1 - -14.5, p<0.05, I2=87.1%) versus BVP. For LVEF, a weighted mean increase of 5.2% (95% CI 3.5-6.9, p<0.05, I2=55.6) was observed following CSP versus BVP. The mean NYHA score was reduced by -0.40 (95% CI -0.6 - -0.2, p<0.05, I2=61.7) post-CSP versus BVP. Subgroup analysis of outcomes by LBBAP and HBP demonstrated statistically significant weighted mean improvements from both CSP modalities for QRSd and LVEF compared to BVP. LBBAP resulted in NYHA improvement compared to BVP without differences between CSP subgroups. LBBAP is associated with a significantly lowered mean pacing threshold of -0.51V (95% CI -0.68 - -0.38) whilst HBP had increased the mean threshold (0.62V, 95% CI -0.03 - 1.26) compared to BVP, however, this was associated with significant heterogeneity. Overall, both CSP techniques are feasible and effective CRT alternatives for heart failure. Further RCTs are needed to establish long-term efficacy and safety.
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Affiliation(s)
- Julian Gin
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Chee Loong Chow
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia; Department of Cardiology, Northern Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Alex Voskoboinik
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Chrishan Nalliah
- Department of Cardiology, Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Chiew Wong
- Department of Cardiology, Northern Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - William Van Gaal
- Department of Cardiology, Northern Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Uwais Mohamed
- Department of Cardiology, St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Han S Lim
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia; Department of Cardiology, Northern Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Jonathan M Kalman
- Department of Cardiac Electrophysiology, Royal Melbourne Hospital, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Geoffrey R Wong
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia; Department of Cardiology, Northern Health, Melbourne, Victoria, Australia.
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20
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Leancă SA, Afrăsânie I, Crișu D, Matei IT, Duca ȘT, Costache AD, Onofrei V, Tudorancea I, Mitu O, Bădescu MC, Șerban LI, Costache II. Cardiac Reverse Remodeling in Ischemic Heart Disease with Novel Therapies for Heart Failure with Reduced Ejection Fraction. Life (Basel) 2023; 13:1000. [PMID: 37109529 PMCID: PMC10143569 DOI: 10.3390/life13041000] [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: 03/07/2023] [Revised: 04/03/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
Despite the improvements in the treatment of coronary artery disease (CAD) and acute myocardial infarction (MI) over the past 20 years, ischemic heart disease (IHD) continues to be the most common cause of heart failure (HF). In clinical trials, over 70% of patients diagnosed with HF had IHD as the underlying cause. Furthermore, IHD predicts a worse outcome for patients with HF, leading to a substantial increase in late morbidity, mortality, and healthcare costs. In recent years, new pharmacological therapies have emerged for the treatment of HF, such as sodium-glucose cotransporter-2 inhibitors, angiotensin receptor-neprilysin inhibitors, selective cardiac myosin activators, and oral soluble guanylate cyclase stimulators, demonstrating clear or potential benefits in patients with HF with reduced ejection fraction. Interventional strategies such as cardiac resynchronization therapy, cardiac contractility modulation, or baroreflex activation therapy might provide additional therapeutic benefits by improving symptoms and promoting reverse remodeling. Furthermore, cardiac regenerative therapies such as stem cell transplantation could become a new therapeutic resource in the management of HF. By analyzing the existing data from the literature, this review aims to evaluate the impact of new HF therapies in patients with IHD in order to gain further insight into the best form of therapeutic management for this large proportion of HF patients.
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Affiliation(s)
- Sabina Andreea Leancă
- Cardiology Clinic, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Irina Afrăsânie
- Cardiology Clinic, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Daniela Crișu
- Cardiology Clinic, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Iulian Theodor Matei
- Cardiology Clinic, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Ștefania Teodora Duca
- Cardiology Clinic, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Alexandru Dan Costache
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
- Department of Cardiovascular Rehabilitation, Clinical Rehabilitation Hospital, 700661 Iași, Romania
| | - Viviana Onofrei
- Cardiology Clinic, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Ionuţ Tudorancea
- Cardiology Clinic, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
- Department of Physiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Ovidiu Mitu
- Cardiology Clinic, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Minerva Codruța Bădescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
- Internal Medicine Clinic, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Lăcrămioara Ionela Șerban
- Department of Physiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Irina Iuliana Costache
- Cardiology Clinic, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
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21
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Strocchi M, Gillette K, Neic A, Elliott MK, Wijesuriya N, Mehta V, Vigmond EJ, Plank G, Rinaldi CA, Niederer SA. Effect of scar and His-Purkinje and myocardium conduction on response to conduction system pacing. J Cardiovasc Electrophysiol 2023; 34:984-993. [PMID: 36738149 PMCID: PMC10089967 DOI: 10.1111/jce.15847] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Conduction system pacing (CSP), in the form of His bundle pacing (HBP) or left bundle branch pacing (LBBP), is emerging as a valuable cardiac resynchronization therapy (CRT) delivery method. However, patient selection and therapy personalization for CSP delivery remain poorly characterized. We aim to compare pacing-induced electrical synchrony during CRT, HBP, LBBP, HBP with left ventricular (LV) epicardial lead (His-optimized CRT [HOT-CRT]), and LBBP with LV epicardial lead (LBBP-optimized CRT [LOT-CRT]) in patients with different conduction disease presentations using computational modeling. METHODS We simulated ventricular activation on 24 four-chamber heart geometries, including His-Purkinje systems with proximal left bundle branch block (LBBB). We simulated septal scar, LV lateral wall scar, and mild and severe myocardium and LV His-Purkinje system conduction disease by decreasing the conduction velocity (CV) down to 70% and 35% of the healthy CV. Electrical synchrony was measured by the shortest interval to activate 90% of the ventricles (90% of biventricular activation time [BIVAT-90]). RESULTS Severe LV His-Purkinje conduction disease favored CRT (BIVAT-90: HBP 101.5 ± 7.8 ms vs. CRT 93.0 ± 8.9 ms, p < .05), with additional electrical synchrony induced by HOT-CRT (87.6 ± 6.7 ms, p < .05) and LOT-CRT (73.9 ± 7.6 ms, p < .05). Patients with slow myocardium CV benefit more from CSP compared to CRT (BIVAT-90: CRT 134.5 ± 24.1 ms; HBP 97.1 ± 9.9 ms, p < .01; LBBP: 101.5 ± 10.7 ms, p < .01). Septal but not lateral wall scar made CSP ineffective, while CRT was able to resynchronize the ventricles in the presence of septal scar (BIVAT-90: baseline 119.1 ± 10.8 ms vs. CRT 85.1 ± 14.9 ms, p < .01). CONCLUSION Severe LV His-Purkinje conduction disease attenuates the benefits of CSP, with additional improvements achieved with HOT-CRT and LOT-CRT. Septal but not lateral wall scars make CSP ineffective.
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Affiliation(s)
| | - Karli Gillette
- BioTechMed-Graz, Graz, Austria
- Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | | | - Mark K. Elliott
- King’s College London, London, UK
- Guy’s and St Thomas’ NHS Foundation trust, London, UK
| | - Nadeev Wijesuriya
- King’s College London, London, UK
- Guy’s and St Thomas’ NHS Foundation trust, London, UK
| | - Vishal Mehta
- King’s College London, London, UK
- Guy’s and St Thomas’ NHS Foundation trust, London, UK
| | - Edward J. Vigmond
- University of Bordeaux, CNRS, Bordeaux, Talence, France
- IHU Liryc, Bordeaux, Talence, France
| | - Gernot Plank
- BioTechMed-Graz, Graz, Austria
- Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
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A conversion CRT strategy combined with AVJA may be a perspective alternative for heart failure patients with persistent atrial fibrillation. Heart Fail Rev 2023; 28:367-377. [PMID: 36662339 DOI: 10.1007/s10741-023-10294-6] [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: 01/11/2023] [Indexed: 01/21/2023]
Abstract
Heart failure (HF) combined with persistent atrial fibrillation (AF) often coexist and may promote the pathological conditions of cardiac dysfunction, leading to poor prognosis. Cardiac resynchronization therapy (CRT) combined with atrioventricular junction ablation (AVJA) is a highly effective treatment for HF patients with underlying AF who either have failed or are not suitable for catheter ablation. The CRT-AVJA combination therapy can improve clinical outcomes in HF patients. Currently, clinical CRT methods are categorized into biventricular pacing (BVP) - based and conduction system pacing (CSP) - based methods. These procedures have inherent advantages and disadvantages, in addition to their considerable differences in clinical applications. This article aims to review the clinical progress of AVJA combined with different CRT strategies for treating HF patients with persistent AF and propose that conversion CRT strategy (BVP/CSP-CRT) combined with AVJA may be a perspective alternative. Meanwhile, we generalize that 7 categories of HF patients with persistent AF may need to consider the CRT-AVJA combination therapy.
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23
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Attia ZI, Friedman PA. Explainable AI for ECG-based prediction of cardiac resynchronization therapy outcomes: learning from machine learning? Eur Heart J 2023; 44:693-695. [PMID: 36546617 DOI: 10.1093/eurheartj/ehac733] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Zachi I Attia
- Mayo Clinic Minnesota, Cardiovascular Diseases, 200 1st st SW, Rochester, MN 55901, USA
| | - Paul A Friedman
- Mayo Clinic Minnesota, Cardiovascular Diseases, 200 1st st SW, Rochester, MN 55901, USA
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24
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Elliott MK, Strocchi M, Sieniewicz BJ, Sidhu B, Mehta V, Wijesuriya N, Behar JM, Thorpe A, Martic D, Wong T, Niederer S, Rinaldi CA. Biventricular endocardial pacing and left bundle branch area pacing for cardiac resynchronization: Mechanistic insights from electrocardiographic imaging, acute hemodynamic response, and magnetic resonance imaging. Heart Rhythm 2023; 20:207-216. [PMID: 36575808 DOI: 10.1016/j.hrthm.2022.10.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/13/2022] [Accepted: 10/21/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Biventricular endocardial pacing (BiV-endo) has demonstrated superior cardiac resynchronization compared to conventional biventricular epicardial pacing (BiV-epi). Left bundle branch area pacing (LBBAP) may also achieve effective cardiac resynchronization therapy (CRT). OBJECTIVE The purpose of this study was to compare the acute electrical and hemodynamic effects of BiV-epi, BiV-endo, and LBBAP delivered from the LV endocardium and to assess how myocardial scar affects response. METHODS Eleven patients with heart failure and indications for CRT underwent a temporary pacing study with electrocardiographic imaging (ECGi) and hemodynamic assessment. BiV-endo was delivered by stimulation of the left ventricular (LV) lateral wall, and LBBAP was delivered by stimulation of the LV septum, at the site of a Purkinje potential. LV activation time (LVAT-95), LV dyssynchrony index (LVDI), biventricular activation time (BIVAT-90), and biventricular dyssynchrony index (BIVDI) were calculated. Myocardial scar was assessed using magnetic resonance imaging (MRI). RESULTS The protocol was completed in 10 patients. Compared to BiV-epi (LVAT-95: 79.2 ± 13.1 ms; LVDI: 26.6 ± 3.4 ms) LV resynchronization was superior during BiV-endo (LVAT-95: 48.5 ± 14.9 ms; P = .001; LVDI: 16.6 ± 6.4 ms; P = .002) and LBBAP (LVAT-95: 48.9 ± 12.5 ms; P = .001; LVDI: 15.3 ± 3.4 ms; P = .001). Biventricular resynchronization was similarly superior during BiV-endo and LBBAP vs BiV-epi (BIVAT-90 and BIVDI; P <.05). The rate of acute hemodynamic responders was higher during BiV-endo (90%) and LBBAP (70%) vs BiV-epi (50%). The benefits of LBBAP (but not BiV-endo) on LV resynchronization were attenuated when septal scar was present in a subset of 8 patients who underwent MRI. CONCLUSION Our findings suggest superior electrical resynchronization and a higher proportion of acute hemodynamic responders during BiV-endo and LBBAP compared to BiV-epi. Electrical resynchronization was similar between BiV-endo and LBBAP; however, septal scar seemed to attenuate response to LBBAP.
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Affiliation(s)
- Mark K Elliott
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Marina Strocchi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Benjamin J Sieniewicz
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Baldeep Sidhu
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jonathan M Behar
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Andrew Thorpe
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Dejana Martic
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Tom Wong
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College School of Medicine, London, United Kingdom
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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25
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Wijesuriya N, Elliott MK, Mehta V, De Vere F, Strocchi M, Behar JM, Niederer SA, Rinaldi CA. Pacing interventions in non-responders to cardiac resynchronization therapy. Front Physiol 2023; 14:1054095. [PMID: 36776979 PMCID: PMC9909021 DOI: 10.3389/fphys.2023.1054095] [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: 09/26/2022] [Accepted: 01/17/2023] [Indexed: 01/28/2023] Open
Abstract
Non-responders to Cardiac Resynchronization Therapy (CRT) represent a high-risk, and difficult to treat population of heart failure patients. Studies have shown that these patients have a lower quality of life and reduced life expectancy compared to those who respond to CRT. Whilst the first-line treatment for dyssynchronous heart failure is "conventional" biventricular epicardial CRT, a range of novel pacing interventions have emerged as potential alternatives. This has raised the question whether these new treatments may be useful as a second-line pacing intervention for treating non-responders, or indeed, whether some patients may benefit from these as a first-line option. In this review, we will examine the current evidence for four pacing interventions in the context of treatment of conventional CRT non-responders: CRT optimization; multisite left ventricular pacing; left ventricular endocardial pacing and conduction system pacing.
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Affiliation(s)
- Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom,Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom,*Correspondence: Nadeev Wijesuriya,
| | - Mark K. Elliott
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom,Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom,Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Felicity De Vere
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom,Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Marina Strocchi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Jonathan M. Behar
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom,Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Steven A. Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom,Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
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26
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Strocchi M, Wijesuriya N, Elliott MK, Gillette K, Neic A, Mehta V, Vigmond EJ, Plank G, Rinaldi CA, Niederer SA. Leadless biventricular left bundle and endocardial lateral wall pacing versus left bundle only pacing in left bundle branch block patients. Front Physiol 2022; 13:1049214. [PMID: 36589454 PMCID: PMC9794756 DOI: 10.3389/fphys.2022.1049214] [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: 09/20/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022] Open
Abstract
Biventricular endocardial (BIV-endo) pacing and left bundle pacing (LBP) are novel delivery methods for cardiac resynchronization therapy (CRT). Both pacing methods can be delivered through leadless pacing, to avoid risks associated with endocardial or transvenous leads. We used computational modelling to quantify synchrony induced by BIV-endo pacing and LBP through a leadless pacing system, and to investigate how the right-left ventricle (RV-LV) delay, RV lead location and type of left bundle capture affect response. We simulated ventricular activation on twenty-four four-chamber heart meshes inclusive of His-Purkinje networks with left bundle branch block (LBBB). Leadless biventricular (BIV) pacing was simulated by adding an RV apical stimulus and an LV lateral wall stimulus (BIV-endo lateral) or targeting the left bundle (BIV-LBP), with an RV-LV delay set to 5 ms. To test effect of prolonged RV-LV delays and RV pacing location, the RV-LV delay was increased to 35 ms and/or the RV stimulus was moved to the RV septum. BIV-endo lateral pacing was less sensitive to increased RV-LV delays, while RV septal pacing worsened response compared to RV apical pacing, especially for long RV-LV delays. To investigate how left bundle capture affects response, we computed 90% BIV activation times (BIVAT-90) during BIV-LBP with selective and non-selective capture, and left bundle branch area pacing (LBBAP), simulated by pacing 1 cm below the left bundle. Non-selective LBP was comparable to selective LBP. LBBAP was worse than selective LBP (BIVAT-90: 54.2 ± 5.7 ms vs. 62.7 ± 6.5, p < 0.01), but it still significantly reduced activation times from baseline. Finally, we compared leadless LBP with RV pacing against optimal LBP delivery through a standard lead system by simulating BIV-LBP and selective LBP alone with and without optimized atrioventricular delay (AVD). Although LBP alone with optimized AVD was better than BIV-LBP, when AVD optimization was not possible BIV-LBP outperformed LBP alone, because the RV pacing stimulus shortened RV activation (BIVAT-90: 54.2 ± 5.7 ms vs. 66.9 ± 5.1 ms, p < 0.01). BIV-endo lateral pacing or LBP delivered through a leadless system could potentially become an alternative to standard CRT. RV-LV delay, RV lead location and type of left bundle capture affect leadless pacing efficacy and should be considered in future trial designs.
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Affiliation(s)
- Marina Strocchi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Mark K. Elliott
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Karli Gillette
- BioTechMed-Graz, Graz, Austria
- Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | | | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Edward J. Vigmond
- University of Bordeaux, CNRS, Bordeaux, France
- IHU Liryc, Bordeaux, France
| | - Gernot Plank
- BioTechMed-Graz, Graz, Austria
- Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Steven A. Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
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27
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Strocchi M, Gillette K, Neic A, Elliott MK, Wijesuriya N, Mehta V, Vigmond EJ, Plank G, Rinaldi CA, Niederer SA. Comparison between conduction system pacing and cardiac resynchronization therapy in right bundle branch block patients. Front Physiol 2022; 13:1011566. [PMID: 36213223 PMCID: PMC9532840 DOI: 10.3389/fphys.2022.1011566] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/29/2022] [Indexed: 11/20/2022] Open
Abstract
A significant number of right bundle branch block (RBBB) patients receive cardiac resynchronization therapy (CRT), despite lack of evidence for benefit in this patient group. His bundle (HBP) and left bundle pacing (LBP) are novel CRT delivery methods, but their effect on RBBB remains understudied. We aim to compare pacing-induced electrical synchrony during conventional CRT, HBP, and LBP in RBBB patients with different conduction disturbances, and to investigate whether alternative ways of delivering LBP improve response to pacing. We simulated ventricular activation on twenty-four four-chamber heart geometries each including a His-Purkinje system with proximal right bundle branch block (RBBB). We simulated RBBB combined with left anterior and posterior fascicular blocks (LAFB and LPFB). Additionally, RBBB was simulated in the presence of slow conduction velocity (CV) in the myocardium, left ventricular (LV) or right ventricular (RV) His-Purkinje system, and whole His-Purkinje system. Electrical synchrony was measured by the shortest interval to activate 90% of the ventricles (BIVAT-90). Compared to baseline, HBP significantly improved activation times for RBBB alone (BIVAT-90: 66.9 ± 5.5 ms vs. 42.6 ± 3.8 ms, p < 0.01), with LAFB (69.5 ± 5.0 ms vs. 58.1 ± 6.2 ms, p < 0.01), with LPFB (81.8 ± 6.6 ms vs. 62.9 ± 6.2 ms, p < 0.01), with slow myocardial CV (119.4 ± 11.4 ms vs. 97.2 ± 10.0 ms, p < 0.01) or slow CV in the whole His-Purkinje system (102.3 ± 7.0 ms vs. 75.5 ± 5.2 ms, p < 0.01). LBP was only effective in RBBB cases if combined with anodal capture of the RV septum myocardium (BIVAT-90: 66.9 ± 5.5 ms vs. 48.2 ± 5.2 ms, p < 0.01). CRT significantly reduced activation times in RBBB in the presence of severely slow RV His-Purkinje CV (95.1 ± 7.9 ms vs. 84.3 ± 9.3 ms, p < 0.01) and LPFB (81.8 ± 6.6 ms vs. CRT: 72.9 ± 8.6 ms, p < 0.01). Both CRT and HBP were ineffective with severely slow CV in the LV His-Purkinje system. HBP is effective in RBBB patients with otherwise healthy myocardium and Purkinje system, while CRT and LBP are ineffective. Response to LBP improves when LBP is combined with RV septum anodal capture. CRT is better than HBP only in patients with severely slow CV in the RV His-Purkinje system, while CV slowing of the whole His-Purkinje system and the myocardium favor HBP over CRT.
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Affiliation(s)
- Marina Strocchi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Karli Gillette
- BioTechMed-Graz, Graz, Austria
- Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | | | - Mark K. Elliott
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | | | - Gernot Plank
- BioTechMed-Graz, Graz, Austria
- Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Steven A. Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
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Chung ES, Rickard J, Lu X, DerSarkissian M, Zichlin ML, Cheung HC, Swartz N, Greatsinger A, Duh MS. Real-world clinical burden among patients with and without heart failure worsening after cardiac resynchronization therapy. Curr Med Res Opin 2022; 38:1489-1498. [PMID: 35727103 DOI: 10.1080/03007995.2022.2092374] [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] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Cardiac resynchronization therapy (CRT) can improve cardiac function in patients with heart failure (HF); however, in some patients, HF worsens despite CRT. This study characterized the long-term clinical burden of patients with and without HF worsening (HFW) within 6 months post CRT implantation. METHODS A claims database (2007-2018) was used to identify two cohorts of adults: those with HFW within 180 days post-CRT and those with no HFW (NHFW). The evaluated clinical outcomes were cardiovascular events/complications, HF-related interventions, hospice enrollment, and all-cause mortality. Inverse probability of treatment weighting (IPTW) was used to adjust for confounders; adjusted comparisons were assessed using weighted Cox proportional hazard ratios (HRs). RESULTS Among the 12,753 adults analyzed (HFW: N = 4,785; NHFW: N = 7,968), the mean age was 72 years and the mean duration of follow-up was approximately 2 years. The clinical burden was greater for HFW than for NHFW in terms of all-cause mortality (19.7% vs. 12.1%) and occurrence of atrial fibrillation (57.4% vs. 51.2%). In the IPTW-adjusted Cox proportional hazard analyses, patients with HFW had a 54% higher average hazard of experiencing all-cause mortality compared to NHFW (adjusted average HR = 1.54, 95% confidence interval [CI]: 1.41-1.70; p < .001). Of the clinical events experienced by ≥5% of patients, the greatest differences in average hazard were for HF decompensation (adjusted average HR = 1.83, 95% CI: 1.60-2.09) and HF decompensation or death (HR = 1.63, 95%CI: 1.50-1.77). CONCLUSION Patients with early HFW post-CRT experienced a significantly higher clinical burden than those without HFW. Vigilance for signs of worsening HF in the first 6 months post-CRT is warranted.
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Affiliation(s)
- Eugene S Chung
- The Lindner Clinical Research Center at The Christ Hospital, Cincinnati, OH, USA
| | | | - Xiaoxiao Lu
- Medtronic Global CRHF Headquarters, Mounds View, MN, USA
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Meshless Electrophysiological Modeling of Cardiac Resynchronization Therapy—Benchmark Analysis with Finite-Element Methods in Experimental Data. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12136438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Computational models of cardiac electrophysiology are promising tools for reducing the rates of non-response patients suitable for cardiac resynchronization therapy (CRT) by optimizing electrode placement. The majority of computational models in the literature are mesh-based, primarily using the finite element method (FEM). The generation of patient-specific cardiac meshes has traditionally been a tedious task requiring manual intervention and hindering the modeling of a large number of cases. Meshless models can be a valid alternative due to their mesh quality independence. The organization of challenges such as the CRT-EPiggy19, providing unique experimental data as open access, enables benchmarking analysis of different cardiac computational modeling solutions with quantitative metrics. We present a benchmark analysis of a meshless-based method with finite-element methods for the prediction of cardiac electrical patterns in CRT, based on a subset of the CRT-EPiggy19 dataset. A data assimilation strategy was designed to personalize the most relevant parameters of the electrophysiological simulations and identify the optimal CRT lead configuration. The simulation results obtained with the meshless model were equivalent to FEM, with the most relevant aspect for accurate CRT predictions being the parameter personalization strategy (e.g., regional conduction velocity distribution, including the Purkinje system and CRT lead distribution).
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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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31
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Abstract
Left ventricular (LV) dP/dtmax provides a sensitive measure of the acute hemodynamic response to cardiac resynchronization therapy (CRT) and can predict reverse remodeling on echocardiography. Its use to guide LV lead placement has been shown to improve outcomes in a multicenter randomized trial. Given the invasive protocol required for measurement, it is unlikely to be universally beneficial for patients undergoing CRT but may be useful for patients who do not respond to conventional CRT, or in those who have borderline indications or risk factors for non-response. In such cases, LV dP/dtmax may help guide LV lead placement, optimize device programming, and select the best alternative method of delivering CRT, such endocardial LV pacing or conduction system pacing.
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Affiliation(s)
- Mark K Elliott
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Vishal S Mehta
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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32
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Russo V, Ammendola E, Gasperetti A, Bottino R, Schiavone M, Masarone D, Pacileo G, Nigro G, Golino P, Lip GYH, D'Andrea A, Boriani G, Proietti R. Add-on Therapy With Sacubitril/Valsartan and Clinical Outcomes in CRT-D Nonresponder Patients. J Cardiovasc Pharmacol 2022; 79:472-478. [PMID: 34935699 PMCID: PMC9012526 DOI: 10.1097/fjc.0000000000001202] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/20/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT No data on the add-on sacubitril/valsartan (S/V) therapy among cardiac resynchronization therapy with a defibrillator (CRT-D) nonresponder patients are currently available in literature. We conducted a prospective observational study including 190 CRT-D nonresponder patients with symptomatic heart failure with reduced ejection fraction despite the optimal medical therapy from at least 1 year. The primary endpoint was the rate of additional responders (left ventricular end-systolic volume reduction >15%) at 12 months from the introduction of S/V therapy. At the end of the 12 months follow-up, 37 patients (19.5%) were deemed as "additional responders" to the combination use of CRT + S/V therapy. The only clinical predictor of additional response was a lower left ventricular ejection fraction [OR 0.881 (0.815-0.953), P = 0.002] at baseline. At 12 months follow-up, there were significant improvements in heart failure (HF) symptoms and functional status [New York Heart Association 2 (2-3) vs. 1 (1-2), P < 0.001; physical activity duration/day: 10 (8-12) vs. 13 (10-18) hours, P < 0.001]. Compared with the 12 months preceding S/V introduction, there were significant reductions in the rate of HF rehospitalization (35.5% vs. 19.5%, P < 0.001), in atrial tachycardia/atrial fibrillation burden [6.0 (5.0-8.0) % vs. 0 (0-2.0) %, P < 0.001] and in the proportions of patients experiencing ventricular arrhythmias (21.6% vs. 6.3%; P < 0.001). Our results indicate that S/V add-on therapy in CRT-D nonresponder patients is associated with 19.5% of additional responders, a reduction in HF symptoms and rehospitalizations, AF burden, and ventricular arrhythmias.
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Affiliation(s)
- Vincenzo Russo
- Department of Medical Translational Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Naples, Italy
| | - Ernesto Ammendola
- Department of Cardiology, Heart Failure Unit, Monaldi Hospital, Naples, Italy
| | - Alessio Gasperetti
- Department of Cardiology, ASST-Fatebenefratelli Sacco, Luigi Sacco Hospital, Milan, Italy
| | - Roberta Bottino
- Department of Medical Translational Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Naples, Italy
| | - Marco Schiavone
- Department of Cardiology, ASST-Fatebenefratelli Sacco, Luigi Sacco Hospital, Milan, Italy
| | - Daniele Masarone
- Department of Cardiology, Heart Failure Unit, Monaldi Hospital, Naples, Italy
| | - Giuseppe Pacileo
- Department of Cardiology, Heart Failure Unit, Monaldi Hospital, Naples, Italy
| | - Gerardo Nigro
- Department of Medical Translational Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Naples, Italy
| | - Paolo Golino
- Department of Medical Translational Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Naples, Italy
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Antonello D'Andrea
- Department of Cardiology and Intensive Coronary Care, Umberto I Hospital, Salerno, Italy; and
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Riccardo Proietti
- Department of Cardiology, ASST-Fatebenefratelli Sacco, Luigi Sacco Hospital, Milan, Italy
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
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Elliott MK, Mehta V, Wijesuriya N, Sidhu BS, Gould J, Niederer S, Rinaldi CA. Multi-lead pacing for cardiac resynchronization therapy in heart failure: a meta-analysis of randomized controlled trials. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac013. [PMID: 35919119 PMCID: PMC9242027 DOI: 10.1093/ehjopen/oeac013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/25/2022] [Accepted: 02/25/2022] [Indexed: 11/13/2022]
Abstract
Aims Multi-lead pacing is a potential therapy to improve response to cardiac resynchronization therapy (CRT) by providing rapid activation of the myocardium from multiple sites. Here, we perform a meta-analysis of randomized controlled trials to assess the efficacy of multi-lead pacing. Methods and results A literature search was performed which identified 251 unique records. After screening, 6 studies were found to meet inclusion criteria, with 415 patients included in the meta-analysis. Four studies performed multi-lead pacing with two left ventricular (LV) leads and one right ventricular (RV) lead. One study used two RV leads and one LV lead, and one study used both configurations. There was no difference between multi-lead pacing and conventional CRT in LV end-systolic volume [mean difference (MD) -0.54 mL, P = 0.93] or LV ejection fraction (MD 1.42%, P = 0.40). There was a borderline significant improvement in Minnesota Living With Heart Failure Questionnaire score for multi-lead pacing vs. conventional CRT (MD -4.46, P = 0.05), but the difference was not significant when only patients receiving LV-only multi-lead pacing were included (MD -3.59, P = 0.25). There was also no difference between groups for 6-min walk test (MD 15.06 m, P = 0.38) or New York Heart Association class at follow-up [odds ratio (OR) 1.49, P = 0.24]. There was no difference in mortality between groups (OR 1.11, P = 0.77). Conclusion This meta-analysis does not support the use of multi-lead pacing for CRT delivery. However, significant variation between studies was noted, and therefore a benefit for multi-lead pacing in select patients cannot be excluded, and further investigation may be warranted.
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Affiliation(s)
- Mark K Elliott
- School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Baldeep S Sidhu
- School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Justin Gould
- School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
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Krzowski B, Rokicki J, Główczyńska R, Fajkis-Zajączkowska N, Barczewska K, Mąsior M, Grabowski M, Balsam P. The Use of Machine Learning Algorithms in the Evaluation of the Effectiveness of Resynchronization Therapy. J Cardiovasc Dev Dis 2022; 9:jcdd9010017. [PMID: 35050227 PMCID: PMC8778735 DOI: 10.3390/jcdd9010017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 01/15/2023] Open
Abstract
Background: Cardiovascular disease remains the leading cause of death in the European Union and worldwide. Constant improvement in cardiac care is leading to an increased number of patients with heart failure, which is a challenging condition in terms of clinical management. Cardiac resynchronization therapy is becoming more popular because of its grounded position in guidelines and clinical practice. However, some patients do not respond to treatment as expected. One way of assessing cardiac resynchronization therapy is with ECG analysis. Artificial intelligence is increasing in terms of everyday usability due to the possibility of everyday workflow improvement and, as a result, shortens the time required for diagnosis. A special area of artificial intelligence is machine learning. AI algorithms learn on their own based on implemented data. The aim of this study was to evaluate using artificial intelligence algorithms for detecting inadequate resynchronization therapy. Methods: A total of 1241 ECG tracings were collected from 547 cardiac department patients. All ECG signals were analyzed by three independent cardiologists. Every signal event (QRS-complex) and rhythm was manually classified by the medical team and fully reviewed by additional cardiologists. The results were divided into two parts: 80% of the results were used to train the algorithm, and 20% were used for the test (Cardiomatics, Cracow, Poland). Results: The required level of detection sensitivity of effective cardiac resynchronization therapy stimulation was achieved: 99.2% with a precision of 92.4%. Conclusions: Artificial intelligence algorithms can be a useful tool in assessing the effectiveness of resynchronization therapy.
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Affiliation(s)
- Bartosz Krzowski
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (J.R.); (R.G.); (M.G.); (P.B.)
- Department of Medical Informatics and Telemedicine, Medical University of Warsaw, 00-582 Warsaw, Poland
- Correspondence: ; Tel.: +48-22-599-2958
| | - Jakub Rokicki
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (J.R.); (R.G.); (M.G.); (P.B.)
- Department of Medical Informatics and Telemedicine, Medical University of Warsaw, 00-582 Warsaw, Poland
| | - Renata Główczyńska
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (J.R.); (R.G.); (M.G.); (P.B.)
| | | | | | - Mariusz Mąsior
- Cardiomatics, 31-339 Cracow, Poland; (N.F.-Z.); (K.B.); (M.M.)
| | - Marcin Grabowski
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (J.R.); (R.G.); (M.G.); (P.B.)
| | - Paweł Balsam
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (J.R.); (R.G.); (M.G.); (P.B.)
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Soejima K, Kondo Y, Sasaki S, Adachi K, Kato R, Hagiwara N, Harada T, Kusano K, Miura F, Morishima I, Yoshitani K, Yotsukura A, Fujimoto M, Nishii N, Shimeno K, Ohe M, Tasaka H, Sasaki H, Schrader J, Ando K. Intracardiac conduction time as a predictor of cardiac resynchronization therapy response: Results of the BIO|SELECT pilot study. Heart Rhythm O2 2022; 2:588-596. [PMID: 34988503 PMCID: PMC8703154 DOI: 10.1016/j.hroo.2021.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Quadripolar left ventricular (LV) leads are capable of sensing and pacing the left ventricle from 4 different electrodes, which may potentially improve patient response to cardiac resynchronization therapy (CRT). Objective We measured 3 different time intervals: right ventricular (RV)-sensed to LV-sensed during intrinsic rhythm (RVs-LVs), RV-paced to LV-sensed (RVp-LVs), and LV-paced to LV-sensed (LVp-LVs, between distal [LV1] and proximal pole on a quadripolar LV lead), and assessed their association with CRT response in terms of LV end-systolic volume (LVESV) and a composite benefit index (CBI) comprising LVESV, LV ejection fraction (LVEF), brain natriuretic peptide level, and NYHA class. Methods A CRT-defibrillator system with quadripolar LV lead was implanted in 196 patients (mean age 69 years, mean LVEF 30%, left bundle-branch block [LBBB] 58%). Conduction intervals were measured before hospital discharge. At baseline and 7-month follow-up, echocardiographic and other components of CBI were determined. Results The mean RVs-LV1s, RVp-LV1s, and LVp-LVs delays were 68 ± 38 ms, 132 ± 34 ms, and 99 ± 31 ms, respectively. From baseline to 7 months, LVESV decreased by 17.3% ± 28.6%. The RVs-LV1s interval correlated stronger with CBI (R2 = 0.12, P < .00001) than with LVESV change (R2 = 0.05, P = .006). In contrast, RVp-LV1s did not correlate and LVp-LVs correlated only weakly with CRT response. The subgroup of patients (44%) with LBBB and RVs-LV1s above the lower quartile (≥34 ms) showed the greatest response to CRT. Conclusion The RVs-LVs interval during intrinsic rhythm is relevant for CRT success, whereas RVp-LVs and LVp-LVs intervals did not predict CRT response.
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Affiliation(s)
| | - Yusuke Kondo
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shingo Sasaki
- Department of Cardiology and Nephrology, Hirosaki University, Graduate School of Medicine, Aomori, Japan
| | | | | | | | - Tomoo Harada
- St. Marianna University School of Medicine, Kanagawa, Japan
| | - Kengo Kusano
- National Cerebral and Cardiovascular Center, Osaka, Japan
| | | | | | | | | | | | | | | | | | | | | | | | - Kenji Ando
- Kokura Memorial Hospital, Fukuoka, Japan
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Asher C, Puyol-Antón E, Rizvi M, Ruijsink B, Chiribiri A, Razavi R, Carr-White G. The Role of AI in Characterizing the DCM Phenotype. Front Cardiovasc Med 2021; 8:787614. [PMID: 34993240 PMCID: PMC8724536 DOI: 10.3389/fcvm.2021.787614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/02/2021] [Indexed: 12/13/2022] Open
Abstract
Dilated Cardiomyopathy is conventionally defined by left ventricular dilatation and dysfunction in the absence of coronary disease. Emerging evidence suggests many patients remain vulnerable to major adverse outcomes despite clear therapeutic success of modern evidence-based heart failure therapy. In this era of personalized medical care, the conventional assessment of left ventricular ejection fraction falls short in fully predicting evolution and risk of outcomes in this heterogenous group of heart muscle disease, as such, a more refined means of phenotyping this disease appears essential. Cardiac MRI (CMR) is well-placed in this respect, not only for its diagnostic utility, but the wealth of information captured in global and regional function assessment with the addition of unique tissue characterization across different disease states and patient cohorts. Advanced tools are needed to leverage these sensitive metrics and integrate with clinical, genetic and biochemical information for personalized, and more clinically useful characterization of the dilated cardiomyopathy phenotype. Recent advances in artificial intelligence offers the unique opportunity to impact clinical decision making through enhanced precision image-analysis tasks, multi-source extraction of relevant features and seamless integration to enhance understanding, improve diagnosis, and subsequently clinical outcomes. Focusing particularly on deep learning, a subfield of artificial intelligence, that has garnered significant interest in the imaging community, this paper reviews the main developments that could offer more robust disease characterization and risk stratification in the Dilated Cardiomyopathy phenotype. Given its promising utility in the non-invasive assessment of cardiac diseases, we firstly highlight the key applications in CMR, set to enable comprehensive quantitative measures of function beyond the standard of care assessment. Concurrently, we revisit the added value of tissue characterization techniques for risk stratification, showcasing the deep learning platforms that overcome limitations in current clinical workflows and discuss how they could be utilized to better differentiate at-risk subgroups of this phenotype. The final section of this paper is dedicated to the allied clinical applications to imaging, that incorporate artificial intelligence and have harnessed the comprehensive abundance of data from genetics and relevant clinical variables to facilitate better classification and enable enhanced risk prediction for relevant outcomes.
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Affiliation(s)
- Clint Asher
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guys and St Thomas' NHS Trust, London, United Kingdom
| | - Esther Puyol-Antón
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Maleeha Rizvi
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guys and St Thomas' NHS Trust, London, United Kingdom
| | - Bram Ruijsink
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guys and St Thomas' NHS Trust, London, United Kingdom
- Division of Heart and Lungs, Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Amedeo Chiribiri
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guys and St Thomas' NHS Trust, London, United Kingdom
| | - Reza Razavi
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guys and St Thomas' NHS Trust, London, United Kingdom
| | - Gerry Carr-White
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guys and St Thomas' NHS Trust, London, United Kingdom
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37
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Schiedat F, Bogossian H, Schöne D, Aweimer A, Patsalis PC, Hanefeld C, Mügge A, Kloppe A. Long-Term Performance Comparison of Bipolar Active vs. Quadripolar Passive Fixation Leads in Cardiac Resynchronisation Therapy. Front Cardiovasc Med 2021; 8:734666. [PMID: 34881300 PMCID: PMC8645570 DOI: 10.3389/fcvm.2021.734666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 10/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Bipolar active fixation (BipolarAFL) and quadripolar passive fixation left-ventricular leads (QuadPFL) have been designed to reduce the risk of phrenic nerve stimulation (PNS), enable targeted left-ventricular pacing, and overcome problems of difficult coronary venous anatomy and lead dislodgment. This study sought to report the long-term safety and performance of a BipolarAFL, Medtronic Attain Stability 20066, compared to QuadPFL. Methods: We performed a single-operator retrospective analysis of 81 patients receiving cardiac resynchronization therapy (CRT) (36 BipolarAFL, 45 QuadPFL). Immediate implant data and electrical and clinical data during follow-up (FU) were analyzed. Results: BipolarAFL has been chosen in patients with significantly larger estimated vein diameter (at the lead tip: 7.2 ± 4.1 Fr vs. 4.1 ± 2.3 Fr, p < 0.001) without significant time difference until the final lead position was achieved (BipolarAFL: 20.9 ± 10.5 min, vs. QuadPFL: 18.9 ± 8.9 min, p = 0.35). At 12 month FU no difference in response rate to CRT was recorded between BipolarAFL and QuadPFL according to left ventricular end-systolic volume (61.1 vs. 60.0%, p = 0.82) and New York Heart Association (66.7 vs. 62.2%, p = 0.32). At median FU of 48 months (IQR: 44-54), no lead dislodgment occurred in both groups but a significantly higher proportion of PNS was recorded in QuadPFL (13 vs. 0%, p < 0.05). Electrical parameters were stable during FU in both groups without significant differences. Conclusion: BipolarAFL can be implanted with ease in challenging coronary venous anatomy, shows excellent electrical performance and no difference in clinical outcome compared to QuadPFL.
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Affiliation(s)
- Fabian Schiedat
- Department of Cardiology and Angiology at University Hospital Bergmannsheil Bochum of the Ruhr-University Bochum, Bochum, Germany.,Department of Cardiology and Angiology at Marienhospital Gelsenkirchen, Gelsenkirchen, Germany
| | | | - Dominik Schöne
- Department of Cardiology and Angiology at Marienhospital Gelsenkirchen, Gelsenkirchen, Germany
| | - Assem Aweimer
- Department of Cardiology and Angiology at University Hospital Bergmannsheil Bochum of the Ruhr-University Bochum, Bochum, Germany
| | - Polykarpos C Patsalis
- Department of Cardiology and Angiology at University Hospital Bergmannsheil Bochum of the Ruhr-University Bochum, Bochum, Germany
| | - Christoph Hanefeld
- Department of Internal Medicine at Elisabeth Krankenhaus Bochum of the Ruhr University Bochum, Bochum, Germany
| | - Andreas Mügge
- Department of Cardiology and Angiology at University Hospital Bergmannsheil Bochum of the Ruhr-University Bochum, Bochum, Germany
| | - Axel Kloppe
- Department of Cardiology and Angiology at Marienhospital Gelsenkirchen, Gelsenkirchen, Germany
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38
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Qin HY, Wang C, Qian DD, Cui C, Chen ML. Epicardial Adipose Tissue Measured From Computed Tomography Predicts Cardiac Resynchronization Therapy Response in Patients With Non-ischemic Systolic Heart Failure. Front Cardiovasc Med 2021; 8:678467. [PMID: 34778385 PMCID: PMC8581137 DOI: 10.3389/fcvm.2021.678467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 09/29/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Epicardial adipose tissue (EAT) has been linked with the pathogenesis of heart failure (HF). Limited data have been reported about the clinical value of EAT for cardiac resynchronization therapy (CRT) in non-ischemic systolic HF. We aimed to explore the values of EAT measured from CT to predict the response to CRT in patients with non-ischemic systolic HF. Methods: Forty-one patients with CRT were consecutively recruited for our study. All patients received both gated resting Single Photon Emission CT (SPECT) myocardial perfusion imaging (MPI) and dual-source multi-detector row CT scans. EAT thickness was assessed on both the parasternal short and horizontal long-axis views. The area of EAT was calculated at the left main coronary artery level. Left ventricular systolic mechanical dyssynchrony (LVMD) was measured by phase standard deviation (PSD) and phase histogram bandwidth (PBW). The definition of CRT response was an improvement of 5% in left ventricular ejection fraction (LVEF) at 6 months after CRT implantation. Results: After 6 months of follow-up, 58.5% (24 of 41) of patients responded to CRT. A greater total perfusion deficit (TPD) was observed in the left ventricle, and a narrower QRS complex was observed in the nonresponse group than in the response group (p < 0.05). Meanwhile, the systolic PSD and systolic PBW were statistically greater in the CRT group with no response than in the response group (p < 0.05). Meanwhile, the baseline QRS duration, TPD, systolic PSD, systolic PBW, EAT thicknesses of the left ventricular (LV) apex, right atrioventricular (AV) groove, and left AV groove were all significantly related to the CRT response in the univariate logistic regression analysis. Furthermore, the QRS duration and EAT thicknesses of the right AV groove and left AV groove were independent predictors of CRT response in the multivariate logistic regression analysis. Conclusions: The EAT thickness of the left AV groove in patients with non-ischemic systolic HF is associated with the TPD of LV and LV systolic dyssynchrony. The EAT thickness of the AV groove has a good predictive value for the CRT response in patients with non-ischemic systolic HF.
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Affiliation(s)
- Hui-Yuan Qin
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Cheng Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Duo-Duo Qian
- Department of Cardiology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Chang Cui
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ming-Long Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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39
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Elliott MK, Mehta VS, Sidhu BS, Niederer S, Rinaldi CA. Endocardial left ventricular pacing. Herz 2021; 46:526-532. [PMID: 34694427 PMCID: PMC8543431 DOI: 10.1007/s00059-021-05074-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 11/23/2022]
Abstract
Cardiac resynchronization therapy (CRT) is an effective treatment for dyssynchronous heart failure; however, 30–50% of patients fail to improve after implant. Endocardial left ventricular (LV) pacing is an alternative therapy for patients who do not respond to conventional CRT or in whom placement of a lead via the coronary sinus is not possible. It enables pacing at a wide variety of sites, without restrictions due to coronary sinus anatomy, and there is evidence of superior electrical resynchronization and hemodynamic response compared with conventional epicardial CRT. In this article, we discuss the potential advantages and disadvantages of endocardial LV pacing compared with conventional CRT, review the evidence for the delivery of endocardial LV pacing using both lead-based and leadless systems, and explore possible future directions of this novel technology.
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Affiliation(s)
- Mark K Elliott
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, SE1 7EH, London, UK. .,Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Vishal S Mehta
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, SE1 7EH, London, UK
| | - Baldeep Singh Sidhu
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, SE1 7EH, London, UK.,Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, SE1 7EH, London, UK
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, SE1 7EH, London, UK.,Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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40
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A successful placement of the left ventricular lead for the cardiac resynchronization device using the orthodromic snare technique: clinical case. КЛИНИЧЕСКАЯ ПРАКТИКА 2021. [DOI: 10.17816/clinpract76720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: The main aim of Cardiac Resynchronization Therapy (CRT) is a positive response of the patient, particularly, reduction of the symptoms and improvement of the heart contractility, that can be reached in 5070% of patients. The possibility of appropriate positioning the left ventricular (LV) lead is of great importance for the response to CRT. Certain instruments and technical approaches are used for the placement of the LV lead. Here, we describe the use of the orthodromic snare technique, which is quite rare in practice, but allows one to overcome some anatomical obstacles.
Clinical case description: Patient A., suffering from the heart failure with a low ejection fraction and left bundle branch block, was admitted to the hospital for CRT implantation. Before the operation, all the necessary routine instrumental and laboratory diagnostics was performed. During the operation, venography of the cardiac veins revealed unsuitability of the lateral cardiac vein for the placement of the LV lead due to its very small diameter. The posterolateral vein was suitable for the LV lead implantation but still had some anatomical difficulties: an acute angle of inflow and local stenosis in the proximal segment. During the procedure, the following techniques were used without success: positioning the LV lead by a simple translational movement forward, a subselective catheter, introduction of several coronary guides in order to smooth out the acute angle of inflow. These circumstances warranted the use of the orthodromic snare technique for a successful LV lead placement.
Conclusion: This clinical case illustrates the possibility of a safe and effective use of the orthodromic snare technique for LV lead implantation. Such anatomical difficulties as a small diameter, acute angle of inflow, local stenosis have also been illustrated and discussed.
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41
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Marwick TH, Chandrashekhar Y. Imaging in Cardiac Resynchronization Therapy Needs to Consider More Than Mechanical Delay. JACC Cardiovasc Imaging 2021; 14:1881-1883. [PMID: 34503694 DOI: 10.1016/j.jcmg.2021.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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42
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Drucker MN, Manyam H, Singh G, Glascock DN, Gillett S, Miller C, Sharmin K, Parks KA. MultiPole pacing in non-responders to cardiac resynchronization therapy: Results from the QP ExCELs/MPP sub-study. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1683-1690. [PMID: 34405423 DOI: 10.1111/pace.14339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/26/2021] [Accepted: 08/15/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Multisite LV stimulation therapy allows for stimulation of two different left ventricular pacing vectors within a single LV lead and may improve responsiveness to cardiac resynchronization therapy (CRT). This study prospectively evaluated the safety and efficacy of the MultiPole Pacing (MPP) feature in CRT non-responder patients. METHODS AND RESULTS CRT non-responders with a standard CRT-D indication were eligible for enrollment into the MPP Sub-Study. Patient status, NYHA classification, Patient Global Assessment (PGA), and adverse events were collected at follow-up. A clinical composite score (CCS) was determined at the 6 month follow-up visit. The primary objective was defined as the proportion of patients with an improved CCS. Safety was evaluated as freedom from MPP system related adverse events requiring additional invasive intervention to resolve. A total of 53 patients were enrolled across 26 U.S. centers. The cumulative follow-up duration was 24.1 years. CCS was improved in 35.6% of patients (p < .0001 when compared to a performance goal of 3%) after 6 months of MPP therapy. When incorporating patient feedback into a modified CCS, 60.0% of patients showed an improvement. Three patients (5.7%) experienced hospitalization for heart failure, and three patient deaths occurred over the follow-up period. No MPP system-related events were reported for an AE-free rate of 100% (95% CI 93.28% to 100.0%). CONCLUSIONS The results of this small, non-randomized study suggest that the MPP feature is safe, and may be effective at converting a percentage of CRT non-responders to responders. Larger, randomized studies are needed to confirm this result.
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Affiliation(s)
| | | | | | | | | | | | | | - Kimberly A Parks
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
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43
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Waddingham PH, Lambiase P, Muthumala A, Rowland E, Chow AW. Fusion Pacing with Biventricular, Left Ventricular-only and Multipoint Pacing in Cardiac Resynchronisation Therapy: Latest Evidence and Strategies for Use. Arrhythm Electrophysiol Rev 2021; 10:91-100. [PMID: 34401181 PMCID: PMC8335856 DOI: 10.15420/aer.2020.49] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/15/2021] [Indexed: 12/11/2022] Open
Abstract
Despite advances in the field of cardiac resynchronisation therapy (CRT), response rates and durability of therapy remain relatively static. Optimising device timing intervals may be the most common modifiable factor influencing CRT efficacy after implantation. This review addresses the concept of fusion pacing as a method for improving patient outcomes with CRT. Fusion pacing describes the delivery of CRT pacing with a programming strategy to preserve intrinsic atrioventricular (AV) conduction and ventricular activation via the right bundle branch. Several methods have been assessed to achieve fusion pacing. QRS complex duration (QRSd) shortening with CRT is associated with improved clinical response. Dynamic algorithm-based optimisation targeting narrowest QRSd in patients with intact AV conduction has shown promise in people with heart failure with left bundle branch block. Individualised dynamic programming achieving fusion may achieve the greatest magnitude of electrical synchrony, measured by QRSd narrowing.
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Affiliation(s)
- Peter H Waddingham
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK.,William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Pier Lambiase
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK.,UCL Institute of Cardiovascular Science University College London, London, UK
| | - Amal Muthumala
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Edward Rowland
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Anthony Wc Chow
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK.,William Harvey Research Institute, Queen Mary University of London, London, UK
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44
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Antoniou CK, Xydis P, Konstantinou K, Magkas N, Manolakou P, Dilaveris P, Chrysohoou C, Gatzoulis KA, Tsioufis C. Multipoint left ventricular pacing as an addition to cardiac resynchronization therapy: a bridge to the holy grail? AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2021; 11:429-440. [PMID: 34548940 PMCID: PMC8449203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/22/2021] [Indexed: 06/13/2023]
Abstract
Cardiac resynchronization therapy (CRT) constitutes a cornerstone to the treatment of advanced dyssynchronous heart failure (DyssHF); moreover it represents one of the few instances that a revolutionary approach was pursued, yielding previously unfathomable benefits to patients out of realistic therapeutic options. However, as is rather extensively established, nonresponse, or even negative response, to CRT continue to plague its course, precluding favourable effects in up to 40% of recipients, for a multitude of reasons. Given the scope of the issue of nonresponse, attempts to negate it by means of altering CRT delivery mode, and, more specifically, by introducing multipoint left ventricular pacing (MPP) have been focused on. Possible reasons for divergent trial results will be presented, as well as potential criteria for predicting whether MPP activation may reap additional benefits as compared to conventional biventricular pacing (BVP). Finally, an alternative framework for approaching CRT in general will be put forward, including advancements which in the (near) future may once more revolutionise heart failure treatment.
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Affiliation(s)
- Christos-Konstantinos Antoniou
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion General Hospital Athens, Greece
| | - Panagiotis Xydis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion General Hospital Athens, Greece
| | - Konstantinos Konstantinou
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion General Hospital Athens, Greece
| | - Nikolaos Magkas
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion General Hospital Athens, Greece
| | - Panagiota Manolakou
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion General Hospital Athens, Greece
| | - Polychronis Dilaveris
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion General Hospital Athens, Greece
| | - Christina Chrysohoou
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion General Hospital Athens, Greece
| | - Konstantinos A Gatzoulis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion General Hospital Athens, Greece
| | - Costas Tsioufis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion General Hospital Athens, Greece
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45
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Okabe T, Hummel JD, Bank AJ, Niazi IK, McGrew FA, Kindsvater S, Oza SR, Scherschel JA, Walsh MN, Singh JP. Leadless left ventricular stimulation with WiSE-CRT System - Initial experience and results from phase I of SOLVE-CRT Study (nonrandomized, roll-in phase). Heart Rhythm 2021; 19:22-29. [PMID: 34332966 DOI: 10.1016/j.hrthm.2021.06.1195] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Left ventricular (LV) endocardial pacing is a promising method to deliver cardiac resynchronization therapy (CRT). WiSE-CRT is a wireless LV endocardial pacing system, and delivers ultrasonic energy to an LV electrode. OBJECTIVE The purpose of this study was to present short-term outcomes with the WiSE-CRT system in centers with no prior implanting experience. METHODS Data were prospectively collected from 19 centers where WiSE-CRT systems were implanted during the roll-in phase of the SOLVE-CRT trial. Patients were followed at 1, 3, and 6 months, including transthoracic echo (TTE) at 6 months. RESULTS The WiSE-CRT was successfully implanted in all 31 attempted cases, and 30 patients completed the 6-month follow-up. One patient underwent heart transplantation 1 month after implantation, and was excluded. Fourteen (46.7%) patients demonstrated ≥1 NYHA class improvement. TTE data were available in 29 patients. LV ejection fraction, LV end-systolic volume, and LV end-diastolic volume improved from 28.3% ± 6.7% to 33.5% ± 6.9% (P < .001), 134.9 ± 51.3 mL to 111.1 ± 40.3 mL (P = .0004), and 185.4 ± 58.8 mL to 164.9 ± 50.6 mL (P = .0017), respectively. There were 3 (9.7%) device-related type 1 complications: 1 insufficient LV pacing, 1 embolization of an unanchored LV electrode, and 1 skin infection. CONCLUSIONS We demonstrated a high success rate of LV endocardial electrode placement in centers with no prior implanting experience. Favorable clinical responses in heart failure symptoms and significant LV reverse remodeling were noted.
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Affiliation(s)
- Toshimasa Okabe
- The Ohio State University Wexner Medical Center, Columbus, Ohio.
| | - John D Hummel
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Alan J Bank
- Minneapolis Heart Institute, Allina Health, St. Paul, Minnesota
| | | | | | | | - Saumil R Oza
- Ascension St. Vincent's Hospital, Jacksonville, Florida
| | | | | | - Jagmeet P Singh
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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46
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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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47
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Sreenivasan J, Jain D. Parameters of left ventricular systolic and diastolic dyssynchrony on radionuclide imaging to improve cardiac resynchronization therapy in heart failure patients with dilated cardiomyopathy. J Nucl Cardiol 2021; 28:1037-1039. [PMID: 32458330 DOI: 10.1007/s12350-020-02202-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/14/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Jayakumar Sreenivasan
- Nuclear Cardiovascular Imaging Laboratory, Department of Cardiology, Westchester Medical Center, Valhalla, USA
| | - Diwakar Jain
- Nuclear Cardiovascular Imaging Laboratory, Department of Cardiology, Westchester Medical Center, Valhalla, USA.
- Department of Cardiovascular Medicine, New York Medical College, Westchester Medical Center, 100 Woods Road, Valhalla, NY, 10595, USA.
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48
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Sidhu BS, Gould J, Elliott MK, Mehta VS, Niederer SA, Carr-White G, Rinaldi CA. Clinical effectiveness of a dedicated cardiac resynchronization therapy pre-assessment clinic incorporating cardiac magnetic resonance imaging and cardiopulmonary exercise testing on patient selection and outcomes. IJC HEART & VASCULATURE 2021; 34:100800. [PMID: 34159251 PMCID: PMC8203725 DOI: 10.1016/j.ijcha.2021.100800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pre-procedural assessment of patients undergoing cardiac resynchronization therapy (CRT) is heterogenous and patients implanted with unfavorable characteristics may account for non-response. A dedicated CRT pre-assessment clinic (CRT PAC) was developed to standardize the review process and undertake structured pre-procedural evaluation. The aim of this analysis was to determine the effectiveness on patient selection and outcomes. METHODS A prospective database of consecutive patients attending the CRT PAC between 2013 and 2018 was analyzed. Pre-operative assessment included cardiac magnetic resonance (CMR) and cardiopulmonary exercise testing (CPET). Patients were considered CRT responders based on improvement in clinical composite score (CCS) and/or reduction in left ventricular end-systolic volume (LVESV) ≥ 15% at 6-months follow-up. RESULTS Of 252 patients reviewed in the CRT PAC during the analysis period, 192 fulfilled consensus guidelines for implantation. Of the patients receiving CRT, 82% showed improvement in their CCS and 57% had a reduction in LVESV ≥ 15%. The presence of subendocardial scar on CMR and a peak VO2 ≤ 12 ml/kg/min on CPET predicted CRT non-response. Two patients were unsuitable for CRT as they had end-stage heart failure and died during follow-up. The majority of patients initially deemed unsuitable for CRT did not suffer from unexpected hospitalization for decompensated heart failure or died from cardiovascular disease; only 8 patients (13%) received CRT devices during follow-up because of symptomatic left ventricular systolic impairment. CONCLUSION A dedicated CRT PAC is able to appropriately select patients for CRT. Pre-procedural investigation/imaging can identify patients unlikely to respond to, or may not yet be suitable for CRT.
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Affiliation(s)
- Baldeep S. Sidhu
- School of Biomedical Engineering and Imaging Sciences, King’s College London, UK
- Guy’s and St Thomas’ Hospital, London, UK
| | - Justin Gould
- School of Biomedical Engineering and Imaging Sciences, King’s College London, UK
- Guy’s and St Thomas’ Hospital, London, UK
| | - Mark K. Elliott
- School of Biomedical Engineering and Imaging Sciences, King’s College London, UK
- Guy’s and St Thomas’ Hospital, London, UK
| | - Vishal S. Mehta
- School of Biomedical Engineering and Imaging Sciences, King’s College London, UK
- Guy’s and St Thomas’ Hospital, London, UK
| | - Steven A. Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, UK
| | - Gerald Carr-White
- School of Biomedical Engineering and Imaging Sciences, King’s College London, UK
- Guy’s and St Thomas’ Hospital, London, UK
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, UK
- Guy’s and St Thomas’ Hospital, London, UK
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49
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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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Bennett S, Tafuro J, Duckett S, Heatlie G, Patwala A, Barker D, Cubukcu A, Ahmed F, Kwok C. Septal Flash as a Predictor of Cardiac Resynchronization Therapy Response: A Systematic Review and Meta-Analysis. J Cardiovasc Echogr 2021; 31:198-206. [PMID: 35284222 PMCID: PMC8893106 DOI: 10.4103/jcecho.jcecho_45_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 08/09/2021] [Accepted: 11/06/2021] [Indexed: 11/04/2022] Open
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