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Zupan Mežnar A, Mrak M, Mullens W, Štublar J, Ivanovski M, Žižek D. AV-optimized conduction system pacing for treatment of AV dromotropathy: A randomized, cross-over study. J Cardiovasc Electrophysiol 2024; 35:1340-1350. [PMID: 38686618 DOI: 10.1111/jce.16268] [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: 10/15/2023] [Revised: 02/04/2024] [Accepted: 03/19/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Severe first-degree atrioventricular (AV) block may produce symptoms similar to heart failure due to AV dyssynchrony, a syndrome termed AV dromotropathy. According to guidelines, it should be considered for permanent pacemaker implantation, yet evidence supporting this treatment is scarce. OBJECTIVES This study aimed to determine the impact of AV-optimized conduction system pacing (CSP) in patients with symptomatic severe first-degree AV block and echocardiographic signs of AV dyssynchrony. METHODS Patients with symptomatic first-degree AV block (PR > 250 ms), preserved left ventricular ejection fraction, narrow QRS, and AV dyssynchrony were included in the study. In a single-blind cross-over design, patients were randomized to AV sequential CSP or backup VVI pacing with a base rate of 40 bpm. We compared exercise capacity, echocardiographic parameters, and symptom occurrence at the end of 3 months of each period. RESULTS Fourteen patients completed the study. During the AV-optimized CSP compared to the backup pacing period, patients achieved a higher workload on exercise test (147.2 ± 50.9 vs. 140.7 ± 55.8 W; p = .032), with a trend towards higher peak VO2 (23.3 ± 7.1 vs. 22.8 ± 7.1 mL/min/kg; p = .224), and higher left ventricular stroke volume (LVSV 74.5 ± 13.8 vs. 66.4 ± 12.5 mL; p < .001). Symptomatic improvement was recorded, with fewer patients reporting general tiredness and 71% of patients preferring the AV-optimized CSP (p = .008). CONCLUSIONS AV-optimized CSP could improve symptoms, exercise capacity and LVSV in patients with severe first-degree AV block.
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Affiliation(s)
- Anja Zupan Mežnar
- Department of Cardiology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Miha Mrak
- Department of Cardiology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Faculty of Medicine and Life Sciences, University Hasselt, Hasselt, Belgium
| | - Jernej Štublar
- Department of Cardiology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Department of Cardiovascular Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Maja Ivanovski
- Department of Cardiology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - David Žižek
- Department of Cardiology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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2
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Zupan Mežnar A, Žižek D, Mewton N. Atrioventricular dromotropathy: an important substrate for complete resynchronization therapy. Europace 2022; 24:868. [PMID: 35352812 DOI: 10.1093/europace/euac036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Anja Zupan Mežnar
- Cardiology Department, University Medical Centre Ljubljana, Zaloška Cesta 7, 1000Ljubljana, Slovenia
| | - David Žižek
- Cardiology Department, University Medical Centre Ljubljana, Zaloška Cesta 7, 1000Ljubljana, Slovenia
| | - Nathan Mewton
- Heart Failure Department, Hôpital Cardio-Vasculaire Louis Pradel, Clinical Investigation Center Inserm 1407, CarMeN Inserm 1060, Hospices Civils de Lyon, Claude Barnard University Lyon 1, Lyon, France
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3
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Salden FCWM, Huntjens PR, Schreurs R, Willemen E, Kuiper M, Wouters P, Maessen JG, Bordachar P, Delhaas T, Luermans J, Meine M, Allaart CP, van Stipdonk AMW, Prinzen FW, Lumens J, Vernooy K. Pacing therapy for atrioventricular dromotropathy: a combined computational-experimental-clinical study. Europace 2021; 24:784-795. [PMID: 34718532 PMCID: PMC9071072 DOI: 10.1093/europace/euab248] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/11/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS Investigate haemodynamic effects, and their mechanisms, of restoring atrioventricular (AV)-coupling using pacemaker therapy in normal and failing hearts in a combined computational-experimental-clinical study. METHODS AND RESULTS Computer simulations were performed in the CircAdapt model of the normal and failing human heart and circulation. Experiments were performed in a porcine model of AV dromotropathy. In a proof-of-principle clinical study, left ventricular (LV) pressure and volume were measured in 22 heart failure (HF) patients (LV ejection fraction <35%) with prolonged PR interval (>230 ms) and narrow or non-left bundle branch block QRS complex. Computer simulations and animal studies in normal hearts showed that restoring of AV-coupling with unchanged ventricular activation sequence significantly increased LV filling, mean arterial pressure, and cardiac output by 10-15%. In computer simulations of failing hearts and in HF patients, reducing PR interval by biventricular (BiV) pacing (patients: from 300 ± 61 to 137 ± 30 ms) resulted in significant increases in LV stroke volume and stroke work (patients: 34 ± 40% and 26 ± 31%, respectively). However, worsening of ventricular dyssynchrony by using right ventricular (RV) pacing abrogated the benefit of restoring AV-coupling. In model simulations, animals and patients, the increase of LV filling and associated improvement of LV pump function coincided with both larger mitral inflow (E- and A-wave area) and reduction of diastolic mitral regurgitation. CONCLUSION Restoration of AV-coupling by BiV pacing in normal and failing hearts with prolonged AV conduction leads to considerable haemodynamic improvement. These results indicate that BiV or physiological pacing, but not RV pacing, may improve cardiac function in patients with HF and prolonged PR interval.
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Affiliation(s)
- Floor C W M Salden
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands.,Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
| | - Peter R Huntjens
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Department of Cardiology, Washington University in Saint Louis, Saint Louis, MO, USA
| | - Rick Schreurs
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands.,Department of Cardiothoracic Surgery, Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands
| | - Erik Willemen
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Marion Kuiper
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
| | - Philippe Wouters
- Department of Cardiology, University Medical Centre Utrecht (UMC Utrecht), Utrecht, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands
| | - Pierre Bordachar
- Department of Cardiology, Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Tammo Delhaas
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Justin Luermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands
| | - Mathias Meine
- Department of Cardiology, University Medical Centre Utrecht (UMC Utrecht), Utrecht, The Netherlands
| | - Cornelis P Allaart
- Department of Cardiology, Amsterdam University Medical Centre (Amsterdam UMC), Amsterdam, The Netherlands
| | - Antonius M W van Stipdonk
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
| | - Joost Lumens
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Department of Cardiology, Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands.,Department of Cardiology, Radboud University Medical Centre (RadboudUMC), Nijmegen, The Netherlands
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4
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Abstract
Over the years, pacemakers have evolved from a life-saving tool to prevent asystole to a device to treat heart rhythm disorders and heart failure, aiming at improving both cardiac function and clinical outcomes. Cardiac stimulation nowadays aims to correct the electrophysiologic roots of mechanical inefficiency in different structural heart diseases. This has led to awareness of the concealed risks of customary cardiac pacing that can inadvertently cause atrioventricular and inter-/intra-ventricular dyssynchrony, and has promoted the development of new pacing modalities and the use of stimulation sites different from the right atrial appendage and the right ventricular apex. The perspective of truly physiologic pacing is the leading concept of the continued research in the past 30 years, which has made cardiac stimulation procedure more sophisticated and challenging. In this article, we analyze the emerging evidence in favor of the available strategies to achieve an individualized physiologic setting in bradycardia pacing.
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Biffi M, Capobianco C, Spadotto A, Bartoli L, Sorrentino S, Minguzzi A, Piemontese GP, Angeletti A, Toniolo S, Statuto G. Pacing devices to treat bradycardia: current status and future perspectives. Expert Rev Med Devices 2020; 18:161-177. [PMID: 33336616 DOI: 10.1080/17434440.2021.1866543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Cardiac stimulation evolved from life-saving devices to prevent asystole to the treatment of heart rhythm disorders and heart failure, capable of remote patient and disease-progression monitoring. Cardiac stimulation nowadays aims to correct the electrophysiologic roots of mechanical inefficiency in different structural heart diseases.Areas covered: Clinical experience, as per available literature, has led to awareness of the concealed risks of customary cardiac pacing, that can inadvertently cause atrio-ventricular and inter/intra-ventricular dyssynchrony. New pacing modalities have emerged, leading to a new concept of what truly represents 'physiologic pacing' beyond maintenance of atrio-ventricular coupling. In this article we will analyze the emerging evidence in favor of the available strategies to achieve an individualized physiologic setting in bradycardia pacing, and the hints of future developments.Expert opinion: 'physiologic stimulation' technologies should evolve to enable an effective and widespread adoption. In one way new guiding catheters and the adoption of electrophysiologic guidance and non-fluoroscopic lead implantation are needed to make His-Purkinje pacing successful and effective at long term in a shorter procedure time; in the other way leadless stimulation needs to upgrade to a superior physiologic setting to mimic customary DDD pacing and possibly His-Purkinje pacing.
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Affiliation(s)
- Mauro Biffi
- Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Claudio Capobianco
- Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine, Bologna, Italy
| | - Alberto Spadotto
- Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine, Bologna, Italy
| | - Lorenzo Bartoli
- Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine, Bologna, Italy
| | - Sergio Sorrentino
- Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine, Bologna, Italy
| | - Alessandro Minguzzi
- Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine, Bologna, Italy
| | - Giuseppe Pio Piemontese
- Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine, Bologna, Italy
| | - Andrea Angeletti
- Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine, Bologna, Italy
| | - Sebastiano Toniolo
- Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine, Bologna, Italy
| | - Giovanni Statuto
- Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine, Bologna, Italy
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6
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Salden FCWM, Kutyifa V, Stockburger M, Prinzen FW, Vernooy K. Atrioventricular dromotropathy: evidence for a distinctive entity in heart failure with prolonged PR interval? Europace 2019; 20:1067-1077. [PMID: 29186415 DOI: 10.1093/europace/eux207] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 05/25/2017] [Indexed: 01/07/2023] Open
Abstract
Heart failure (HF) is often accompanied by atrioventricular (AV) conduction disturbance, represented by prolongation of the PR interval on the electrocardiogram. Studies suggest that PR prolongation exists in at least 10% of HF patients, and it seems more prevalent in the presence of prolonged QRS duration. A prolonged PR interval may result in elevated left ventricular (LV) end-diastolic pressure, diastolic mitral regurgitation, and reduced LV pump function. This seems especially the case in patients with heart disease, in whom it is associated with an increased risk for atrial fibrillation, advanced AV heart block, HF, and death. These findings point towards the importance of proper AV coupling in HF patients. A few studies, strongly differing in design, suggest that restoration of AV coupling in patients with PR prolongation by pacing improves cardiac function and clinical outcomes. These observations argue for AV-dromotropathy as a potential target for pacing therapy, but other studies show inconsistent results. Given its potential clinical implications, restoration of AV coupling by pacing warrants further investigation. Additional possible future research goals include assessing different techniques to measure compromised AV coupling, determine the best site(s) of ventricular pacing, and assess a potential influence of diastolic mitral regurgitation in the efficacy of such therapy.
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Affiliation(s)
- Floor C W M Salden
- Departments of Physiology and Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, ER Maastricht, The Netherlands
| | - Valentina Kutyifa
- Heart Research Follow-Up Program, University of Rochester Medical Center, 265 Crittenden Blvd, Rochester, NY, USA
| | - Martin Stockburger
- Department of Cardiology, Havelland Kliniken, Ketziner Straße 21, Nauen, Germany.,Department of Cardiology and Angiology, Charité - Universitaetsmedizin Berlin, Charitéplatz 1, Berlin, Germany
| | - Frits W Prinzen
- Departments of Physiology and Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, ER Maastricht, The Netherlands
| | - Kevin Vernooy
- Departments of Physiology and Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, ER Maastricht, The Netherlands
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7
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Goette A, Auricchio A, Boriani G, Braunschweig F, Terradellas JB, Burri H, Camm AJ, Crijns H, Dagres N, Deharo JC, Dobrev D, Hatala R, Hindricks G, Hohnloser SH, Leclercq C, Lewalter T, Lip GYH, Merino JL, Mont L, Prinzen F, Proclemer A, Pürerfellner H, Savelieva I, Schilling R, Steffel J, van Gelder IC, Zeppenfeld K, Zupan I, Heidbüchel H, Boveda S, Defaye P, Brignole M, Chun J, Guerra Ramos JM, Fauchier L, Svendsen JH, Traykov VB, Heinzel FR. EHRA White Paper: knowledge gaps in arrhythmia management—status 2019. Europace 2019; 21:993-994. [DOI: 10.1093/europace/euz055] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/15/2019] [Indexed: 12/23/2022] Open
Abstract
Abstract
Clinicians accept that there are many unknowns when we make diagnostic and therapeutic decisions. Acceptance of uncertainty is essential for the pursuit of the profession: bedside decisions must often be made on the basis of incomplete evidence. Over the years, physicians sometimes even do not realize anymore which the fundamental gaps in our knowledge are. As clinical scientists, however, we have to halt and consider what we do not know yet, and how we can move forward addressing those unknowns. The European Heart Rhythm Association (EHRA) believes that scanning the field of arrhythmia / cardiac electrophysiology to identify knowledge gaps which are not yet the subject of organized research, should be undertaken on a regular basis. Such a review (White Paper) should concentrate on research which is feasible, realistic, and clinically relevant, and should not deal with futuristic aspirations. It fits with the EHRA mission that these White Papers should be shared on a global basis in order to foster collaborative and needed research which will ultimately lead to better care for our patients. The present EHRA White Paper summarizes knowledge gaps in the management of atrial fibrillation, ventricular tachycardia/sudden death and heart failure.
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Affiliation(s)
- Andreas Goette
- St. Vincenz-Krankenhaus GmbH, Cardiology and Intensive Care Medicine, Am Busdorf 2, Paderborn, Germany
- Working Group Molecular Electrophysiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Angelo Auricchio
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano (Ticino), Switzerland
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | | | | | - Haran Burri
- Department of Cardiology, University Hospital of Geneva, Geneva, Switzerland
| | - A John Camm
- St. George's, University of London, Molecular and Clinical Sciences Research Institute, London, UK
| | - Harry Crijns
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht UMC+, Maastricht, The Netherlands
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Jean-Claude Deharo
- Department of Cardiology, Aix Marseille Université, CHU la Timone, Marseille, France
| | - Dobromir Dobrev
- University Duisburg-Essen, Institute of Pharmacology, Essen, Germany
| | - Robert Hatala
- Department of Cardiology and Angiology, National Cardiovascular Institute, NUSCH, Bratislava, Slovak Republic
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Stefan H Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, J.W. Goethe University, Frankfurt, Germany
| | | | - Thorsten Lewalter
- Department of Cardiology and Intensive Care, Hospital for Internal Medicine Munich South, Munich, Germany
- Department of Cardiology, University of Bonn, Bonn, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jose Luis Merino
- Hospital Universitario La Paz, Arrhythmia and Robotic EP Unit, Madrid, Spain
| | - Lluis Mont
- Department of Cardiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Frits Prinzen
- Department of Physiology, Maastricht University, Maastricht, Netherlands
| | | | - Helmut Pürerfellner
- Department of Cardiology, Ordensklinikum Linz Elisabethinen, Academic Teaching Hospital, Linz, Austria
| | - Irina Savelieva
- St. George's, University of London, Molecular and Clinical Sciences Research Institute, London, UK
| | | | - Jan Steffel
- University Heart Center Zurich, Zurich, Switzerland
| | - Isabelle C van Gelder
- Department Of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center (Lumc), Leiden, Netherlands
| | - Igor Zupan
- Department Of Cardiology, University Clinical Centre Ljubljana, Ljubljana, Slovenia
| | - Hein Heidbüchel
- Antwerp University and Antwerp University Hospital, Antwerp, Belgium
| | - Serge Boveda
- Cardiology Department, Clinique Pasteur, Toulouse, France
| | - Pascal Defaye
- CHU Hôpital Albert Michalon, Unité de Rythmologie Service De Cardiologie, FR-38043 Grenoble Cedex 09, France
| | - Michele Brignole
- Department of Cardiology, Ospedali Del Tigullio, Via Don Bobbio 25, IT-16033 Lavagna (GE), Italy
| | - Jongi Chun
- CCB, Cardiology Department, Med. Klinik Iii, Markuskrankenhaus, Wilhelm Epstein Str. 4, DE-60431 Frankfurt, Germany
| | | | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau et Université de Tours, Faculté de Médecine, Tours, France
| | - Jesper Hastrup Svendsen
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Vassil B Traykov
- Department of Invasive Electrophysiology and Cardiac Pacing, Clinic of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Frank R Heinzel
- Charité University Medicine, Campus Virchow-Klinikum, Berlin, Germany
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Rattanawong P, Prasitlumkum N, Riangwiwat T, Kanjanahattakij N, Vutthikraivit W, Chongsathidkiet P, Simpson RJ. Baseline Prolonged PR Interval and Outcome of Cardiac Resynchronization Therapy: A Systematic Review and Meta-analysis. Arq Bras Cardiol 2018; 111:710-719. [PMID: 30328947 PMCID: PMC6248241 DOI: 10.5935/abc.20180198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 05/09/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Recent studies suggest that baseline prolonged PR interval is associated with worse outcome in cardiac resynchronization therapy (CRT). However, a systematic review and meta-analysis of the literature have not been made. OBJECTIVE To assess the association between baseline prolonged PR interval and adverse outcomes of CRT by a systematic review of the literature and a meta-analysis. METHODS We comprehensively searched the databases of MEDLINE and EMBASE from inception to March 2017. The included studies were published prospective or retrospective cohort studies that compared all-cause mortality, HF hospitalization, and composite outcome of CRT with baseline prolonged PR (> 200 msec) versus normal PR interval. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate the risk ratios and 95% confidence intervals. RESULTS Six studies from January 1991 to May 2017 were included in this meta-analysis. All-cause mortality rate is available in four studies involving 17,432 normal PR and 4,278 prolonged PR. Heart failure hospitalization is available in two studies involving 16,152 normal PR and 3,031 prolonged PR. Composite outcome is available in four studies involving 17,001 normal PR and 3,866 prolonged PR. Prolonged PR interval was associated with increased risk of all-cause mortality (pooled risk ratio = 1.34, 95 % confidence interval: 1.08-1.67, p < 0.01, I2= 57.0%), heart failure hospitalization (pooled risk ratio = 1.30, 95 % confidence interval: 1.16-1.45, p < 0.01, I2= 6.6%) and composite outcome (pooled risk ratio = 1.21, 95% confidence interval: 1.13-1.30, p < 0.01, I2= 0%). CONCLUSIONS Our systematic review and meta-analysis support the hypothesis that baseline prolonged PR interval is a predictor of all-cause mortality, heart failure hospitalization, and composite outcome in CRT patients.
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Affiliation(s)
- Pattara Rattanawong
- University of Hawaii Internal Medicine Residency Program, Honolulu, Havaí - EUA
| | - Narut Prasitlumkum
- University of Hawaii Internal Medicine Residency Program, Honolulu, Havaí - EUA
| | - Tanawan Riangwiwat
- University of Hawaii Internal Medicine Residency Program, Honolulu, Havaí - EUA
| | | | | | | | - Ross J Simpson
- The University of North Carolina, Chapel Hill, Carolina do Norte - EUA
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9
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Effect of PR interval prolongation on long-term outcomes in patients with left bundle branch block vs non–left bundle branch block morphologies undergoing cardiac resynchronization therapy. Heart Rhythm 2017; 14:1523-1528. [DOI: 10.1016/j.hrthm.2017.05.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Indexed: 11/20/2022]
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10
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Stępniewski J, Kopeć G, Magoń W, Podolec P. Atrioventricular Conduction Delay Predicts Impaired Exercise Capacity in Patients with Heart Failure with Reduced Ejection Fraction. Med Sci Monit 2017; 23:3989-3995. [PMID: 28819094 PMCID: PMC5572778 DOI: 10.12659/msm.902908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Atrioventricular conduction delay (AVCD) impairs left ventricular (LV) filling and consequently leads to a reduction of cardiac output. We hypothesized that in patients with severely depressed LV function and coexisting intraventricular conduction disturbances (IVCD), AVCD can affect exercise performance. Therefore, we evaluated the association of AVCD and exercise capacity in patients with heart failure (HFREF) and coexisting IVCD. Material/Methods We included patients with stable, chronic HFREF, LVEF <35%, sinus rhythm, and QRS ≥120 ms. PR interval and peak oxygen consumption (VO2 peak) were specifically investigated. Multiple regression analysis was used to adjust the association between PR interval and VO2 peak for possible confounders. Results Most (57.5%) of the 40 included patients [20% female, aged 63±12, 47.5% of ischemic etiology (IHD)] were in NYHA class III. Mean PR interval was 196±38.1 ms. There were 26 (65%) patients with PR interval ≤200 ms and 14 (35%) with >200 ms. Groups were similar in clinical, laboratory, echocardiographic parameters, QRS morphology, and treatment regimens. VO2 peak was lower in patients with longer PR interval group as compared to shorter PR interval group (12.3±4.1 vs. 17.06±4.4, p=0.002). In the regression model, PR interval, female sex, and IHD remained important predictors of VO2 peak (partial=−0.50, p=0.003; rpartial=−0.48, p=0.005; rpartial=−0.44, p=0.01; R2=0.61). Conclusions Delayed AV conduction contributes to decreased exercise capacity in patients with HFREF and coexisting IVCD.
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Affiliation(s)
- Jakub Stępniewski
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Cracow, Cracow, Poland
| | - Grzegorz Kopeć
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Cracow, Cracow, Poland
| | - Wojciech Magoń
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Cracow, Cracow, Poland
| | - Piotr Podolec
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Cracow, Cracow, Poland
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Friedman DJ, Bao H, Spatz ES, Curtis JP, Daubert JP, Al-Khatib SM. Association Between a Prolonged PR Interval and Outcomes of Cardiac Resynchronization Therapy: A Report From the National Cardiovascular Data Registry. Circulation 2016; 134:1617-1628. [PMID: 27760795 DOI: 10.1161/circulationaha.116.022913] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 09/26/2016] [Indexed: 01/29/2023]
Abstract
BACKGROUND A prolonged PR interval is common among cardiac resynchronization therapy (CRT) candidates; however, the association between PR interval and outcomes is unclear, and the data are conflicting. METHODS We conducted inverse probability weighted analyses of 26 451 CRT-eligible (ejection fraction ≤35, QRS ≥120 ms) patients from the National Cardiovascular Data Registry ICD Registry to assess the association between a prolonged PR interval (≥230 ms), receipt of CRT with defibrillator (CRT-D) versus implantable cardioverter defibrillator (ICD), and outcomes. We first tested the association between a prolonged PR interval and outcomes among patients stratified by device type. Next, we performed a comparative effectiveness analysis of CRT-D versus ICD among patients when stratified by PR interval. Using Medicare claims data, we followed up with patients up to 5 years for incident heart failure hospitalization or death. RESULTS Patients with a PR≥230 ms (15%; n=4035) were older and had more comorbidities, including coronary artery disease, atrial arrhythmias, diabetes mellitus, and chronic kidney disease. After risk adjustment, a PR≥230 ms (versus PR<230 ms) was associated with increased risk of heart failure hospitalization or death among CRT-D (hazard ratio, 1.23; 95% confidence interval, 1.14-1.31; P<0.001) but not ICD recipients (hazard ratio, 1.08; 95% confidence interval, 0.97-1.20; P=0.17) (Pinteraction=0.043). CRT-D (versus ICD) was associated with lower rates of heart failure hospitalization or death among patients with PR<230 ms (hazard ratio, 0.79; 95% confidence interval, 0.73-0.85; P<0.001) but not PR≥230 ms (hazard ratio, 1.01; 95% confidence interval, 0.87-1.17; P=0.90) (Pinteraction=0.0025). CONCLUSIONS A PR≥230 ms is associated with increased rates of heart failure hospitalization or death among CRT-D patients. The real-world comparative effectiveness of CRT-D (versus ICD) is significantly less among patients with a PR≥230 ms in comparison with patients with a PR<230 ms.
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Affiliation(s)
- Daniel J Friedman
- From Division of Cardiology, Duke University Hospital, Durham, NC (D.J.F., J.P.D., S.M.A.-K.); Duke Clinical Research Institute, Durham, NC (D.J.F., S.M.A.-K.); and Yale University School of Medicine, New Haven, CT (H.B., E.S.S., J.P.C.).
| | - Haikun Bao
- From Division of Cardiology, Duke University Hospital, Durham, NC (D.J.F., J.P.D., S.M.A.-K.); Duke Clinical Research Institute, Durham, NC (D.J.F., S.M.A.-K.); and Yale University School of Medicine, New Haven, CT (H.B., E.S.S., J.P.C.)
| | - Erica S Spatz
- From Division of Cardiology, Duke University Hospital, Durham, NC (D.J.F., J.P.D., S.M.A.-K.); Duke Clinical Research Institute, Durham, NC (D.J.F., S.M.A.-K.); and Yale University School of Medicine, New Haven, CT (H.B., E.S.S., J.P.C.)
| | - Jeptha P Curtis
- From Division of Cardiology, Duke University Hospital, Durham, NC (D.J.F., J.P.D., S.M.A.-K.); Duke Clinical Research Institute, Durham, NC (D.J.F., S.M.A.-K.); and Yale University School of Medicine, New Haven, CT (H.B., E.S.S., J.P.C.)
| | - James P Daubert
- From Division of Cardiology, Duke University Hospital, Durham, NC (D.J.F., J.P.D., S.M.A.-K.); Duke Clinical Research Institute, Durham, NC (D.J.F., S.M.A.-K.); and Yale University School of Medicine, New Haven, CT (H.B., E.S.S., J.P.C.)
| | - Sana M Al-Khatib
- From Division of Cardiology, Duke University Hospital, Durham, NC (D.J.F., J.P.D., S.M.A.-K.); Duke Clinical Research Institute, Durham, NC (D.J.F., S.M.A.-K.); and Yale University School of Medicine, New Haven, CT (H.B., E.S.S., J.P.C.)
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Nikolaidou T, Ghosh JM, Clark AL. Outcomes Related to First-Degree Atrioventricular Block and Therapeutic Implications in Patients With Heart Failure. JACC Clin Electrophysiol 2016; 2:181-192. [PMID: 29766868 DOI: 10.1016/j.jacep.2016.02.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 02/18/2016] [Accepted: 02/25/2016] [Indexed: 02/08/2023]
Abstract
The prevalence of first-degree atrioventricular block in the general population is approximately 4%, and it is associated with an increased risk of atrial fibrillation. Cardiac pacing for any indication in patients with first-degree heart block is associated with worse outcomes compared with patients with normal atrioventricular conduction. Among patients with heart failure, first-degree atrioventricular block is present in anywhere between 15% and 51%. Data from cardiac resynchronization therapy studies have shown that first-degree atrioventricular block is associated with an increased risk of mortality and heart failure hospitalization. Recent studies suggest that optimization of atrioventricular delay in patients with cardiac resynchronization therapy is an important target for therapy; however, the optimal method for atrioventricular resynchronization remains unknown. Understanding the role of first-degree atrioventricular block in the treatment of patients with heart failure will improve medical and device therapy.
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Affiliation(s)
- Theodora Nikolaidou
- Department of Academic Cardiology, Hull York Medical School, University of Hull, Hull, United Kingdom.
| | - Justin M Ghosh
- Department of Academic Cardiology, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Andrew L Clark
- Department of Academic Cardiology, Hull York Medical School, University of Hull, Hull, United Kingdom
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Rogers PA, Morin DP. Editorial commentary: MADIT–CRT and his many sons. Trends Cardiovasc Med 2016; 26:147-9. [DOI: 10.1016/j.tcm.2015.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 05/27/2015] [Indexed: 10/23/2022]
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Zusterzeel R, Selzman KA, Sanders WE, O’Callaghan KM, Caños DA, Vernooy K, Prinzen FW, Gorgels APM, Strauss DG. Toward Sex-Specific Guidelines for Cardiac Resynchronization Therapy? J Cardiovasc Transl Res 2015; 9:12-22. [DOI: 10.1007/s12265-015-9663-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 11/30/2015] [Indexed: 11/28/2022]
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Ellenbogen KA, Vijayaraman P. His Bundle Pacing: A New Promise in Heart Failure Therapy? JACC Clin Electrophysiol 2015; 1:592-595. [PMID: 29759413 DOI: 10.1016/j.jacep.2015.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 09/24/2015] [Indexed: 10/22/2022]
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