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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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2
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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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3
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Three-dimensional echocardiographic evaluation of mechanical dyssynchrony in systolic heart failure with narrow QRS complex. Indian Heart J 2017; 70:387-393. [PMID: 29961455 PMCID: PMC6034020 DOI: 10.1016/j.ihj.2017.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 09/20/2017] [Accepted: 10/24/2017] [Indexed: 11/30/2022] Open
Abstract
Objectives To investigate the role of three-dimensional echocardiography (3DE) in evaluation of left ventricular mechanical dyssynchrony (LVMD) in heart failure (HF) patients with narrow QRS. Methods 143 subjects (70 with HF and narrow QRS, 23 with HF and LBBB and 50 controls) were subjected to 3DE, evaluating global and regional dyssynchrony using systolic dyssynchrony index, maximum segmental dyssynchrony and opposite segment dyssynchrony. Spatial distribution of LVMD was studied in each patient using 3DE derived regional time volume curves. Extent of LVMD in HF patients with narrow QRS was compared to those with left bundle branch block (LBBB). Results Frequency of LVMD was similar in HF patients with narrow QRS or LBBB (55.7% vs. 47.8%, p = NS). There was no difference in the severity of LVMD between these two groups (10.7 ± 6.7% vs. 12.1 ± 7.4%, p = NS). Both HF groups had significantly more dyssynchrony than controls. A scattered pattern of distribution of asynchronous segments was seen in narrow QRS patients; 33.96% of them had their earliest contracting segment, instead of delayed segment, located in areas conventionally targeted for LV pacing i.e. anterolateral, inferolateral or inferior segments. Conclusions 3DE confirmed significant dyssynchrony in > 50% HF patients with narrow QRS as demonstrated by other imaging methods. 3D distribution patterns of asynchronous segments indicate possibility of left ventricular mechanics related reasons responsible for lack of CRT responsiveness, an observation that generates hypothesis on possible reasons of CRT non-responsiveness.
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4
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Gasparini M, Galimberti P, Bragato R, Ghio S, Raineri C, Landolina M, Chieffo E, Lunati M, Mulargia E, Proclemer A, Facchin D, Rordorf R, Vicentini A, Marcantoni L, Zanon F, Klersy C. Multipoint Pacing versus conventional ICD in Patients with a Narrow QRS complex (MPP Narrow QRS trial): study protocol for a pilot randomized controlled trial. Trials 2016; 17:572. [PMID: 27927248 PMCID: PMC5143452 DOI: 10.1186/s13063-016-1698-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 11/11/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Despite an intensive search for predictors of the response to cardiac resynchronization therapy (CRT), the QRS duration remains the simplest and most robust predictor of a positive response. QRS duration of ≥ 130 ms is considered to be a prerequisite for CRT; however, some studies have shown that CRT may also be effective in heart failure (HF) patients with a narrow QRS (<130 ms). Since CRT can now be performed by pacing the left ventricle from multiple vectors via a single quadripolar lead, it is possible that multipoint pacing (MPP) might be effective in HF patients with a narrow QRS. This article reports the design of the MPP Narrow QRS trial, a prospective, randomized, multicenter, controlled feasibility study to investigate the efficacy of MPP using two LV pacing vectors in patients with a narrow QRS complex (100-130 ms). METHODS Fifty patients with a standard ICD indication will be enrolled and randomized (1:1) to either an MPP group or a Standard ICD group. All patients will undergo a low-dose dobutamine stress echo test and only those with contractile reserve will be included in the study and randomized. The primary endpoint will be the percentage of patients in each group that have reverse remodeling at 12 months, defined as a reduction in left ventricular end-systolic volume (LVESV) of >15% from the baseline. DISCUSSION This feasibility study will determine whether MPP improves reverse remodeling, as compared with standard ICD, in HF patients who have a narrow QRS complex (100-130 ms). TRIAL REGISTRATION ClinicalTrials.gov, NCT02402816 . Registered on 25 March 2015.
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Affiliation(s)
| | | | - Renato Bragato
- Humanitas Research Hospital, Via Manzoni 56, Rozzano, Italy
| | - Stefano Ghio
- Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | | | | | | | | | | | | | | | | | | | | | | | - Catherine Klersy
- Servizio di Biometria e Statistica, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
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5
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Voskoboinik A, McGavigan AD, Mariani JA. Cardiac resynchronisation therapy in 2015: keeping up with the pace. Intern Med J 2016; 46:255-65. [DOI: 10.1111/imj.12774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 03/24/2015] [Indexed: 11/28/2022]
Affiliation(s)
- A. Voskoboinik
- Department of Cardiology; Western Hospital; Melbourne Victoria Australia
- Department of Cardiology; Alfred Hospital; Melbourne Victoria Australia
| | - A. D. McGavigan
- Department of Cardiovascular Medicine; Adelaide South Australia Australia
| | - J. A. Mariani
- Department of Cardiology; Alfred Hospital; Melbourne Victoria Australia
- Cardiac Investigation Unit; St Vincent' Hospital; Melbourne Victoria Australia
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6
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FISHBERGER STEVENB, KANTER RONALDJ. Applying Cardiac Resynchronization Criteria to Pediatric Patients: Fitting a Square Peg into a Round Hole? J Cardiovasc Electrophysiol 2015; 26:890-892. [DOI: 10.1111/jce.12720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- STEVEN B. FISHBERGER
- Nicklaus Childrens Hospital; Florida International University School of Medicine; Miami Florida USA
| | - RONALD J. KANTER
- Nicklaus Childrens Hospital; Florida International University School of Medicine; Miami Florida USA
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7
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Jackson T, Claridge S, Behar J, Sammut E, Webb J, Carr-White G, Razavi R, Rinaldi CA. Narrow QRS systolic heart failure: is there a target for cardiac resynchronization? Expert Rev Cardiovasc Ther 2015; 13:783-97. [PMID: 26048215 DOI: 10.1586/14779072.2015.1049945] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cardiac resynchronization therapy has revolutionized the management of systolic heart failure in patients with prolonged QRS during the past 20 years. Initially, the use of this treatment in patients with shorter QRS durations showed promising results, which have since been opposed by larger randomized controlled trials. Despite this, some questions remain, such as, whether correction of mechanical dyssynchrony is the therapeutic target by which biventricular pacing may confer benefit in this group, or are there other mechanisms that need consideration? In addition, novel techniques of cardiac resynchronization therapy delivery such as endocardial and multisite pacing may reduce potential detrimental effects of biventricular pacing, thereby improving the benefit/harm balance of this therapy in some patients.
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Affiliation(s)
- Tom Jackson
- Department of Cardiovascular Imaging, 4th Floor Lambeth Wing, St Thomas' Hospital, London, SE1 7EH, UK
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8
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Yap LB, Qadir F, Nguyen ST, Ma SK, Koh KW, Muhammad Z, Arshad AH, Ali Z, Daud A, Tay GS, Sahat NA, Said AA, Tamin SS, Hussin A, Kaur S, Omar R. The clinical benefit of cardiac resynchronization therapy for narrow QRS compared to broad QRS complex patients. Int J Cardiol 2015; 183:178-9. [DOI: 10.1016/j.ijcard.2015.01.042] [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: 11/11/2014] [Revised: 01/11/2015] [Accepted: 01/25/2015] [Indexed: 11/25/2022]
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9
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Jabbour RJ, Shun-Shin MJ, Finegold JA, Afzal Sohaib SM, Cook C, Nijjer SS, Whinnett ZI, Manisty CH, Brugada J, Francis DP. Effect of study design on the reported effect of cardiac resynchronization therapy (CRT) on quantitative physiological measures: stratified meta-analysis in narrow-QRS heart failure and implications for planning future studies. J Am Heart Assoc 2015; 4:e000896. [PMID: 25564370 PMCID: PMC4330047 DOI: 10.1161/jaha.114.000896] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Biventricular pacing (CRT) shows clear benefits in heart failure with wide QRS, but results in narrow QRS have appeared conflicting. We tested the hypothesis that study design might have influenced findings. Method and Results We identified all reports of CRT‐P/D therapy in subjects with narrow QRS reporting effects on continuous physiological variables. Twelve studies (2074 patients) met these criteria. Studies were stratified by presence of bias‐resistance steps: the presence of a randomized control arm over a single arm, and blinded outcome measurement. Change in each endpoint was quantified using a standardized effect size (Cohen's d). We conducted separate meta‐analyses for each variable in turn, stratified by trial quality. In non‐randomized, non‐blinded studies, the majority of variables (10 of 12, 83%) showed significant improvement, ranging from a standardized mean effect size of +1.57 (95%CI +0.43 to +2.7) for ejection fraction to +2.87 (+1.78 to +3.95) for NYHA class. In the randomized, non‐blinded study, only 3 out of 6 variables (50%) showed improvement. For the randomized blinded studies, 0 out of 9 variables (0%) showed benefit, ranging from −0.04 (−0.31 to +0.22) for ejection fraction to −0.1 (−0.73 to +0.53) for 6‐minute walk test. Conclusions Differences in degrees of resistance to bias, rather than choice of endpoint, explain the variation between studies of CRT in narrow‐QRS heart failure addressing physiological variables. When bias‐resistance features are implemented, it becomes clear that these patients do not improve in any tested physiological variable. Guidance from studies without careful planning to resist bias may be far less useful than commonly perceived.
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Affiliation(s)
- Richard J Jabbour
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Matthew J Shun-Shin
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Judith A Finegold
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - S M Afzal Sohaib
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Christopher Cook
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Sukhjinder S Nijjer
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Zachary I Whinnett
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Charlotte H Manisty
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Josep Brugada
- Hospital Clinic, University of Barcelona, Barcelona, Spain (J.B.)
| | - Darrel P Francis
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
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10
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Kanzaki H, Satomi K, Noda T, Shimizu W, Kamakura S, Kitaura Y, Ishizaka N, Kitakaze M. Comparison of the acute effects of right ventricular apical pacing and biventricular pacing in patients with heart failure. Intern Med 2015; 54:1329-35. [PMID: 26027982 DOI: 10.2169/internalmedicine.54.3081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Upgrading to biventricular (BiV) pacing benefits heart failure patients with right ventricular (RV) apical pacing. However, the impact of switching from RV apical pacing to BiV pacing on the left ventricular (LV) function accompanied by changes in the QRS duration remains unknown. We aimed to investigate the effects of BiV pacing in heart failure patients under RV apical pacing. METHODS In 37 patients with heart failure (LV ejection fraction: 22±9%), the maximum rate of LV pressure rise (LV dP/dtmax) and time constant of LV relaxation (tau) were determined in order to assess LV contractility and diastolic relaxation, respectively, under RV apical pacing and BiV pacing. Switching from RV pacing to BiV pacing, the QRS duration was shortened from 209±42 to 162±28 ms (p<0.001) and the LV dP/dtmax values were increased in all patients (+18.4±11.3%, p<0.001), whereas the LV tau values varied (-1.5±13.0%, p=0.723). Shortening of the QRS duration correlated with the increase in LV dP/dtmax (r=-0.689, p<0.001); however, it was not closely associated with the changes in LV tau. CONCLUSION Switching from RV apical pacing to BiV pacing improves the LV contractile function in proportion to the degree of QRS shortening. BiV pacing is recommended in patients with systolic heart failure and a prolonged RV-paced QRS duration.
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Affiliation(s)
- Hideaki Kanzaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
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11
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Atta S, Bashandy M, Zaky S. Baseline QRS width and mitral regurgitation behavior after cardiac resynchronization therapy among patients with dilated cardiomyopathy. Egypt Heart J 2014. [DOI: 10.1016/j.ehj.2013.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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12
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Shah RM, Patel D, Molnar J, Ellenbogen KA, Koneru JN. Cardiac-resynchronization therapy in patients with systolic heart failure and QRS interval <=130 ms: insights from a meta-analysis. Europace 2014; 17:267-73. [DOI: 10.1093/europace/euu214] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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13
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Kutyifa V, Stockburger M, Daubert JP, Holmqvist F, Olshansky B, Schuger C, Klein H, Goldenberg I, Brenyo A, McNitt S, Merkely B, Zareba W, Moss AJ. PR Interval Identifies Clinical Response in Patients With Non–Left Bundle Branch Block. Circ Arrhythm Electrophysiol 2014; 7:645-51. [DOI: 10.1161/circep.113.001299] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
In Multicenter Automatic Defibrillator Implantation Trial–Cardiac Resynchronization Therapy (MADIT-CRT), patients with non–left bundle branch block (LBBB; including right bundle branch block, intraventricular conduction delay) did not have clinical benefit from cardiac resynchronization therapy with defibrillator (CRT-D). We hypothesized that baseline PR interval modulates clinical response to CRT-D therapy in patients with non-LBBB.
Methods and Results—
Non-LBBB patients (n=537; 30%) were divided into 2 groups based on their baseline PR interval as normal (including minimally prolonged) PR (PR <230 ms) and prolonged PR (PR ≥230 ms). The primary end point was heart failure or death. Separate secondary end points included heart failure events and all-cause mortality. Cox proportional hazards regression models were used to compare risk of end point events by CRT-D to implantable cardioverter defibrillator therapy in the PR subgroups. There were 96 patients (22%) with a prolonged PR and 438 patients (78%) with a normal PR interval. In non-LBBB patients with a prolonged PR interval, CRT-D treatment was associated with a 73% reduction in the risk of heart failure/death (hazard ratio, 0.27; 95% confidence interval, 0.13–0.57;
P
<0.001) and 81% decrease in the risk of all-cause mortality (hazard ratio, 0.19; 95% confidence interval, 0.13–0.57;
P
<0.001) compared with implantable cardioverter defibrillator therapy. In non-LBBB patients with normal PR, CRT-D therapy was associated with a trend toward an increased risk of heart failure/death (hazard ratio, 1.45; 95% confidence interval, 0.96–2.19;
P
=0.078; interaction
P
<0.001) and a more than 2-fold higher mortality (hazard ratio, 2.14; 95% confidence interval, 1.12–4.09;
P
=0.022; interaction
P
<0.001) compared with implantable cardioverter defibrillator therapy.
Conclusions—
The data support the use of CRT-D in MADIT-CRT non-LBBB patients with a prolonged PR interval. In non-LBBB patients with a normal PR interval, implantation of a CRT-D may be deleterious.
Clinical Trial Registration—
http://clinicaltrials.gov
; Unique Identifier: NCT00180271.
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Affiliation(s)
- Valentina Kutyifa
- From the University of Rochester Medical Center, NY (V.K., H.K., I.G., A.B., S.M., W.Z., A.J.M.); Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (M.S.); Cardiology Department, Duke University, Durham, NC (J.P.D., F.H.); Department of Medicine, University of Iowa Health Care (B.O.); Henry Ford Hospital, Detroit, MI (C.S.); and Semmelweis University, Heart Center, Budapest, Hungary
| | - Martin Stockburger
- From the University of Rochester Medical Center, NY (V.K., H.K., I.G., A.B., S.M., W.Z., A.J.M.); Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (M.S.); Cardiology Department, Duke University, Durham, NC (J.P.D., F.H.); Department of Medicine, University of Iowa Health Care (B.O.); Henry Ford Hospital, Detroit, MI (C.S.); and Semmelweis University, Heart Center, Budapest, Hungary
| | - James P. Daubert
- From the University of Rochester Medical Center, NY (V.K., H.K., I.G., A.B., S.M., W.Z., A.J.M.); Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (M.S.); Cardiology Department, Duke University, Durham, NC (J.P.D., F.H.); Department of Medicine, University of Iowa Health Care (B.O.); Henry Ford Hospital, Detroit, MI (C.S.); and Semmelweis University, Heart Center, Budapest, Hungary
| | - Fredrik Holmqvist
- From the University of Rochester Medical Center, NY (V.K., H.K., I.G., A.B., S.M., W.Z., A.J.M.); Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (M.S.); Cardiology Department, Duke University, Durham, NC (J.P.D., F.H.); Department of Medicine, University of Iowa Health Care (B.O.); Henry Ford Hospital, Detroit, MI (C.S.); and Semmelweis University, Heart Center, Budapest, Hungary
| | - Brian Olshansky
- From the University of Rochester Medical Center, NY (V.K., H.K., I.G., A.B., S.M., W.Z., A.J.M.); Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (M.S.); Cardiology Department, Duke University, Durham, NC (J.P.D., F.H.); Department of Medicine, University of Iowa Health Care (B.O.); Henry Ford Hospital, Detroit, MI (C.S.); and Semmelweis University, Heart Center, Budapest, Hungary
| | - Claudio Schuger
- From the University of Rochester Medical Center, NY (V.K., H.K., I.G., A.B., S.M., W.Z., A.J.M.); Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (M.S.); Cardiology Department, Duke University, Durham, NC (J.P.D., F.H.); Department of Medicine, University of Iowa Health Care (B.O.); Henry Ford Hospital, Detroit, MI (C.S.); and Semmelweis University, Heart Center, Budapest, Hungary
| | - Helmut Klein
- From the University of Rochester Medical Center, NY (V.K., H.K., I.G., A.B., S.M., W.Z., A.J.M.); Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (M.S.); Cardiology Department, Duke University, Durham, NC (J.P.D., F.H.); Department of Medicine, University of Iowa Health Care (B.O.); Henry Ford Hospital, Detroit, MI (C.S.); and Semmelweis University, Heart Center, Budapest, Hungary
| | - Ilan Goldenberg
- From the University of Rochester Medical Center, NY (V.K., H.K., I.G., A.B., S.M., W.Z., A.J.M.); Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (M.S.); Cardiology Department, Duke University, Durham, NC (J.P.D., F.H.); Department of Medicine, University of Iowa Health Care (B.O.); Henry Ford Hospital, Detroit, MI (C.S.); and Semmelweis University, Heart Center, Budapest, Hungary
| | - Andrew Brenyo
- From the University of Rochester Medical Center, NY (V.K., H.K., I.G., A.B., S.M., W.Z., A.J.M.); Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (M.S.); Cardiology Department, Duke University, Durham, NC (J.P.D., F.H.); Department of Medicine, University of Iowa Health Care (B.O.); Henry Ford Hospital, Detroit, MI (C.S.); and Semmelweis University, Heart Center, Budapest, Hungary
| | - Scott McNitt
- From the University of Rochester Medical Center, NY (V.K., H.K., I.G., A.B., S.M., W.Z., A.J.M.); Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (M.S.); Cardiology Department, Duke University, Durham, NC (J.P.D., F.H.); Department of Medicine, University of Iowa Health Care (B.O.); Henry Ford Hospital, Detroit, MI (C.S.); and Semmelweis University, Heart Center, Budapest, Hungary
| | - Bela Merkely
- From the University of Rochester Medical Center, NY (V.K., H.K., I.G., A.B., S.M., W.Z., A.J.M.); Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (M.S.); Cardiology Department, Duke University, Durham, NC (J.P.D., F.H.); Department of Medicine, University of Iowa Health Care (B.O.); Henry Ford Hospital, Detroit, MI (C.S.); and Semmelweis University, Heart Center, Budapest, Hungary
| | - Wojciech Zareba
- From the University of Rochester Medical Center, NY (V.K., H.K., I.G., A.B., S.M., W.Z., A.J.M.); Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (M.S.); Cardiology Department, Duke University, Durham, NC (J.P.D., F.H.); Department of Medicine, University of Iowa Health Care (B.O.); Henry Ford Hospital, Detroit, MI (C.S.); and Semmelweis University, Heart Center, Budapest, Hungary
| | - Arthur J. Moss
- From the University of Rochester Medical Center, NY (V.K., H.K., I.G., A.B., S.M., W.Z., A.J.M.); Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (M.S.); Cardiology Department, Duke University, Durham, NC (J.P.D., F.H.); Department of Medicine, University of Iowa Health Care (B.O.); Henry Ford Hospital, Detroit, MI (C.S.); and Semmelweis University, Heart Center, Budapest, Hungary
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Affiliation(s)
- Frits W. Prinzen
- From the Departments of Physiology (F.W.P.) and Cardiology (K.V.), Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands; and the Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland (A.A.)
| | - Kevin Vernooy
- From the Departments of Physiology (F.W.P.) and Cardiology (K.V.), Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands; and the Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland (A.A.)
| | - Angelo Auricchio
- From the Departments of Physiology (F.W.P.) and Cardiology (K.V.), Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands; and the Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland (A.A.)
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15
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Ruschitzka F, Abraham WT, Singh JP, Bax JJ, Borer JS, Brugada J, Dickstein K, Ford I, Gorcsan J, Gras D, Krum H, Sogaard P, Holzmeister J. Cardiac-resynchronization therapy in heart failure with a narrow QRS complex. N Engl J Med 2013; 369:1395-405. [PMID: 23998714 DOI: 10.1056/nejmoa1306687] [Citation(s) in RCA: 585] [Impact Index Per Article: 53.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Cardiac-resynchronization therapy (CRT) reduces morbidity and mortality in chronic systolic heart failure with a wide QRS complex. Mechanical dyssynchrony also occurs in patients with a narrow QRS complex, which suggests the potential usefulness of CRT in such patients. METHODS We conducted a randomized trial involving 115 centers to evaluate the effect of CRT in patients with New York Heart Association class III or IV heart failure, a left ventricular ejection fraction of 35% or less, a QRS duration of less than 130 msec, and echocardiographic evidence of left ventricular dyssynchrony. All patients underwent device implantation and were randomly assigned to have CRT capability turned on or off. The primary efficacy outcome was the composite of death from any cause or first hospitalization for worsening heart failure. RESULTS On March 13, 2013, the study was stopped for futility on the recommendation of the data and safety monitoring board. At study closure, the 809 patients who had undergone randomization had been followed for a mean of 19.4 months. The primary outcome occurred in 116 of 404 patients in the CRT group, as compared with 102 of 405 in the control group (28.7% vs. 25.2%; hazard ratio, 1.20; 95% confidence interval [CI], 0.92 to 1.57; P=0.15). There were 45 deaths in the CRT group and 26 in the control group (11.1% vs. 6.4%; hazard ratio, 1.81; 95% CI, 1.11 to 2.93; P=0.02). CONCLUSIONS In patients with systolic heart failure and a QRS duration of less than 130 msec, CRT does not reduce the rate of death or hospitalization for heart failure and may increase mortality. (Funded by Biotronik and GE Healthcare; EchoCRT ClinicalTrials.gov number, NCT00683696.).
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Affiliation(s)
- Frank Ruschitzka
- Clinic for Cardiology, University Hospital Zurich, Zurich, Switzerland
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16
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Thibault B, Harel F, Ducharme A, White M, Ellenbogen KA, Frasure-Smith N, Roy D, Philippon F, Dorian P, Talajic M, Dubuc M, Guerra PG, Macle L, Rivard L, Andrade J, Khairy P. Cardiac Resynchronization Therapy in Patients With Heart Failure and a QRS Complex <120 Milliseconds. Circulation 2013; 127:873-81. [PMID: 23388213 DOI: 10.1161/circulationaha.112.001239] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background—
Although the benefits of cardiac resynchronization therapy are well established in selected patients with heart failure and a prolonged QRS duration, salutary effects in patients with narrow QRS complexes remain to be demonstrated.
Methods and Results—
The Evaluation of Resynchronization Therapy for Heart Failure (LESSER-EARTH) trial is a randomized, double-blind, 12-center study that was designed to compare the effects of active and inactive cardiac resynchronization therapy in patients with severe left ventricular dysfunction and a QRS duration <120 milliseconds. The trial was interrupted prematurely by the Data Safety and Monitoring Board because of futility and safety concerns after 85 patients were randomized. Changes in exercise duration after 12 months were no different in patients with and without active cardiac resynchronization therapy (−0.7 minutes [95% confidence interval (CI), −2.9 to 1.5] versus 0.8 minutes [95% CI, −1.2 to 2.9];
P
=0.31]. Similarly, no significant differences were observed in left ventricular end-systolic volumes (−6.4 mL [95% CI, −18.8 to 5.9] versus 3.1 mL [95% CI, −9.2 to 15.5];
P
=0.28) and ejection fraction (3.3% [95% CI, 0.7–6.0] versus 2.1% [95% CI, −0.5 to 4.8];
P
=0.52). Moreover, cardiac resynchronization therapy was associated with a significant reduction in the 6-minute walk distance (−11.3 m [95% CI, −31.7 to 9.7] versus 25.3 m [95% CI, 6.1–44.5];
P
=0.01), an increase in QRS duration (40.2 milliseconds [95% CI, 34.2–46.2] versus 3.4 milliseconds [95% CI, 0.6–6.2];
P
<0.0001), and a nonsignificant trend toward an increase in heart failure–related hospitalizations (15 hospitalizations in 5 patients versus 4 hospitalizations in 4 patients).
Conclusions—
In patients with a left ventricular ejection fraction ≤35%, symptoms of heart failure, and a QRS duration <120 milliseconds, cardiac resynchronization therapy did not improve clinical outcomes or left ventricular remodeling and was associated with potential harm.
Clinical Trial Registration
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00900549.
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Affiliation(s)
- Bernard Thibault
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - François Harel
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Anique Ducharme
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Michel White
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Kenneth A. Ellenbogen
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Nancy Frasure-Smith
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Denis Roy
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - François Philippon
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Paul Dorian
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Mario Talajic
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Marc Dubuc
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Peter G. Guerra
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Laurent Macle
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Léna Rivard
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Jason Andrade
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Paul Khairy
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
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17
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Gorcsan J, Prinzen FW. Understanding the cardiac substrate and the underlying physiology: Implications for individualized treatment algorithm. Heart Rhythm 2012; 9:S18-26. [PMID: 22521936 DOI: 10.1016/j.hrthm.2012.04.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Indexed: 11/27/2022]
Affiliation(s)
- John Gorcsan
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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