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Lavanya K, Mgbemena ON, Keim SG. Atrio-Ventricular Dyssynchrony After Cardiac Resynchronization Therapy: An Unusual Contributor to Heart Failure Symptoms. Cureus 2023; 15:e35661. [PMID: 37012950 PMCID: PMC10065866 DOI: 10.7759/cureus.35661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 03/01/2023] [Indexed: 03/05/2023] Open
Abstract
Cardiac resynchronization therapy (CRT) is the mainstay for the management of systolic heart failure with LVEF <35% and evidence of dyssynchrony despite optimal medical therapy. After CRT placement, persistent dyssynchronization is possible and can contribute to heart failure symptoms despite a well-functioning CRT device. Echo-guided imaging can be beneficial for the optimization of CRT in selected patients who have evidence of continued dyssynchrony despite a well-functioning CRT device.
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2
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Galli E, Baritussio A, Sitges M, Donnellan E, Jaber WA, Gimelli A. Multi-modality imaging to guide the implantation of cardiac electronic devices in heart failure: is the sum greater than the individual components? Eur Heart J Cardiovasc Imaging 2023; 24:163-176. [PMID: 36458875 DOI: 10.1093/ehjci/jeac237] [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: 07/22/2022] [Accepted: 11/03/2022] [Indexed: 12/05/2022] Open
Abstract
Heart failure is a clinical syndrome with an increasing prevalence and incidence worldwide that impacts patients' quality of life, morbidity, and mortality. Implantable cardioverter-defibrillator and cardiac resynchronization therapy are pillars of managing patients with HF and reduced left ventricular ejection fraction. Despite the advances in cardiac imaging, the assessment of patients needing cardiac implantable electronic devices relies essentially on the measure of left ventricular ejection fraction. However, multi-modality imaging can provide important information concerning the aetiology of heart failure, the extent and localization of myocardial scar, and the pathophysiological mechanisms of left ventricular conduction delay. This paper aims to highlight the main novelties and progress in the field of multi-modality imaging to identify patients who will benefit from cardiac resynchronization therapy and/or implantable cardioverter-defibrillator. We also want to underscore the boundaries that prevent the application of imaging-derived parameters to patients who will benefit from cardiac implantable electronic devices and orient the choice of the device. Finally, we aim at providing some reflections for future research in this field.
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Affiliation(s)
- Elena Galli
- Department of Cardiology, University Hospital of Rennes, 35000 Rue Henri Le Guilloux, Rennes, France
| | - Anna Baritussio
- Cardiology, Department of Cardiac, Vascular, Thoracic Sciences and Public Health, University Hospital of Padua, 35121 Via Nicolò Giustiniani, Padua, Italy
| | - Marta Sitges
- Cardiovascular Institute, Hospital Clínic, Universitat de Barcelona, 08036 C. de Villarroel, Barcelona, Spain
| | - Eoin Donnellan
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Wael A Jaber
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Alessia Gimelli
- Fondazione Toscana G. Monasterio, 56124 Via Giuseppe Moruzzi, Pisa, Italy
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3
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Fudim M, Dalgaard F, Fathallah M, Iskandrian AE, Borges-Neto S. Mechanical dyssynchrony: How do we measure it, what it means, and what we can do about it. J Nucl Cardiol 2021; 28:2174-2184. [PMID: 31144228 DOI: 10.1007/s12350-019-01758-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 05/15/2019] [Indexed: 01/14/2023]
Abstract
Left ventricular mechanical dyssynchrony (LVMD) is defined by a difference in the timing of mechanical contraction or relaxation between different segments of the left ventricle (LV). Mechanical dyssynchrony is distinct from electrical dyssynchrony as measured by QRS duration and has been of increasing interest due to its association with worse prognosis and potential role in patient selection for cardiac resynchronization therapy (CRT). Although echocardiography is the most used modality to assess LVMD, some limitations apply to this modality. Compared to echo-based modalities, nuclear imaging by gated single-photon emission computed tomography (GSPECT) myocardial perfusion imaging (MPI) has clear advantages in evaluating systolic and diastolic LVMD. GSPECT MPI can determine systolic and diastolic mechanical dyssynchrony by the variability in the timing in which different LV segments contract or relax, which has prognostic impact in patients with coronary artery disease and heart failure. As such, by targeting mechanical dyssynchrony instead of electrical dyssynchrony, GSPECT MPI can potentially improve patient selection for CRT. So far, few studies have investigated the role of diastolic dyssynchrony, but recent evidence seems to suggest high prevalence and more prognostic impact than previously recognized. In the present review, we provide an oversight of mechanical dyssynchrony.
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Affiliation(s)
- Marat Fudim
- Duke University Medical Center, Duke University, 2301 Erwin Road, Durham, NC, 27710, USA.
- Duke Clinical Research Institute, Durham, NC, USA.
| | - Frederik Dalgaard
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Cardiology, Herlev & Gentofte Hospital, Copenhagen, Denmark
| | | | - Ami E Iskandrian
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Salvator Borges-Neto
- Duke University Medical Center, Duke University, 2301 Erwin Road, Durham, NC, 27710, USA
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4
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Kheiri B, Przybylowicz R, Simpson TF, Merrill M, Osman M, Dalouk K, Rahmouni H, Stecker E, Nazer B, Henrikson CA. Imaging-guided cardiac resynchronization therapy: A meta-analysis of randomized controlled trials. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1570-1576. [PMID: 34255376 DOI: 10.1111/pace.14316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/07/2021] [Accepted: 07/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Among patients with heart failure and left ventricular (LV) dysfunction despite guideline directed medical therapy, cardiac resynchronization (CRT) is an effective technology to reverse LV remodeling. Given that a large portion of patients are non-responders, alternatives to traditional LV-lead placement have been explored. A promising alternative is image targeted placement of an LV-lead to latest mechanically activated segment without scar. METHODS Electronic database search for randomized controlled trials (RCTs) that evaluated the imaging-guided LV-lead placement on clinical, echocardiographic, and functional outcomes. The primary outcome was a composite of mortality and heart failure hospitalization. The secondary outcomes included CRT responders, New York Heart Association (NYHA), 6-minute walk test, Minnesota Living with Heart Failure Questionnaire (MLHFQ), and ejection fraction (EF) changes. RESULTS Analysis included 4 RCTs of 691 patients with an average follow-up of 2 years (age 69.5 ± 10.3 years, 76% males, 54% ischemic cardiomyopathy, 81% with NYHA classes III/IV, and EF of 24.4% ± 8). The most common site for LV-lead paced segment was the anterolateral segment (45%) and at mid-LV (49%). Compared with the control, imaging-guided LV-lead placement was associated with a significant reduction of the primary outcome (hazard ratio [HR] = 0.60; 95% CI = 0.40-0.88; p = .01), higher CRT responders (odd ratio [OR] = 2.10; p < .01), more NYHA improvements by ≥1 (OR = 1.89; p = .01), increased 6MWT (mean difference [MD] = 25.78 feet; p < .01), and lower MLHFQ (MD = -4.04; p = .04), without significant differences in the LVEF (p = .08). CONCLUSIONS In patients undergoing CRT, imaging-guided LV-lead placement was associated with improved clinical, echocardiographic, and functional status.
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Affiliation(s)
- Babikir Kheiri
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Ryle Przybylowicz
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Timothy F Simpson
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Miranda Merrill
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Mohammed Osman
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA.,Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Khidir Dalouk
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Hind Rahmouni
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Eric Stecker
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Babak Nazer
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Charles A Henrikson
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
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5
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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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Keiler J, Meinel FG, Ortak J, Weber MA, Wree A, Streckenbach F. Morphometric Characterization of Human Coronary Veins and Subvenous Epicardial Adipose Tissue-Implications for Cardiac Resynchronization Therapy Leads. Front Cardiovasc Med 2021; 7:611160. [PMID: 33426007 PMCID: PMC7793918 DOI: 10.3389/fcvm.2020.611160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 11/16/2020] [Indexed: 11/13/2022] Open
Abstract
Subvenous epicardial fat tissue (SEAT), which acts as an electrical insulation, and the venous diameter (VD) both constitute histomorphological challenges for optimal application and lead design in cardiac synchronization therapy (CRT). In this study, we characterized the morphology of human coronary veins to improve the technical design of future CRT systems and to optimize the application of CRT leads. We retrospectively analyzed data from cardiac computed tomography (CT) of 53 patients and did studies of 14 human hearts using the postmortem freeze section technique and micro CT. Morphometric parameters (tributary distances, offspring angles, luminal VD, and SEAT thickness) were assessed. The left posterior ventricular vein (VVSP) had a mean proximal VD of 4.0 ± 1.4 mm, the left marginal vein (VMS) of 3.2 ± 1.5 mm and the anterior interventricular vein (VIA) of 3.9 ± 1.3 mm. More distally (5 cm), VDs decreased to 2.4 ± 0.6 mm, 2.3 ± 0.7 mm, and 2.4 ± 0.6 mm, respectively. In their proximal portions (15 mm), veins possessed mean SEAT thicknesses of 3.2 ± 2.4 (VVSP), 3.4 ± 2.4 mm (VMS), and 4.2 ± 2.8 mm (VIA), respectively. More distally (20-70 mm), mean SEAT thicknesses decreased to alternating low levels of 1.3 ± 1.1 mm (VVSP), 1.7 ± 1.1 mm (VMS), and 4.3 ± 2.6 mm (VIA), respectively. In contrast to the VD, SEAT thicknesses alternated along the further distal vein course and did not display a continuous decrease. Besides the CRT responsiveness of different areas of the LV myocardium, SEAT is a relevant electrophysiological factor in CRT, potentially interfering with sensing and pacing. A sufficient VD is crucial for successful CRT lead placement. Measurements revealed a trend toward greater SEAT thickness for the VIA compared to VVSP and VMS, suggesting a superior signal-to-noise-ratio in VVSP and VMS.
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Affiliation(s)
- Jonas Keiler
- Department of Anatomy, Rostock University Medical Center, Rostock, Germany
| | - Felix G Meinel
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, Rostock, Germany
| | - Jasmin Ortak
- Rhythmology and Clinical Electrophysiology, Divisions of Cardiology, Rostock University Medical Center, Rostock, Germany
| | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, Rostock, Germany
| | - Andreas Wree
- Department of Anatomy, Rostock University Medical Center, Rostock, Germany
| | - Felix Streckenbach
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, Rostock, Germany.,Center for Transdisciplinary Neurosciences Rostock (CTNR), Rostock University Medical Center, Rostock, Germany
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7
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Fudim M, Borges-Neto S. Moving towards a synchronized left ventricle. J Nucl Cardiol 2020; 27:431-433. [PMID: 31087264 DOI: 10.1007/s12350-019-01749-1] [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: 04/15/2019] [Accepted: 04/15/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Marat Fudim
- Department of Medicine, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA.
- Duke Clinical Research Institute, Durham, NC, USA.
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Singh JP, Abraham WT, Auricchio A, Delnoy PP, Gold M, Reddy VY, Sanders P, Lindenfeld J, Rinaldi CA. Design and rationale for the Stimulation Of the Left Ventricular Endocardium for Cardiac Resynchronization Therapy in non-responders and previously untreatable patients (SOLVE-CRT) trial. Am Heart J 2019; 217:13-22. [PMID: 31472360 DOI: 10.1016/j.ahj.2019.04.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/02/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) improves outcomes, functional capacity and quality of life in patients with heart failure. Despite two decades of experience with CRT, the rate of non-response remains approximately 30%. CRT efficacy is impacted by pacing location, which is anatomically limited in conventional systems. A new wireless endocardial left ventricular (LV) pacing system allows CRT without such limitations and has shown promise in open-label studies. The purpose of this study is to evaluate its use in a patient population with poor therapeutic alternatives. METHODS The SOLVE CRT study is an international, multi-center, randomized, double-blind, sham-controlled trial of patients with Class I and IIa indications for CRT who have either failed to respond to or have been unable to receive conventional CRT. Enrollment will comprise 350 patients implanted with the wireless CRT system randomized 1:1 to therapy on (Treatment) or therapy off (Control) for the six-month period over which trial primary endpoints will be evaluated. The primary safety endpoint will measure the proportion of patients free from system- and procedure-related complications. Primary efficacy endpoints will assess absolute change in LV end-systolic volume LVESV, proportion of patients reducing LVESV by ≥15% and clinical composite score for Treatment versus Control patients. Primary endpoints will be evaluated on an intention-to-treat basis, though per-protocol and as-treated analysis will also be performed. CONCLUSION SOLVE-CRT will quantify the safety and effectiveness of wireless CRT in non-responders to conventional CRT and indicated patients who have been unable to receive CRT via the usual transvenous approach.
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9
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Technological and Clinical Challenges in Lead Placement for Cardiac Rhythm Management Devices. Ann Biomed Eng 2019; 48:26-46. [DOI: 10.1007/s10439-019-02376-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 09/25/2019] [Indexed: 01/29/2023]
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10
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Zhou W, Tao N, Hou X, Wang Y, Folks RD, Cooke DC, Moncayo VM, Garcia EV, Zou J. Development and validation of an automatic method to detect the latest contracting viable left ventricular segments to assist guide CRT therapy from gated SPECT myocardial perfusion imaging. J Nucl Cardiol 2018; 25:1948-1957. [PMID: 28353213 PMCID: PMC10981925 DOI: 10.1007/s12350-017-0853-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 03/05/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The purpose of this study is to use ECG-gated SPECT MPI to detect the latest contracting viable left ventricular (LV) segments to help guide the LV probe placement used in CRT therapy and to validate segment selection against the visual integration method by experts. METHODS For each patient, the resting ECG-gated SPECT MPI short-axis images were sampled in 3D to generate a polar map of the perfusion distribution used to determine LV myocardial viability, and to measure LV synchronicity using our phase analysis tool. In the visual integration method, two experts visually interpreted the LV viability and mechanical dyssynchrony from the short-axis images and polar maps of viability and phase, to determine the latest contracting viable segments using the 17-segment model. In the automatic method, the apical segments, septal segments, and segments with more than 50% scar were excluded as these are not candidates for CRT LV probe placement. Amongst the remaining viable segments, the segments, whose phase angles were within 10° of the latest phase angle (the most delayed contracting segment), were identified for potential CRT LV probe placement and ranked based on the phase angles of the segments. Both methods were tested in 36 pre-CRT patients who underwent ECG-gated SPECT MPI. The accuracy was determined as the percent agreement between the visual integration and automatic methods. The automatic method was performed by a second independent operator to evaluate the inter-operator processing reproducibility. RESULTS In all the 36 patients, the LV lead positions of the 1st choices recommended by the automatic and visual integration methods were in the same segments in 35 patients, which achieved an agreement rate of 97.2%. In the inter-operator reproducibility test, the LV lead positions of the 1st choices recommended by the two operators were in the same segments in 25 patients, and were in the adjacent segments in 7 patients, which achieved an overall agreement of 88.8%. CONCLUSIONS An automatic method has been developed to detect the latest contracting viable LV segments to help guide the LV probe placement used in CRT therapy. The retrospective clinical study with 36 patients suggests that this method has high agreement against the visual integration method by experts and good inter-operator reproducibility. Consequently, this method is promising to be a clinical tool to recommend the CRT LV lead positions.
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Affiliation(s)
- Weihua Zhou
- School of Computing, University of Southern Mississippi, Long Beach, MS, USA
| | - Ningchao Tao
- Department of Cardiology, Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Xiaofeng Hou
- Department of Cardiology, Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Yao Wang
- Department of Cardiology, Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Russell D Folks
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, 30032, USA
| | - David C Cooke
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, 30032, USA
| | - Valeria M Moncayo
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, 30032, USA
| | - Ernest V Garcia
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, 30032, USA.
| | - Jiangang Zou
- Department of Cardiology, Nanjing Medical University, Nanjing, 210029, Jiangsu, China.
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11
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Stephansen C, Sommer A, Kronborg MB, Jensen JM, Bouchelouche K, Nielsen JC. Electrically guided versus imaging-guided implant of the left ventricular lead in cardiac resynchronization therapy: a study protocol for a double-blinded randomized controlled clinical trial (ElectroCRT). Trials 2018; 19:600. [PMID: 30382923 PMCID: PMC6211399 DOI: 10.1186/s13063-018-2930-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 09/24/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is an established treatment in patients with heart failure and prolonged QRS duration where a biventricular pacemaker is implanted to achieve faster activation and more synchronous contraction of the left ventricle (LV). Despite the convincing effect of CRT, 30-40% of patients do not respond. Among the most important correctable causes of non-response to CRT is non-optimal LV lead position. METHODS We will enroll 122 patients in this patient-blinded and assessor-blinded, randomized, clinical trial aiming to investigate if implanting the LV lead guided by electrical mapping towards the latest LV activation as compared with imaging-guided implantation, causes an excess increase in left ventricular (LV) ejection fraction (LVEF). The patients are randomly assigned to either the intervention group: preceded by cardiac computed tomography of the cardiac venous anatomy, the LV lead is placed according to the latest LV activation in the coronary sinus (CS) branches identified by systematic electrical mapping of the CS at implantation and post-implant optimization of the interventricular pacing delay; or patients are assigned to the control group: placement of the LV lead guided by cardiac imaging. The LV lead is targeted towards the latest mechanical LV activation as identified by echocardiography and outside myocardial scar as identified by myocardial perfusion (MP) imaging. The primary endpoint is change in LVEF at 6-month follow up (6MFU) as compared with baseline measured by two-dimensional echocardiography. Secondary endpoints include relative percentage reduction in LV end-systolic volume, all-cause mortality, hospitalization for heart failure, and a clinical combined endpoint of response to CRT at 6MFU defined as the patient being alive, not hospitalized for heart failure, and experiencing improvement in NYHA functional class or/and > 10% increase in 6-minute walk test. DISCUSSION We assume an absolute increase in LVEF of 12% in the intervention group versus 8% in the control group. If an excess increase in LVEF can be achieved by LV lead implantation guided by electrical mapping, this study supports the conduct of larger trials investigating the impact of this strategy for LV-lead implantation on clinical outcomes in patients treated with CRT. TRIAL REGISTRATION ClinicalTrials.gov, NCT02346097 . Registered on 12 January 2015. Patients were enrolled between 16 February 2015 and 13 December 2017.
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Affiliation(s)
- Charlotte Stephansen
- Department of Cardiology – Research, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| | - Anders Sommer
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| | - Mads Brix Kronborg
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| | - Jesper Møller Jensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| | - Kirsten Bouchelouche
- Department of Nuclear Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
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13
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Sieniewicz BJ, Gould J, Porter B, Sidhu BS, Behar JM, Claridge S, Niederer S, Rinaldi CA. Optimal site selection and image fusion guidance technology to facilitate cardiac resynchronization therapy. Expert Rev Med Devices 2018; 15:555-570. [PMID: 30019954 PMCID: PMC6178093 DOI: 10.1080/17434440.2018.1502084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/12/2018] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Cardiac resynchronization therapy (CRT) has emerged as one of the few effective treatments for heart failure. However, up to 50% of patients derive no benefit. Suboptimal left ventricle (LV) lead position is a potential cause of poor outcomes while targeted lead deployment has been associated with enhanced response rates. Image-fusion guidance systems represent a novel approach to CRT delivery, allowing physicians to both accurately track and target a specific location during LV lead deployment. AREAS COVERED This review will provide a comprehensive evaluation of how to define the optimal pacing site. We will evaluate the evidence for delivering targeted LV stimulation at sites displaying favorable viability or advantageous mechanical or electrical properties. Finally, we will evaluate several emerging image-fusion guidance systems which aim to facilitate optimal site selection during CRT. EXPERT COMMENTARY Targeted LV lead deployment is associated with reductions in morbidity and mortality. Assessment of tissue characterization and electrical latency are critical and can be achieved in a number of ways. Ultimately, the constraints of coronary sinus anatomy have forced the exploration of novel means of delivering CRT including endocardial pacing which hold promise for the future of CRT delivery.
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Affiliation(s)
- Benjamin J. Sieniewicz
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Justin Gould
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Bradley Porter
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Baldeep S Sidhu
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Jonathan M Behar
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Simon Claridge
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Steve Niederer
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
| | - Christopher A. Rinaldi
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
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14
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Muto C, Solimene F, Russo V, Nigro G, Rago A, Chianese R, Chiariello P, Ciardiello C, Caliendo L. Optimal left ventricular lead placement for cardiac resynchronization therapy in postmyocardial infarction patients. Future Cardiol 2018; 14:215-224. [PMID: 29767542 DOI: 10.2217/fca-2017-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To evaluate at a 12-month follow-up, the clinical and echocardiographic outcomes in postmyocardial infarction (MI) heart failure patients who underwent cardiac resynchronization therapy (CRT) device implantation. MATERIALS & METHODS A total of 100 patients received a CRT device, and the study population was divided into three groups, according to the site of MI and left ventricular (LV) lead placed downstream of the ischemic area, as evaluated by echocardiography. RESULTS At the end of the 12-month follow-up, we reported a general improvement of LV ejection fraction from 28 ± 7% to 35 ± 9% (p < 0.001) and a significant reverse remodeling: LV end-systolic volume changed from 147 ± 54 to 125 ± 63 (p = 0.001) with a 53% of echocardiographic responders. We also observed 67% of CRT responders in the group with optimal LV lead placement compared with 38% in the remaining population (p = 0.01). CONCLUSION The optimal positioning of LV lead is a feasible method to improve the percentage of CRT responders in post-MI heart failure patients.
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Affiliation(s)
- Carmine Muto
- Cardiologia, Ospedale Santa Maria della Pietà, Nola, Napoli, Italy
| | - Francesco Solimene
- Elttrostimolazione ed Elettrofisiologia, Casa Di Cura Montevergine, Mercogliano, Avellino, Italy
| | - Vincenzo Russo
- Chair of Cardiology, Cardiologia, Second University of Naples, Monaldi Hospital - Napoli, Italy
| | - Gerardo Nigro
- Chair of Cardiology, Cardiologia, Second University of Naples, Monaldi Hospital - Napoli, Italy
| | - Anna Rago
- Chair of Cardiology, Cardiologia, Second University of Naples, Monaldi Hospital - Napoli, Italy
| | | | - Paola Chiariello
- Cardiologia, Ospedale Santa Maria dell'Olmo, Cava de'Tirreni, Salerno, Italy
| | | | - Luigi Caliendo
- Cardiologia, Ospedale Santa Maria della Pietà, Nola, Napoli, Italy
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15
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Höke U, Bax JJ, Delgado V, Ajmone Marsan N. Assessment of left ventricular dyssynchrony by three-dimensional echocardiography: Prognostic value in patients undergoing cardiac resynchronization therapy. J Cardiovasc Electrophysiol 2018; 29:780-787. [PMID: 29377419 DOI: 10.1111/jce.13445] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 01/10/2018] [Accepted: 01/22/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Systolic dyssynchrony index (SDI) using three-dimensional echocardiography (3DE) was shown to be a reliable measure of left ventricular (LV) dyssynchrony. However, the prognostic value of SDI on long-term outcomes after cardiac resynchronization therapy (CRT) remains unknown. METHODS AND RESULTS A total of 414 patients (mean age 67 ± 10 years, 60% ischemic etiology) with 3DE evaluation before CRT implantation were included. SDI was evaluated as continuous value and in quartiles. The study endpoint was combined all-cause mortality, heart transplantation, and LV assist device implantation. At baseline, median SDI was 8.0% (IQR 5.6-11.3%). During a median follow-up of 45 months (IQR 25-59 months), the endpoint was observed in 94 (23%) patients. SDI was independently associated with the endpoint together with ischemic etiology, diabetes, and renal function (HR 0.914, P = 0.003) after adjustment for age, atrial fibrillation, hemoglobin level, NYHA functional class, and posterolateral LV lead position. Patients from the 1st, 2nd, and 3rd SDI quartiles showed similar survival and superior as compared to the 4th quartile with the lowest SDI values (≤5.5%; χ²: 30.4, log-rank P < 0.001). From receiver operating characteristic curve analysis, the optimal SDI cut-off value associated with the endpoint was >6.8% (area under the curve 0.634). Finally, a subgroup analysis (293 patients) demonstrated that a more pronounced reduction in SDI immediately after CRT (resynchronization) was independently associated with superior survival (HR 0.461, P = 0.011) after adjustment for prognostic relevant parameters. CONCLUSION SDI is independently associated with long-term prognosis after CRT and might therefore be important to optimize risk-stratification in these patients.
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Affiliation(s)
- Ulas Höke
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands.,Interuniversity Cardiology Institute of The Netherlands, Utrecht, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
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16
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Hesselson AB, Duggal S, Rukavina M, Gallagher PL, Tomassoni GF. Coronary venous angioplasty to facilitate transvenous left ventricular lead placement: A single-center 13-year experience. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:383-388. [PMID: 29435997 DOI: 10.1111/pace.13303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/10/2018] [Accepted: 01/28/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Barriers to successful left ventricular lead placement within the coronary venous anatomy may include focal stenoses, thromboses, phrenic nerve stimulation, vessel tortuosity, small vessel caliber, nonexcitable tissue, and valve presence. A large series describing the utilization of coronary venous angioplasty (CVAP) for relief of these issues is absent in the literature. OBJECTIVE We report our experience on all patients treated with CVAP in a single-center 13-year experience. METHODS Forty-seven patients with CVAP (64% male, mean age 67 ± 12 years) were treated by five different implanting physicians for approved cardiac resynchronization therapy indications. The reason for CVAP was categorized by obstacle (focal occlusion, valve presence, small caliber vessel) and location. The number, type, and size of balloon used, inflation characteristics, complications, and success of lead deployment crossing the point of intervention were all tabulated. RESULTS Seventy-seven percent of patients (36/47) had successful CVAP. The most common reason for intervention was a focal occlusion (24/47; 51%), followed by valve presence (13/47; 28%), and small vessel caliber (10/47; 21%). Focal occlusions were most successfully managed with CVAP (23/24; 96%), followed by small vessel caliber (7/10; 70%) and valve presence (6/13; 46%). The reason for failure was most commonly due to failure to relieve the obstruction (5/11; 45%), thrombosis (3/11; 27.3%), dissection (2/11; 18.2%), and inability to pass the balloon through the occlusion (1/11; 9.0%). There were no significant complications developed from CVAP utilization. CONCLUSION In a large analysis, CVAP can be safely and successfully performed in the majority of instances required.
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Affiliation(s)
- Aaron B Hesselson
- Department of Cardiac Electrophysiology, Baptist Health Lexington, Lexington, KY, USA
| | - Sandeep Duggal
- Department of Cardiac Electrophysiology, Baptist Health Lexington, Lexington, KY, USA
| | - Michael Rukavina
- Department of Cardiac Electrophysiology, Baptist Health Lexington, Lexington, KY, USA
| | - Peter L Gallagher
- Department of Cardiac Electrophysiology, Baptist Health Lexington, Lexington, KY, USA
| | - Gery F Tomassoni
- Department of Cardiac Electrophysiology, Baptist Health Lexington, Lexington, KY, USA
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17
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Papageorgiou N, Providência R, Lambiase PD, Tousoulis D, Lloyd G, Bhattacharyya S. Does presence of left ventricular contractile reserve improve response to cardiac resynchronization therapy? An updated meta-analysis. Int J Cardiol 2018; 252:224-228. [DOI: 10.1016/j.ijcard.2017.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 07/26/2017] [Accepted: 09/12/2017] [Indexed: 10/18/2022]
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18
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Mountney P, Behar JM, Toth D, Panayiotou M, Reiml S, Jolly MP, Karim R, Zhang L, Brost A, Rinaldi CA, Rhode K. A Planning and Guidance Platform for Cardiac Resynchronization Therapy. IEEE TRANSACTIONS ON MEDICAL IMAGING 2017; 36:2366-2375. [PMID: 28678701 DOI: 10.1109/tmi.2017.2720158] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Patients with drug-refractory heart failure can greatly benefit from cardiac resynchronization therapy (CRT). A CRT device can resynchronize the contractions of the left ventricle (LV) leading to reduced mortality. Unfortunately, 30%-50% of patients do not respond to treatment when assessed by objective criteria such as cardiac remodeling. A significant contributing factor is the suboptimal placement of the LV lead. It has been shown that placing this lead away from scar and at the point of latest mechanical activation can improve response rates. This paper presents a comprehensive and highly automated system that uses scar and mechanical activation to plan and guide CRT procedures. Standard clinical preoperative magnetic resonance imaging is used to extract scar and mechanical activation information. The data are registered to a single 3-D coordinate system and visualized in novel 2-D and 3-D American Heart Association plots enabling the clinician to select target segments. During the procedure, the planning information is overlaid onto live fluoroscopic images to guide lead deployment. The proposed platform has been used during 14 CRT procedures and validated on synthetic, phantom, volunteer, and patient data.
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19
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Dressler FF, Bodi I, Menza M, Moss R, Bugger H, Bode C, Behrends JC, Seemann G, Odening KE. Interregional electro-mechanical heterogeneity in the rabbit myocardium. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 2017; 130:344-355. [PMID: 28655649 DOI: 10.1016/j.pbiomolbio.2017.06.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 06/21/2017] [Accepted: 06/22/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Increased electrical heterogeneity has been causatively linked to arrhythmic disorders, yet the knowledge about physiological heterogeneity remains incomplete. This study investigates regional electro-mechanical heterogeneities in rabbits, one of the key animal models for arrhythmic disorders. METHODS AND FINDINGS 7 wild-type rabbits were examined by phase-contrast magnetic resonance imaging in vivo to assess cardiac wall movement velocities. Using a novel data-processing algorithm regional contraction-like profiles were calculated. Contraction started earlier and was longer in left ventricular (LV) apex than base. Patch clamp recordings showed longer action potentials (AP) in LV apex compared to the base of LV, septum, and right ventricle. Western blots of cardiac ion channels and calcium handling proteins showed lower expression of Cav1.2, KvLQT1, Kv1.4, NCX and Phospholamban in LV apex vs. base. A single-cell in silico model integrating the quantitative regional differences in ion channels reproduced a longer contraction and longer AP in apex vs. base. CONCLUSIONS Apico-basal electro-mechanical heterogeneity is physiologically present in the healthy rabbit heart. An apico-basal electro-mechanical gradient exists with longer APD and contraction duration in the apex and associated regionally heterogeneous expression of five key proteins. This pattern of apical mechanical dominance probably serves to increase pumping efficiency.
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Affiliation(s)
- Franz F Dressler
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany; Faculty of Medicine, University of Freiburg, Breisacher Strasse 153, 79110 Freiburg, Germany
| | - Ilona Bodi
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany; Faculty of Medicine, University of Freiburg, Breisacher Strasse 153, 79110 Freiburg, Germany
| | - Marius Menza
- Faculty of Medicine, University of Freiburg, Breisacher Strasse 153, 79110 Freiburg, Germany; Department of Medical Physics, Medical Center - University of Freiburg, Breisacher Straße 60a, 79106 Freiburg, Germany
| | - Robin Moss
- Faculty of Medicine, University of Freiburg, Breisacher Strasse 153, 79110 Freiburg, Germany; Institute of Biomedical Engineering, Karlsruhe Institute of Technology, Kaiserstrasse 12, 76128 Karlsruhe, Germany; Institute for Experimental Cardiovascular Medicine, Heart Center University of Freiburg, Medical Center - University of Freiburg, Elsaesserstrasse 2q, 79110 Freiburg, Germany
| | - Heiko Bugger
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany; Faculty of Medicine, University of Freiburg, Breisacher Strasse 153, 79110 Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany; Faculty of Medicine, University of Freiburg, Breisacher Strasse 153, 79110 Freiburg, Germany
| | - Jan C Behrends
- Faculty of Medicine, University of Freiburg, Breisacher Strasse 153, 79110 Freiburg, Germany; Department of Physiology, Laboratory for Membrane Physiology and -Technology, University of Freiburg, Hermann-Herder-Strasse 7, 79104 Freiburg, Germany
| | - Gunnar Seemann
- Faculty of Medicine, University of Freiburg, Breisacher Strasse 153, 79110 Freiburg, Germany; Institute of Biomedical Engineering, Karlsruhe Institute of Technology, Kaiserstrasse 12, 76128 Karlsruhe, Germany; Institute for Experimental Cardiovascular Medicine, Heart Center University of Freiburg, Medical Center - University of Freiburg, Elsaesserstrasse 2q, 79110 Freiburg, Germany
| | - Katja E Odening
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany; Faculty of Medicine, University of Freiburg, Breisacher Strasse 153, 79110 Freiburg, Germany; Institute for Experimental Cardiovascular Medicine, Heart Center University of Freiburg, Medical Center - University of Freiburg, Elsaesserstrasse 2q, 79110 Freiburg, Germany.
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20
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Abstract
Randomized, controlled trials have shown that cardiac resynchronization therapy (CRT) is beneficial in patients with heart failure, impaired left ventricular (LV) systolic function, and a wide QRS complex. Other studies have shown that targeting the LV pacing site can also improve patient outcomes. Cardiovascular magnetic resonance (CMR) is a radiation-free imaging modality that provides unparalleled spatial resolution. In addition, emerging data suggest that targeted LV lead deployment over viable myocardium improves the outcome of patients undergoing CRT. This review explores the role of CMR in the preoperative workup of patients undergoing CRT.
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21
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Tang H, Tang S, Zhou W. A Review of Image-guided Approaches for Cardiac Resynchronisation Therapy. Arrhythm Electrophysiol Rev 2017; 6:69-74. [PMID: 28845234 DOI: 10.15420/aer.2016.32.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cardiac resynchronisation therapy (CRT) is a standard treatment for patients with heart failure; however, the low response rate significantly reduces its cost-effectiveness. A favourable CRT response primarily depends on whether implanters can identify the optimal left ventricular (LV) lead position and accurately place the lead at the recommended site. Myocardial imaging techniques, including echocardiography, cardiac magnetic resonance imaging and nuclear imaging, have been used to assess LV myocardial viability and mechanical dyssynchrony, and deduce the optimal LV lead position. The optimal position, presented as a segment of the myocardial wall, is then overlaid with images of the coronary veins from fluoroscopy to aid navigation of the LV lead to the target venous site. Once validated by large clinical trials, these image-guided techniques for CRT lead placement may have an impact on current clinical practice.
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Affiliation(s)
- Haipeng Tang
- School of Computing, University of Southern Mississippi, Long Beach, MS, USA
| | - Shaojie Tang
- School of Automation, Xi'an University of Posts and Telecommunications, Xi'an, Shaanxi, China
| | - Weihua Zhou
- School of Computing, University of Southern Mississippi, Long Beach, MS, USA
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22
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Soto Iglesias D, Duchateau N, Kostantyn Butakov CB, Andreu D, Fernandez-Armenta J, Bijnens B, Berruezo A, Sitges M, Camara O. Quantitative Analysis of Electro-Anatomical Maps: Application to an Experimental Model of Left Bundle Branch Block/Cardiac Resynchronization Therapy. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE-JTEHM 2016; 5:1900215. [PMID: 29164019 PMCID: PMC5477765 DOI: 10.1109/jtehm.2016.2634006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 08/08/2016] [Accepted: 11/14/2016] [Indexed: 01/02/2023]
Abstract
Electro-anatomical maps (EAMs) are commonly acquired in clinical routine for guiding
ablation therapies. They provide voltage and activation time information on a 3-D
anatomical mesh representation, making them useful for analyzing the electrical
activation patterns in specific pathologies. However, the variability between the
different acquisitions and anatomies hampers the comparison between different maps.
This paper presents two contributions for the analysis of electrical patterns in EAM
data from biventricular surfaces of cardiac chambers. The first contribution is an
integrated automatic 2-D disk representation (2-D bull’s eye plot) of the left
ventricle (LV) and right ventricle (RV) obtained with a quasi-conformal mapping from
the 3-D EAM meshes, that allows an analysis of cardiac resynchronization therapy
(CRT) lead positioning, interpretation of global (total activation time), and local
indices (local activation time (LAT), surrogates of conduction velocity,
inter-ventricular, and transmural delays) that characterize changes in the electrical
activation pattern. The second contribution is a set of indices derived from the
electrical activation: speed maps, computed from LAT values, to study the electrical
wave propagation, and histograms of isochrones to analyze regional electrical
heterogeneities in the ventricles. We have applied the proposed methods to look for
the underlying physiological mechanisms of left bundle branch block (LBBB) and CRT,
with the goal of optimizing the therapy by improving CRT response. To better
illustrate the benefits of the proposed tools, we created a set of synthetically
generated and fully controlled activation patterns, where the proposed representation
and indices were validated. Then, the proposed analysis tools are used to analyze EAM
data from an experimental swine model of induced LBBB with an implanted CRT device.
We have analyzed and compared the electrical activation patterns at baseline, LBBB,
and CRT stages in four animals: two without any structural disease and two with an
induced infarction. By relating the CRT lead location with electrical dyssynchrony,
we evaluated current hypotheses about lead placement in CRT and showed that optimal
pacing sites should target the RV lead close to the apex and the LV one distant from
it.
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Affiliation(s)
- David Soto Iglesias
- PhySense, Information and Communication Technologies DepartmentUniversitat Pompeu Fabra.,Cardiology DepartmentThorax Institute, Hospital Clinic
| | | | | | - David Andreu
- Cardiology DepartmentThorax Institute, Hospital Clinic
| | | | - Bart Bijnens
- PhySense, Information and Communication Technologies DepartmentUniversitat Pompeu Fabra.,Catalan Institution for Research and Advanced Studies
| | | | - Marta Sitges
- Cardiology DepartmentThorax Institute, Hospital Clinic
| | - Oscar Camara
- PhySense, Information and Communication Technologies DepartmentUniversitat Pompeu Fabra
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23
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Matthaios I, Kaladaridou A, Skaltsiotes E, Agrios J, Antoniou A, Georgiopoulos G, Papadopoulou E, Pamboucas C, Toumanidis S. Acute Haemodynamic and Echocardiographic Effects of Multiple Configurations of Left Ventricular Pacing Sites in Acute Myocardial Infarction: Experimental Study. Heart Lung Circ 2016; 26:383-394. [PMID: 27670586 DOI: 10.1016/j.hlc.2016.07.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 07/25/2016] [Accepted: 07/29/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Left ventricular (LV) pacing is unsuccessful in a significant number of patients, mainly due to sub-optimal LV pacing location. Nevertheless, data about the impact of different pacing sites on LV function in ischaemic myocardium are scarce. The purpose of this study was to investigate the effect of combinations of alternative LV pacing sites on LV mechanics after experimental acute anterior myocardial infarction (AMI), in order to define the optimal configuration. METHODS Atrioventricular epicardial pacing at alternative pacing sites was performed in 16 healthy pigs simultaneously, after experimental AMI. Standard right ventricular (RV) apical pacing was combined with: i) LV apex lateral wall; ii) LV basal posterior wall; iii) LV basal anterior wall, and; iv) LV basal anterior wall + LV basal posterior wall. Moreover the pacing configurations of, v) LV basal posterior wall + LV apex lateral wall; vi) LV basal posterior wall + LV basal anterior wall, and; vii) LV basal anterior wall + LV apex lateral wall were also investigated. Haemodynamic parameters, together with classic and novel echocardiographic indices were used, to evaluate the effect of each pacing combination. A speckle tracking technique using EchoPAC software was used. RESULTS After AMI, the pacing combination of LV apex lateral wall and LV basal posterior wall had the most favourable effect on LV function, leading to similar haemodynamic and torsional effects with sinus rhythm (all variables p>0.05). CONCLUSIONS In pig hearts after AMI, the combination of pacing LV apex lateral wall and LV basal posterior wall managed to maintain the LV function at a level comparable to the sinus rhythm.
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Affiliation(s)
- I Matthaios
- Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece.
| | - A Kaladaridou
- Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece
| | - E Skaltsiotes
- Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece
| | - J Agrios
- Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece
| | - A Antoniou
- Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece
| | - G Georgiopoulos
- Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece
| | - E Papadopoulou
- Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece
| | - C Pamboucas
- Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece
| | - S Toumanidis
- Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece
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24
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The Role of Cardiovascular Magnetic Resonance in Cardiac Resynchronization Therapy. Card Electrophysiol Clin 2016; 7:619-33. [PMID: 26596807 DOI: 10.1016/j.ccep.2015.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Randomized, controlled trials have shown that cardiac resynchronization therapy (CRT) is beneficial in patients with heart failure, impaired left ventricular (LV) systolic function, and a wide QRS complex. Other studies have shown that targeting the LV pacing site can also improve patient outcomes. Cardiovascular magnetic resonance (CMR) is a radiation-free imaging modality that provides unparalleled spatial resolution. In addition, emerging data suggest that targeted LV lead deployment over viable myocardium improves the outcome of patients undergoing CRT. This review explores the role of CMR in the preoperative workup of patients undergoing CRT.
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25
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MITTAL SUNEET, NAIR DEVI, PADANILAM BENZYJ, CIUFFO ALLEN, GUPTA NIGEL, GALLAGHER PETER, GOLDNER BRUCE, HAMMILL ERICF, WOLD NICOLAS, STEIN KENNETH, BURKE MARTIN. Performance of Anatomically Designed Quadripolar Left Ventricular Leads: Results from the NAVIGATE X4 Clinical Trial. J Cardiovasc Electrophysiol 2016; 27:1199-1205. [DOI: 10.1111/jce.13044] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 06/24/2016] [Accepted: 07/05/2016] [Indexed: 11/26/2022]
Affiliation(s)
| | - DEVI NAIR
- Division of Cardiac Electrophysiology, Department of Medicine St. Bernard's Heart & Vascular Center Jonesboro AR USA
| | | | - ALLEN CIUFFO
- Department of Medicine Sentara Heart Hospital Norfolk VA USA
| | - NIGEL GUPTA
- Department of Medicine, Kaiser Permanente Los Angeles Medical Center Los Angeles CA USA
| | - PETER GALLAGHER
- Department of Medicine Nebraska Heart Institute Lincoln NE USA
| | - BRUCE GOLDNER
- Department of Medicine Northwell Health System New Hyde Park NY USA
| | | | | | | | - MARTIN BURKE
- Section of Cardiology, Department of Medicine, Heart Rhythm Center University of Chicago USA
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26
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Marek J, Gandalovičová J, Kejřová E, Pšenička M, Linhart A, Paleček T. Echocardiography and cardiac resynchronization therapy. COR ET VASA 2016. [DOI: 10.1016/j.crvasa.2015.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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To ACY, Benatti RD, Sato K, Grimm RA, Thomas JD, Wilkoff BL, Agler D, Popović ZB. Strain-time curve analysis by speckle tracking echocardiography in cardiac resynchronization therapy: Insight into the pathophysiology of responders vs. non-responders. Cardiovasc Ultrasound 2016; 14:14. [PMID: 27090784 PMCID: PMC4835914 DOI: 10.1186/s12947-016-0057-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 04/08/2016] [Indexed: 11/17/2022] Open
Abstract
Background Patients with non-ischemic heart failure etiology and left bundle branch block (LBBB) show better response to cardiac resynchronization therapy (CRT). While these patients have the most pronounced left ventricular (LV) dyssynchrony, LV dyssynchrony assessment often fails to predict outcome. We hypothesized that patients with favorable outcome from CRT can be identified by a characteristic strain distribution pattern. Methods From 313 patients who underwent CRT between 2003 and 2006, we identified 10 patients who were CRT non-responders (no LV end-systolic volume [LVESV] reduction) with non-ischemic cardiomyopathy and LBBB and compared with randomly selected CRT responders (n = 10; LVESV reduction ≥15 %). Longitudinal strain (εlong) data were obtained by speckle tracking echocardiography before and after (9 ± 5 months) CRT implantation and standardized segmental εlong-time curves were obtained by averaging individual patients. Results In responders, ejection fraction (EF) increased from 25 ± 9 to 40 ± 11 % (p = 0.002), while in non-responders, EF was unchanged (20 ± 8 to 21 ± 5 %, p = 0.57). Global εlong was significantly lower in non-responders at pre CRT (p = 0.02) and only improved in responders (p = 0.04) after CRT. Pre CRT septal εlong -time curves in both groups showed early septal contraction with mid-systolic decrease, while lateral εlong showed early stretch followed by vigorous mid to late contraction. Restoration of contraction synchrony was observed in both groups, though non-responder remained low amplitude of εlong. Conclusions CRT non-responders with LBBB and non-ischemic etiology showed a similar improvement of εlong pattern with responders after CRT implantation, while amplitude of εlong remained unchanged. Lower εlong in the non-responders may account for their poor response to CRT.
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Affiliation(s)
- Andrew C Y To
- Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.,Department of Cardiology, North Shore Hospital, 124 Shakespeare Rd, Takapuna, Auckland, New Zealand
| | - Rodolfo D Benatti
- Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA
| | - Kimi Sato
- Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA
| | - Richard A Grimm
- Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA
| | - James D Thomas
- Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA
| | - Bruce L Wilkoff
- Section of Electrophysiology, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA
| | - Deborah Agler
- Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA
| | - Zoran B Popović
- Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.
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Sommer A, Kronborg MB, Nørgaard BL, Poulsen SH, Bouchelouche K, Böttcher M, Jensen HK, Jensen JM, Kristensen J, Gerdes C, Mortensen PT, Nielsen JC. Multimodality imaging-guided left ventricular lead placement in cardiac resynchronization therapy: a randomized controlled trial. Eur J Heart Fail 2016; 18:1365-1374. [PMID: 27087019 DOI: 10.1002/ejhf.530] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Revised: 02/25/2016] [Accepted: 03/03/2016] [Indexed: 12/13/2022] Open
Abstract
AIM Left ventricular (LV) lead position at the latest mechanically activated non-scarred myocardial LV region confers improved response to cardiac resynchronization therapy (CRT). We conducted a double-blind, randomized controlled trial to evaluate the clinical benefit of multimodality imaging-guided LV lead placement in CRT. METHODS AND RESULTS Patients were allocated (1:1) to imaging-guided LV lead placement using cardiac computed tomography (CT) venography, 99m Technetium myocardial perfusion imaging, and speckle-tracking echocardiography radial strain to target the optimal coronary sinus (CS) branch closest to the non-scarred myocardial segment with latest mechanical activation (imaging group, n = 89) or to routine LV lead implantation in a posterolateral region with late electrical activation (control group, n = 93). The primary endpoint was clinical non-response to CRT [≥1 of the following after 6 months: (1) death, (2) heart failure hospitalization, or (3) no improvement in New York Heart Association class and <10% increase in 6-min walk distance]. Secondary outcomes included LV remodelling and the combination of all-cause mortality and hospitalization owing to heart failure during 1.8 ± 0.9 years. Analysis was intention-to-treat. In the imaging group, fewer patients reached the primary endpoint (26% vs. 42%, P = 0.02). More patients in the imaging group had the LV lead placed in the optimal CS branch (83% vs. 65%, P = 0.01). There were no between-group differences in reverse LV remodelling or the combined endpoint of death or hospitalizations for heart failure. CONCLUSIONS Multimodality imaging-guided LV lead placement towards the CS branch closest to latest mechanically activated non-scarred myocardial LV segment reduces the proportion of clinical non-responders to CRT. Larger long-term multicentre studies are needed.
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Affiliation(s)
- Anders Sommer
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark.
| | - Mads Brix Kronborg
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Bjarne Linde Nørgaard
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Steen Hvitfeldt Poulsen
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Kirsten Bouchelouche
- Department of Nuclear Medicine, Aarhus University Hospital, Skejby, Aarhus N, Denmark
| | - Morten Böttcher
- Department of Cardiology, Herning Hospital, Herning, Denmark
| | - Henrik Kjaerulf Jensen
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Jesper Møller Jensen
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Jens Kristensen
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Christian Gerdes
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Peter Thomas Mortensen
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
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Is speckle tracking actually helpful for cardiac resynchronization therapy? J Echocardiogr 2016; 14:53-60. [PMID: 26767529 DOI: 10.1007/s12574-016-0275-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 12/09/2015] [Accepted: 12/28/2015] [Indexed: 10/22/2022]
Abstract
What is the specific role of echocardiography in cardiac resynchronization therapy (CRT)? CRT has proven to be highly effective for improving symptoms and survival of patients with advanced heart failure (HF) and wide QRS. However, a significant minority of patients do not respond favorably to CRT on the basis of standard clinical selection criteria, including the electrocardiographic QRS width. Subsequently, echocardiographic assessment of left ventricular (LV) dyssynchrony has been considered useful for CRT for selected responders, but findings by multicenter studies suggest that its predictive value was not sufficiently robust to replace routine selection criteria for CRT. A more recent approach, however, using speckle-tracking echocardiography yields more accurate quantification of regional wall contraction. Speckle-tracking approaches have therefore generated a great deal of interest about their clinical applications for CRT. Although reports on speckle tracking have not been included in any recommendations as to whether patients should undergo CRT based on the current guidelines, speckle tracking can play an important supplementary part in CRT on the basis of a case-by-case clinical decision for challenging cases. Here, we review the strengths of speckle-tracking methods, and their current potential for clinical use in CRT.
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Abstract
Cardiac resynchronization therapy (CRT) is a standard treatment for patients with heart failure. However, 30-40 % of the patients having CRT do not respond to CRT with improved clinical symptom and cardiac functions. It is important for CRT response that left ventricular (LV) lead is placed away from scar and at or near the site of the latest mechanical activation. Nuclear image-guided approaches for CRT have shown significant clinical value to assess LV myocardial viability and mechanical dyssynchrony, recommend the optimal LV lead position, and navigate the LV lead to the target coronary venous site. All these techniques, once validated and implemented, should impact the current clinical practice.
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Affiliation(s)
- Weihua Zhou
- School of Computing, University of Southern Mississippi, 730 East Beach Blvd, Long Beach, MS, 39560, USA.
| | - Ernest V Garcia
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, USA.
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31
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Tournoux F, Chequer R, Sroussi M, Hyafil F, Algalarrondo V, Cohen-Solal A, Bodson-Clermont P, Le Guludec D, Rouzet F. Value of mechanical dyssynchrony as assessed by radionuclide ventriculography to predict the cardiac resynchronization therapy response. Eur Heart J Cardiovasc Imaging 2015; 17:1250-1258. [PMID: 26613747 DOI: 10.1093/ehjci/jev286] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 10/05/2015] [Indexed: 12/30/2022] Open
Abstract
AIMS To assess the value of mechanical dyssynchrony measured by equilibrium radionuclide angiography (ERNA) in predicting long-term outcome in cardiac resynchronization therapy (CRT) patients. METHODS AND RESULTS We reviewed 146 ERNA studies performed in heart failure patients between 2001 and 2011 at our institution. Long-term follow-up focused on death from any cause or heart transplantation. Phase images were computed using the first harmonic Fourier transform. Intra-ventricular dyssynchrony was calculated as the delay between the earliest and most delayed 20% of the left ventricular (LV) (IntraV-20/80) and inter-ventricular dyssynchrony as the difference between LV- and right ventricular (RV)-mode phase angles (InterV). Eighty-three patients (57%) were implanted with a CRT device after ERNA. Median follow-up was 35 [21-50] months. Twenty-four events were observed during the first 41 months. Median baseline ERNA dyssynchrony values were 28 [3 to 46] degrees for intraV-20/80 and 9 [-6 to 24] degrees for interV. Comparing survival between CRT and non-CRT patients according to dyssynchrony status, log-rank tests showed no difference in survival in patients with no ERNA dyssynchrony (P = 0.34) while a significant difference was observed in ERNA patients with high level of mechanical dyssynchrony (P = 0.004). CONCLUSION ERNA mechanical dyssynchrony could be of value in CRT patient selection.
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Affiliation(s)
- Francois Tournoux
- Cardiologie, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Renata Chequer
- AP-HP, Groupe Hospitalier Bichat-Claude Bernard, Service de Médecine Nucléaire, Paris, France
| | - Marjorie Sroussi
- Groupe Hospitalier Cochin-Saint Vincent de Paul, Université René Descartes-Paris 5, Paris, France
| | - Fabien Hyafil
- AP-HP, Groupe Hospitalier Bichat-Claude Bernard, Service de Médecine Nucléaire, Paris, France.,Université Denis Diderot-Paris 7, U1148 Inserm, Paris, France
| | - Vincent Algalarrondo
- Service de Cardiologie, CHU A. Béclère, APHP. U769, Labex Lermit, Clamart, France
| | - Alain Cohen-Solal
- Service de Cardiologie, Hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, Paris 75010, France
| | | | - Dominique Le Guludec
- AP-HP, Groupe Hospitalier Bichat-Claude Bernard, Service de Médecine Nucléaire, Paris, France.,Université Denis Diderot-Paris 7, U1148 Inserm, Paris, France
| | - Francois Rouzet
- AP-HP, Groupe Hospitalier Bichat-Claude Bernard, Service de Médecine Nucléaire, Paris, France.,Université Denis Diderot-Paris 7, U1148 Inserm, Paris, France
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CHEN LU, FU HAIXIA, PRETORIUS VICTORG, YANG DACHUN, WISTE HEATHERJ, YUAN HONGTAO, FELD GREGORYK, CHA YONGMEI, BIRGERSDOTTER-GREEN ULRIKAM. Clinical Outcomes of Cardiac Resynchronization with Epicardial Left Ventricular Lead. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:1201-9. [DOI: 10.1111/pace.12687] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/26/2015] [Accepted: 07/05/2015] [Indexed: 11/30/2022]
Affiliation(s)
- LU CHEN
- Division of Cardiology, Department of Medicine; University of California; San Diego California
| | - HAIXIA FU
- Department of Cardiovascular Diseases; Henan Provincial People's Hospital, Zhengzhou University; Henan China
- Department of Cardiovascular Diseases; Mayo Clinics; Rochester Minnesota
| | - VICTOR G. PRETORIUS
- Department of Surgery, Division of Cardiothoracic Surgery; University of California; San Diego California
| | - DACHUN YANG
- Department of Cardiovascular Diseases; Mayo Clinics; Rochester Minnesota
| | - HEATHER J. WISTE
- Department of Health Science Research; Mayo Clinics; Rochester Minnesota
| | - HONGTAO YUAN
- Department of Cardiovascular Diseases; Mayo Clinics; Rochester Minnesota
| | - GREGORY K. FELD
- Division of Cardiology, Department of Medicine; University of California; San Diego California
| | - YONG-MEI CHA
- Department of Cardiovascular Diseases; Mayo Clinics; Rochester Minnesota
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Hung GU, Huang JL, Lin WY, Tsai SC, Wang KY, Chen SA, Lloyd MS, Chen J. Impact of right-ventricular apical pacing on the optimal left-ventricular lead positions measured by phase analysis of SPECT myocardial perfusion imaging. Eur J Nucl Med Mol Imaging 2014; 41:1224-31. [PMID: 24577949 DOI: 10.1007/s00259-014-2693-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 01/02/2014] [Indexed: 11/27/2022]
Abstract
PURPOSE The use of SPECT phase analysis to optimize left-ventricular (LV) lead positions for cardiac resynchronization therapy (CRT) was performed at baseline, but CRT works as simultaneous right ventricular (RV) and LV pacing. The aim of this study was to assess the impact of RV apical (RVA) pacing on optimal LV lead positions measured by SPECT phase analysis. METHODS This study prospectively enrolled 46 patients. Two SPECT myocardial perfusion scans were acquired under sinus rhythm with complete left bundle branch block and RVA pacing, respectively, following a single injection of (99m)Tc-sestamibi. LV dyssynchrony parameters and optimal LV lead positions were measured by the phase analysis technique and then compared between the two scans. RESULTS The LV dyssynchrony parameters were significantly larger with RVA pacing than with sinus rhythm (p ~0.01). In 39 of the 46 patients, the optimal LV lead positions were the same between RVA pacing and sinus rhythm (kappa = 0.861). In 6 of the remaining 7 patients, the optimal LV lead positions were along the same radial direction, but RVA pacing shifted the optimal LV lead positions toward the base. CONCLUSION The optimal LV lead positions measured by SPECT phase analysis were consistent, no matter whether the SPECT images were acquired under sinus rhythm or RVA pacing. In some patients, RVA pacing shifted the optimal LV lead positions toward the base. This study supports the use of baseline SPECT myocardial perfusion imaging to optimize LV lead positions to increase CRT efficacy.
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Affiliation(s)
- Guang-Uei Hung
- Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
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34
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GOLD MICHAELR, LEMAN ROBERTB, WOLD NICHOLAS, STURDIVANT JLACY, YU YINGHONG. The Effect of Left Ventricular Electrical Delay on the Acute Hemodynamic Response with Cardiac Resynchronization Therapy. J Cardiovasc Electrophysiol 2014; 25:624-30. [DOI: 10.1111/jce.12372] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 01/05/2014] [Accepted: 01/07/2014] [Indexed: 11/28/2022]
Affiliation(s)
- MICHAEL R. GOLD
- Medical University of South Carolina; Charleston South Carolina USA
| | - ROBERT B. LEMAN
- Medical University of South Carolina; Charleston South Carolina USA
| | - NICHOLAS WOLD
- Boston Scientific Corporation; Saint Paul Minnesota USA
| | | | - YINGHONG YU
- Boston Scientific Corporation; Saint Paul Minnesota USA
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Left ventricular pacing site in cardiac resynchronization therapy: Clinical follow-up and predictors of failed lateral implant. Eur J Heart Fail 2014; 10:421-7. [PMID: 18395673 DOI: 10.1016/j.ejheart.2008.02.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Revised: 12/22/2007] [Accepted: 02/28/2008] [Indexed: 11/23/2022] Open
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Abstract
Today's healthcare delivery system is challenged with an escalating number of heart failure patients who have exhausted medical therapy and overwhelmed the limits of organ transplantation. Scientific and technological advances over the last 20 years have now brought new surgical options to this vast patient population, ranging from ventricular restoration surgery to surgical gene therapy and beyond. This article reviews the myriad of surgical options that are available to these patients, their benefits and shortcomings, as well as potential future directions.
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Marek JJ, Saba S, Onishi T, Ryo K, Schwartzman D, Adelstein EC, Gorcsan J. Usefulness of echocardiographically guided left ventricular lead placement for cardiac resynchronization therapy in patients with intermediate QRS width and non-left bundle branch block morphology. Am J Cardiol 2014; 113:107-16. [PMID: 24169014 DOI: 10.1016/j.amjcard.2013.09.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 09/19/2013] [Accepted: 09/19/2013] [Indexed: 10/26/2022]
Abstract
The current guidelines most strongly support cardiac resynchronization therapy (CRT) for patients with heart failure with a QRS width of ≥150 ms and left bundle branch block (LBBB). Our objective was to assess the potential benefit of echocardiographically guided left ventricular (LV) lead positioning for patients with a QRS width <150 ms or non-LBBB as a substudy of the Speckle Tracking Assisted Resynchronization Therapy for Electrode Region (STARTER) prospective, randomized controlled trial. The STARTER trial randomized 187 patients with heart failure, a QRS of ≥120 ms, and ejection fraction of ≤35% to LV lead guided to the site of latest mechanical activation by speckle tracking radial strain versus routine implantation. The predefined primary end point was heart failure hospitalization or death within 2 years. This substudy included 151 CRT patients with matching echocardiographic and LV lead position data and complete follow-up data. Patients with a QRS width of 120 to 149 ms or non-LBBB and LV lead concordant or adjacent to the site of latest mechanical activation had favorable outcomes after CRT similar to those with LBBB or a QRS width of ≥150 ms. In contrast, patients with a QRS of 120 to 149 ms or non-LBBB and remote LV leads had unfavorable outcomes (hazard ratio 5.45, 95% confidence interval 2.36 to 12.6, p <0.001, and hazard ratio 4.92, 95% confidence interval 2.12 to 11.39, p <0.001, respectively, with significant interaction after adjusting for baseline variables, p = 0.038 and p = 0.008). In conclusion, LV lead positioning with respect to the echocardiographic site of latest activation was significantly associated with more favorable clinical outcomes in patients with a QRS duration <150 ms and/or non-LBBB. Additional prospective study is warranted.
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Abstract
Patients with heart failure and decreased function frequently develop discoordinate contraction because of electric activation delay. Often termed dyssynchrony, this further decreases systolic function and chamber efficiency and worsens morbidity and mortality. In the mid- 1990s, a pacemaker-based treatment termed cardiac resynchronization therapy (CRT) was developed to restore mechanical synchrony by electrically activating both right and left sides of the heart. It is a major therapeutic advance for the new millennium. Acute chamber effects of CRT include increased cardiac output and mechanical efficiency and reduced mitral regurgitation, whereas reduction in chamber volumes ensues more chronically. Patient candidates for CRT have a prolonged QRS duration and discoordinate wall motion, although other factors may also be important because ≈30% of such selected subjects do not respond to the treatment. In contrast to existing pharmacological inotropes, CRT both acutely and chronically increases cardiac systolic function and work, yet it also reduces long-term mortality. Recent studies reveal unique molecular and cellular changes from CRT that may also contribute to this success. Heart failure with dyssynchrony displays decreased myocyte and myofilament function, calcium handling, β-adrenergic responsiveness, mitochondrial ATP synthase activity, cell survival signaling, and other changes. CRT reverses many of these abnormalities often by triggering entirely new pathways. In this review, we discuss chamber, circulatory, and basic myocardial effects of dyssynchrony and CRT in the failing heart, and we highlight new research aiming to better target and implement CRT, as well as leverage its molecular effects.
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Affiliation(s)
- Jonathan A Kirk
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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A detailed assessment of the human coronary venous system using contrast computed tomography of perfusion-fixed specimens. Heart Rhythm 2013; 11:282-8. [PMID: 24144884 DOI: 10.1016/j.hrthm.2013.10.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Access to the coronary venous system is required for the delivery of several cardiac therapies including cardiac resynchronization therapy, coronary sinus ablation, and coronary drug delivery. Therefore, characterization of the coronary venous anatomy will provide insights to gain improved access to these vessels and subsequently improved therapies. For example, cardiac resynchronization therapy has a 30% nonresponder rate, partially due to suboptimal lead placement within the coronary veins. OBJECTIVE To understand the implications of coronary venous anatomy for the development of devices deployed within these vessels. METHODS We cannulated the coronary sinus of 121 perfusion-fixed human hearts with a venogram balloon catheter and injected contrast into the venous system while obtaining computed tomographic images. For each major coronary vein, distance to the coronary sinus, branching angle, arc length, tortuosity, number of branches, and ostial diameter were assessed from the reconstructed anatomy. RESULTS Twenty-nine percent (35/121) specimens did not have a venous branch overlying the inferolateral side of the heart large enough to fit a 5F pacing lead. No significant differences in anatomy were found between subgroups with varying cardiac medical histories. CONCLUSION The anatomical approach employed in this study has allowed for the development of a unique database of human coronary venous anatomy that can be used for the optimization of design and delivery of cardiac devices.
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The amount of viable and dyssynchronous myocardium is associated with response to cardiac resynchronization therapy: initial clinical results using multiparametric ECG-gated [18F]FDG PET. Eur J Nucl Med Mol Imaging 2013; 40:1876-83. [DOI: 10.1007/s00259-013-2516-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 07/07/2013] [Indexed: 10/26/2022]
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Kydd AC, McCormick LM, Dutka DP. Optimizing benefit from CRT: role of speckle tracking echocardiography, the importance of LV lead position and scar. Expert Rev Med Devices 2013; 9:521-36. [PMID: 23116079 DOI: 10.1586/erd.12.39] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cardiac resynchronization therapy is demonstrated to be effective in patients with advanced heart failure. Correcting mechanical dyssynchrony is proposed as the predominant mechanism of response. Achieving optimum left ventricular lead position, at the site of maximal mechanical dyssynchrony but away from transmural scar, is identified as one of the main determinants of both symptomatic and prognostic benefit. Strategies employing multimodality cardiac imaging techniques have been used to identify this optimal pacing site, in addition to any potential anatomical limitations to successful implantation. Speckle tracking echocardiography offers prospective lead targeting, incorporating pathophysiological determinants of cardiac resynchronization therapy response. This review considers the key factors in defining optimum left ventricular lead location, emphasizing the role of myocardial scar. The use of speckle tracking echocardiography and the potential for this technique to be incorporated into routine practice to guide the implant strategy in an individual patient is discussed.
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Affiliation(s)
- Anna C Kydd
- Division of Cardiovascular Medicine, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, UK
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Abstract
Although cardiac resynchronization therapy (CRT) has been established as an important treatment modality for heart failure patients, at least one third of CRT recipients do not respond to this therapy or derive minimal benefit from it. The impact of the site of left ventricular (LV) pacing on outcome after CRT has been examined extensively. Initial studies suggested benefit of posterior or lateral sites but subsequent work has yielded conflicting results. There also remain conflicting results of apical vs basal pacing sites. Avoiding LV lead placement at sites of transmural scar is however a viable strategy. In addition, The TARGET and STARTER trials, 2 independent, randomized, prospective studies, have demonstrated that targeting LV lead placement to sites of latest LV mechanical activation as defined by speckle tracking echocardiography remains the most promising method to improve clinical outcome after CRT.
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Left ventricular systolic and diastolic dyssynchrony assessed by phase analysis of gated SPECT myocardial perfusion imaging: a comparison with speckle tracking echocardiography. Ann Nucl Med 2013; 27:764-71. [PMID: 23775229 DOI: 10.1007/s12149-013-0744-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 06/10/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The objective of this study was to compare left ventricular (LV) systolic and diastolic dyssynchrony parameters measured by phase analysis on gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) with those measured by speckle tracking echocardiography (STE). MATERIALS AND METHODS Two patient groups were enrolled from the Chang Bing Show Chwan Memorial Hospital. The systolic group consisted of patients with reduced LV ejection fraction (LVEF) of <50 % as assessed by routine echocardiography. The diastolic group consisted of patients with normal LVEF (>50 %) and diastolic dysfunction according to routine echocardiography (E/A <1, E/E' >8). LV systolic and diastolic dyssynchrony parameters were calculated using STE as the maximal peak-time delay between peak radial strains of two opposing LV walls and as the standard deviation of the time to peak radial strains in 6 mid-LV segments. All of the patients had gated SPECT MPI within 6 ± 11 days post STE. Phase analysis was performed on the resting gated SPECT MPI images to calculate systolic and diastolic phase standard deviation and phase histogram bandwidth as markers of LV systolic and diastolic dyssynchrony, respectively. RESULTS Fifty-two consecutive patients (40 men, mean age = 66 ± 13 years, LVEF = 34.4 ± 10.2 %) were enrolled in the systolic group, whereas 30 consecutive patients (15 men, mean age = 69 ± 11 years, LVEF = 72.3 ± 4.7 %, E/A all <1, E/E' = 11.7 ± 2.2) were enrolled in the diastolic group. LV systolic and diastolic dyssynchrony parameters measured by phase analysis of gated SPECT MPI and STE were correlated well in both systolic and diastolic groups, respectively. CONCLUSION Phase analysis on gated SPECT MPI showed good correlations with STE and is suitable for the assessment of LV systolic and diastolic dyssynchrony. As assessed with the phase analysis and STE techniques, the patients with severe LV systolic dysfunction had severe LV systolic dyssynchrony, but the patients with LV diastolic dysfunction were not necessarily with LV diastolic dyssynchrony, indicating that the LV diastolic dyssynchrony parameters characterized independent mechanisms of LV regional diastolic function.
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Sommer A, Kronborg MB, Poulsen SH, Böttcher M, Nørgaard BL, Bouchelouche K, Mortensen PT, Gerdes C, Nielsen JC. Empiric versus imaging guided left ventricular lead placement in cardiac resynchronization therapy (ImagingCRT): study protocol for a randomized controlled trial. Trials 2013; 14:113. [PMID: 23782792 PMCID: PMC3762069 DOI: 10.1186/1745-6215-14-113] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 04/08/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is an established treatment in heart failure patients. However, a large proportion of patients remain nonresponsive to this pacing strategy. Left ventricular (LV) lead position is one of the main determinants of response to CRT. This study aims to clarify whether multimodality imaging guided LV lead placement improves clinical outcome after CRT. METHODS/DESIGN The ImagingCRT study is a prospective, randomized, patient- and assessor-blinded, two-armed trial. The study is designed to investigate the effect of imaging guided left ventricular lead positioning on a clinical composite primary endpoint comprising all-cause mortality, hospitalization for heart failure, or unchanged or worsened functional capacity (no improvement in New York Heart Association class and <10% improvement in six-minute-walk test). Imaging guided LV lead positioning is targeted to the latest activated non-scarred myocardial region by speckle tracking echocardiography, single-photon emission computed tomography, and cardiac computed tomography. Secondary endpoints include changes in LV dimensions, ejection fraction and dyssynchrony. A total of 192 patients are included in the study. DISCUSSION Despite tremendous advances in knowledge with CRT, the proportion of patients not responding to this treatment has remained stable since the introduction of CRT. ImagingCRT is a prospective, randomized study assessing the clinical and echocardiographic effect of multimodality imaging guided LV lead placement in CRT. The results are expected to make an important contribution in the pursuit of increasing response rate to CRT. TRIAL REGISTRATION Clinicaltrials.gov identifier NCT01323686. The trial was registered March 25, 2011 and the first study subject was randomized April 11, 2011.
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MESH Headings
- Cardiac Resynchronization Therapy/adverse effects
- Cardiac Resynchronization Therapy/methods
- Cardiac Resynchronization Therapy/mortality
- Cardiac Resynchronization Therapy Devices
- Clinical Protocols
- Denmark
- Diagnostic Imaging/methods
- Disease Progression
- Double-Blind Method
- Echocardiography, Doppler
- Exercise Test
- Exercise Tolerance
- Heart Failure/diagnosis
- Heart Failure/mortality
- Heart Failure/physiopathology
- Heart Failure/therapy
- Hospitalization
- Humans
- Predictive Value of Tests
- Prospective Studies
- Recovery of Function
- Research Design
- Stroke Volume
- Therapy, Computer-Assisted/instrumentation
- Therapy, Computer-Assisted/methods
- Time Factors
- Tomography, Emission-Computed, Single-Photon
- Tomography, X-Ray Computed
- Treatment Outcome
- Ventricular Dysfunction, Left/diagnosis
- Ventricular Dysfunction, Left/mortality
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Left/therapy
- Ventricular Function, Left
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Affiliation(s)
- Anders Sommer
- Department of Cardiology, Aarhus University Hospital, Brendstrupgaardsvej 100, Skejby DK-8200, Aarhus N, Denmark
| | - Mads Brix Kronborg
- Department of Cardiology, Aarhus University Hospital, Brendstrupgaardsvej 100, Skejby DK-8200, Aarhus N, Denmark
| | - Steen Hvitfeldt Poulsen
- Department of Cardiology, Aarhus University Hospital, Brendstrupgaardsvej 100, Skejby DK-8200, Aarhus N, Denmark
| | - Morten Böttcher
- Department of Cardiology, Aarhus University Hospital, Brendstrupgaardsvej 100, Skejby DK-8200, Aarhus N, Denmark
| | - Bjarne Linde Nørgaard
- Department of Cardiology, Aarhus University Hospital, Brendstrupgaardsvej 100, Skejby DK-8200, Aarhus N, Denmark
| | - Kirsten Bouchelouche
- Department of Nuclear Medicine, Aarhus University Hospital, Brendstrupgaardsvej 100, Skejby DK-8200, Aarhus N, Denmark
| | - Peter Thomas Mortensen
- Department of Cardiology, Aarhus University Hospital, Brendstrupgaardsvej 100, Skejby DK-8200, Aarhus N, Denmark
| | - Christian Gerdes
- Department of Cardiology, Aarhus University Hospital, Brendstrupgaardsvej 100, Skejby DK-8200, Aarhus N, Denmark
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Brendstrupgaardsvej 100, Skejby DK-8200, Aarhus N, Denmark
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Saba S, Marek J, Schwartzman D, Jain S, Adelstein E, White P, Oyenuga OA, Onishi T, Soman P, Gorcsan J. Echocardiography-guided left ventricular lead placement for cardiac resynchronization therapy: results of the Speckle Tracking Assisted Resynchronization Therapy for Electrode Region trial. Circ Heart Fail 2013; 6:427-34. [PMID: 23476053 DOI: 10.1161/circheartfailure.112.000078] [Citation(s) in RCA: 281] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy improves mortality and morbidity in patients with heart failure (HF) with wide QRS complex and diminished left ventricular (LV) function, but response is variable. METHODS AND RESULTS The Speckle Tracking Assisted Resynchronization Therapy for Electrode Region (STARTER) was a prospective, double-blind, randomized controlled trial testing the hypothesis that an incremental benefit to cardiac resynchronization therapy would be gained by echo-guided (EG) transvenous LV lead placement versus a routine fluoroscopic approach. EG LV lead placement was attempted at the site of latest time to peak radial strain by speckle tracking echocardiography. The prespecified primary end point was first HF hospitalization or death. Of 187 New York Heart Association class II to IV patients with HF (62% ischemic; ejection fraction 26±6%; QRS 159±27 ms), 110 were randomized to EG and 77 to routine strategies. Primary events included 30 deaths and 37 HF hospitalizations over 1.8 years. Using intention-to-treat, patients randomized to an EG strategy had a significantly more favorable event-free survival (hazard ratio, 0.48; 95% confidence interval, 0.28-0.82; P=0.006). Exact or adjacent concordance of LV lead with latest site could be achieved in 85% of the EG group and occurred fortuitously in 66% of controls (P=0.010) and was associated with an improvement in event-free survival (hazard ratio, 0.40; 95% confidence interval, 0.22-0.71; P=0.002). CONCLUSIONS A strategy of EG LV lead placement for cardiac resynchronization therapy improved patient outcomes by reducing the combined risk of death or HF hospitalizations and has implications for delivery of cardiac resynchronization therapy. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00156390.
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Affiliation(s)
- Samir Saba
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA 15213-2582, USA.
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Daubert JC, Saxon L, Adamson PB, Auricchio A, Berger RD, Beshai JF, Breithard O, Brignole M, Cleland J, DeLurgio DB, Dickstein K, Exner DV, Gold M, Grimm RA, Hayes DL, Israel C, Leclercq C, Linde C, Lindenfeld J, Merkely B, Mont L, Murgatroyd F, Prinzen F, Saba SF, Shinbane JS, Singh J, Tang AS, Vardas PE, Wilkoff BL, Zamorano JL, Anand I, Blomström-Lundqvist C, Boehmer JP, Calkins H, Cazeau S, Delgado V, Estes NAM, Haines D, Kusumoto F, Leyva P, Ruschitzka F, Stevenson LW, Torp-Pedersen CT. 2012 EHRA/HRS expert consensus statement on cardiac resynchronization therapy in heart failure: implant and follow-up recommendations and management. Europace 2013; 14:1236-86. [PMID: 22930717 DOI: 10.1093/europace/eus222] [Citation(s) in RCA: 201] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Döring M, Braunschweig F, Eitel C, Gaspar T, Wetzel U, Nitsche B, Hindricks G, Piorkowski C. Individually tailored left ventricular lead placement: lessons from multimodality integration between three-dimensional echocardiography and coronary sinus angiogram. ACTA ACUST UNITED AC 2013; 15:718-27. [PMID: 23388184 DOI: 10.1093/europace/eus396] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Michael Döring
- Department of Electrophysiology, University of Leipzig-Heart Center, Strümpellstrasse 39, Leipzig, Germany.
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Dickfeld T, Dauer L, Deodhar A, Berger RD, Fleiter T, Solomon S. Real-time CT-guided percutaneous placement of LV pacing leads. JACC Cardiovasc Imaging 2013; 6:96-104. [PMID: 23328567 DOI: 10.1016/j.jcmg.2012.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 08/03/2012] [Accepted: 08/09/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The aim of this study was to assess the feasibility of real-time computed tomographic (CT) imaging to guide the percutaneous placement of left ventricular (LV) leads in an animal model. BACKGROUND Cardiac resynchronization therapy has been shown to improve morbidity and mortality in patients with chronic heart failure. However, placement of the coronary sinus lead can be challenging and may require a more aggressive surgical approach. METHODS Nine swine were placed in a real-time CT scanner to define the safest percutaneous access strategy. Under real-time CT guidance, a 3.5-F pacing lead was placed percutaneously in the anterolateral LV epicardium (n = 6 swine) or to the posterolateral wall after the creation of intentional left pneumothorax (n = 3 swine) in a tangential (n = 12) or perpendicular (n = 1) approach. Pacing parameters and CT images were assessed during 30-min follow-up. Necropsy findings were compared with real-time CT images. RESULTS CT imaging successfully defined the safest percutaneous access route in all 13 lead placements and guided the therapeutic creation of pneumothoraces. Needle trajectory remained within 5 mm of the access route defined on CT imaging. LV lead placement under CT guidance was successful in all attempts within 19 ± 7 min. The mean pacing thresholds was 2.5 ± 1.5 V, the mean R wave amplitude was 11.2 ± 5.6 mV, and the mean impedance was 686 ± 103 Ω and remained unchanged after tangential placement during 30-min follow-up. Although no cardiac complications were observed with tangential lead placement (12 of 12), the perpendicular approach resulted in a pericardial effusion requiring pericardiocentesis. At necropsy, CT images correlated well with the in situ pathological results. CONCLUSIONS Percutaneous placement of LV pacing leads under CT guidance is feasible and might offer an alternative to more invasive surgical approaches in patients with complicated coronary sinus lead placement.
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Affiliation(s)
- Timm Dickfeld
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Division of Cardiology, University of Maryland, Baltimore, Maryland 21201, USA.
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PADELETTI LUIGI, PIERAGNOLI PAOLO, RICCIARDI GIUSEPPE, PERROTTA LAURA, PERINI ALESSANDROP, GRIFONI GINO, RICCERI ILARIA, PADELETTI MARGHERITA, LIONETTI VINCENZO, VALSECCHI SERGIO. Larger Interventricular Conduction Time Enhances Mechanical Response to Resynchronization Therapy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2013; 36:416-23. [DOI: 10.1111/pace.12068] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 10/21/2012] [Accepted: 11/13/2012] [Indexed: 11/28/2022]
Affiliation(s)
| | - PAOLO PIERAGNOLI
- Institute of Internal Medicine and Cardiology, University of Florence; Florence; Italy
| | - GIUSEPPE RICCIARDI
- Institute of Internal Medicine and Cardiology, University of Florence; Florence; Italy
| | - LAURA PERROTTA
- Institute of Internal Medicine and Cardiology, University of Florence; Florence; Italy
| | - ALESSANDRO P. PERINI
- Institute of Internal Medicine and Cardiology, University of Florence; Florence; Italy
| | - GINO GRIFONI
- Institute of Internal Medicine and Cardiology, University of Florence; Florence; Italy
| | - ILARIA RICCERI
- Institute of Internal Medicine and Cardiology, University of Florence; Florence; Italy
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