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Vereckei A. New Pacing Techniques and Non-Invasive Methods That May Improve Response to Cardiac Resynchronization Therapy. J Cardiovasc Dev Dis 2024; 11:208. [PMID: 39057628 PMCID: PMC11277212 DOI: 10.3390/jcdd11070208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 06/22/2024] [Accepted: 06/27/2024] [Indexed: 07/28/2024] Open
Abstract
Although cardiac resynchronization therapy (CRT) is an evidence-based effective therapy of symptomatic heart failure with reduced ejection fraction (HFrEF), refractory to optimal medical treatment and associated with intraventricular conduction disturbance, the non-response rate to CRT is still around 30% [...].
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Affiliation(s)
- András Vereckei
- Department of Medicine and Hematology, Semmelweis University, Szentkirályi u. 46, 1088 Budapest, Hungary
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2
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Skeete J, Huang HD, Mazur A, Sharma PS, Engelstein E, Trohman RG, Larsen TR. Evolving Concepts in Cardiac Physiologic Pacing in the Era of Conduction System Pacing. Am J Cardiol 2024; 212:51-66. [PMID: 38012990 DOI: 10.1016/j.amjcard.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/22/2023] [Accepted: 11/11/2023] [Indexed: 11/29/2023]
Abstract
Cardiac physiologic pacing (CPP) has become a well-established therapy for patients with cardiomyopathy (left ventricular ejection fraction <35%) in the presence of a left bundle branch block. In addition, CPP can be highly beneficial in patients with pacing-induced cardiomyopathy and patients with existing cardiomyopathy expected to have a right ventricular pacing burden of >40%. The benefits of CPP with traditional biventricular pacing are only realized if adequate resynchronization can be achieved. However, left ventricular lead implantation can be limited by individual anatomic variation within the coronary venous system and can be adversely affected by underlying abnormal myocardial substrate (i.e., scar tissue), especially if located within the basal lateral wall. In the last 7 years the investigation of conduction system pacing (CSP) and its potential salutary benefits are being realized and have led to a rapid evolution in the field of cardiac resynchronization pacing. However, supportive evidence for CSP for patients eligible for cardiac resynchronization remains limited compared with data available for biventricular cardiac resynchronization, mostly derived from leading CSP investigative centers. In this review, we perform an up-to-date comprehensive review of the available literature on CPP.
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Affiliation(s)
- Jamario Skeete
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Henry D Huang
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Alex Mazur
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Parikshit S Sharma
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Erica Engelstein
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Richard G Trohman
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Timothy R Larsen
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois.
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3
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Chousou PA, Chattopadhyay RK, Matthews GDK, Vassiliou VS, Pugh PJ. Location, Location, Location: A Pilot Study to Compare Electrical with Echocardiographic-Guided Targeting of Left Ventricular Lead Placement in Cardiac Resynchronisation Therapy. Diagnostics (Basel) 2024; 14:299. [PMID: 38337816 PMCID: PMC10855693 DOI: 10.3390/diagnostics14030299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/21/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
Introduction: Cardiac resynchronisation therapy is ineffective in 30-40% of patients with heart failure with reduced ejection fraction. Targeting non-scarred myocardium by selecting the site of latest mechanical activation using echocardiography has been suggested to improve outcomes but at the cost of increased resource utilisation. The interval between the beginning of the QRS complex and the local LV lead electrogram (QLV) might represent an alternative electrical marker. Aims: To determine whether the site of latest myocardial electrical and mechanical activation are concordant. Methods: This was a single-centre, prospective pilot study, enrolling patients between March 2019 and June 2021. Patients underwent speckle-tracking echocardiography (STE) prior to CRT implantation. Intra-procedural QLV measurement and R-wave amplitude were performed in a blinded fashion at all accessible coronary sinus branches. Pearson's correlation coefficient and Cohen's Kappa coefficient were utilised for the comparison of electrical and echocardiographic parameters. Results: A total of 20 subjects had complete data sets. In 15, there was a concordance at the optimal site between the electrically targeted region and the mechanically targeted region; in four, the regions were adjacent (within one segment). There was discordance (≥2 segments away) in only one case between the two methods of targeting. There was a statistically significant increase in procedure time and fluoroscopy duration using the intraprocedural QLV strategy. There was no statistical correlation between the quantitative electrical and echocardiographic data. Conclusions: A QLV-guided approach to targeting LV lead placement appears to be a potential alternative to the established echocardiographic-guided technique. However, it is associated with prolonged fluoroscopy and overall procedure time.
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Affiliation(s)
- Panagiota A. Chousou
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
- Department of Cardiology, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Rahul K. Chattopadhyay
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
- Department of Cardiology, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | | | | | - Peter J. Pugh
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
- Department of Cardiology, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
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4
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Nazar W, Szymanowicz S, Nazar K, Kaufmann D, Wabich E, Braun-Dullaeus R, Daniłowicz-Szymanowicz L. Artificial intelligence models in prediction of response to cardiac resynchronization therapy: a systematic review. Heart Fail Rev 2024; 29:133-150. [PMID: 37861853 PMCID: PMC10904439 DOI: 10.1007/s10741-023-10357-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 10/21/2023]
Abstract
The aim of the presented review is to summarize the literature data on the accuracy and clinical applicability of artificial intelligence (AI) models as a valuable alternative to the current guidelines in predicting cardiac resynchronization therapy (CRT) response and phenotyping of patients eligible for CRT implantation. This systematic review was performed according to the PRISMA guidelines. After a search of Scopus, PubMed, Cochrane Library, and Embase databases, 675 records were identified. Twenty supervised (prediction of CRT response) and 9 unsupervised (clustering and phenotyping) AI models were analyzed qualitatively (22 studies, 14,258 patients). Fifty-five percent of AI models were based on retrospective studies. Unsupervised AI models were able to identify clusters of patients with significantly different rates of primary outcome events (death, heart failure event). In comparison to the guideline-based CRT response prediction accuracy of 70%, supervised AI models trained on cohorts with > 100 patients achieved up to 85% accuracy and an AUC of 0.86 in their prediction of response to CRT for echocardiographic and clinical outcomes, respectively. AI models seem to be an accurate and clinically applicable tool in phenotyping of patients eligible for CRT implantation and predicting potential responders. In the future, AI may help to increase CRT response rates to over 80% and improve clinical decision-making and prognosis of the patients, including reduction of mortality rates. However, these findings must be validated in randomized controlled trials.
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Affiliation(s)
- Wojciech Nazar
- Faculty of Medicine, Medical University of Gdańsk, Marii Skłodowskiej-Curie 3a, 80-210, Gdańsk, Poland
| | | | - Krzysztof Nazar
- Faculty of Electronics, Telecommunications and Informatics, Gdańsk University of Technology, Gabriela Narutowicza 11/12, 80-233, Gdańsk, Poland
| | - Damian Kaufmann
- Department of Cardiology and Electrotherapy, Faculty of Medicine, Medical University of Gdańsk, Smoluchowskiego 17, 80-213, Gdańsk, Poland
| | - Elżbieta Wabich
- Department of Cardiology and Electrotherapy, Faculty of Medicine, Medical University of Gdańsk, Smoluchowskiego 17, 80-213, Gdańsk, Poland
| | - Rüdiger Braun-Dullaeus
- Department of Cardiology and Angiology, Otto von Guericke University Magdeburg, Leipziger Street 44, 39120, Magdeburg, Germany
| | - Ludmiła Daniłowicz-Szymanowicz
- Department of Cardiology and Electrotherapy, Faculty of Medicine, Medical University of Gdańsk, Smoluchowskiego 17, 80-213, Gdańsk, Poland.
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5
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Ballantyne BA, Chew DS, Vandenberk B. Paradigm Shifts in Cardiac Pacing: Where Have We Been and What Lies Ahead? J Clin Med 2023; 12:jcm12082938. [PMID: 37109274 PMCID: PMC10146747 DOI: 10.3390/jcm12082938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/07/2023] [Accepted: 04/09/2023] [Indexed: 04/29/2023] Open
Abstract
The history of cardiac pacing dates back to the 1930s with externalized pacing and has evolved to incorporate transvenous, multi-lead, or even leadless devices. Annual implantation rates of cardiac implantable electronic devices have increased since the introduction of the implantable system, likely related to expanding indications, and increasing global life expectancy and aging demographics. Here, we summarize the relevant literature on cardiac pacing to demonstrate the enormous impact it has had within the field of cardiology. Further, we look forward to the future of cardiac pacing, including conduction system pacing and leadless pacing strategies.
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Affiliation(s)
- Brennan A Ballantyne
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Derek S Chew
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Bert Vandenberk
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium
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6
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Santoro A, Landra F, Marallo C, Taddeucci S, Sisti N, Pica A, Stefanini A, Tavera MC, Pagliaro A, Baiocchi C, Cameli M. Biventricular or Conduction System Pacing for Cardiac Resynchronization Therapy: A Strategy for Cardiac Resynchronization Based on a Hybrid Approach. J Cardiovasc Dev Dis 2023; 10:jcdd10040169. [PMID: 37103048 PMCID: PMC10146594 DOI: 10.3390/jcdd10040169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is usually performed with biventricular pacing (BiVP), but recently, conduction system pacing (CSP) has been proposed as an alternative in case of BiVP failure. The aim of this study is to define an algorithm to choose between BiVP and CSP resynchronization using the interventricular conduction delays (IVCD) as a guide. METHODS Consecutive patients from January 2018 to December 2020 with an indication for CRT were prospectively enrolled in the study group (delays-guided resynchronization group, DRG). A treatment algorithm based on IVCD was used to decide whether to leave the left ventricular (LV) lead to perform BiVP or pull it out and perform CSP. Outcomes from the DRG group were compared to a historical cohort of CRT patients who underwent CRT procedures between January 2016 and December 2017 (resynchronization standard guide group, SRG). The primary endpoint was a composite of cardiovascular mortality, heart failure (HF) hospitalization, or HF event at 1 year after the date of intervention. RESULTS The study population consisted of 292 patients, of which 160 (54.8%) were in the DRG and 132 (45.2%) in the SRG. In the DRG, 41 of 160 patients underwent CSP based on the treatment algorithm (25.6%). The primary endpoint was significantly higher in the SRG (48/132, 36.4%) compared to the DRG (35/160, 21.8%) (hazard ratio (HR): 1.72; 95% confidence interval (CI): 1.12-2.65; p = 0.013). CONCLUSIONS A treatment algorithm based on IVCD shifted one patient out of every four from BiVP to CSP, with consequent reduction in the primary endpoint after implantation. Therefore, its application could be useful to determine whether to perform BiVP or CSP.
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Affiliation(s)
- Amato Santoro
- Division of Cardiology, Azienda Ospedaliera Universitaria Senese, Viale Bracci 1, 53100 Siena, Italy
| | - Federico Landra
- Division of Cardiology, Università degli Studi di Siena, Viale Bracci 4, 53100 Siena, Italy
| | - Carmine Marallo
- Division of Cardiology, Università degli Studi di Siena, Viale Bracci 4, 53100 Siena, Italy
| | - Simone Taddeucci
- Division of Cardiology, Università degli Studi di Siena, Viale Bracci 4, 53100 Siena, Italy
| | - Nicolò Sisti
- Division of Cardiology, San Donato Hospital, Via Pietro Nenni, 52100 Arezzo, Italy
| | - Andrea Pica
- Division of Cardiology, Università degli Studi di Siena, Viale Bracci 4, 53100 Siena, Italy
| | - Andrea Stefanini
- Division of Cardiology, Università degli Studi di Siena, Viale Bracci 4, 53100 Siena, Italy
| | - Maria Cristina Tavera
- Division of Cardiology, Azienda Ospedaliera Universitaria Senese, Viale Bracci 1, 53100 Siena, Italy
| | - Antonio Pagliaro
- Division of Cardiology, Azienda Ospedaliera Universitaria Senese, Viale Bracci 1, 53100 Siena, Italy
| | - Claudia Baiocchi
- Division of Cardiology, Azienda Ospedaliera Universitaria Senese, Viale Bracci 1, 53100 Siena, Italy
| | - Matteo Cameli
- Division of Cardiology, Università degli Studi di Siena, Viale Bracci 4, 53100 Siena, Italy
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7
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In the right place at the right (conduction) time. Heart Rhythm 2023; 20:393-394. [PMID: 36496134 DOI: 10.1016/j.hrthm.2022.12.004] [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: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022]
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8
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Haqqani HM, Burri H, Kayser T, Carter N, Gold MR. Association of interventricular activation delay with clinical outcomes in cardiac resynchronization therapy. Heart Rhythm 2023; 20:385-392. [PMID: 36436813 DOI: 10.1016/j.hrthm.2022.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/16/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pacing at sites of longest interventricular delay has been associated with greater reverse remodeling in cardiac resynchronization therapy (CRT). However, the effects of pacing at such sites on clinical outcomes is less well studied. OBJECTIVE The purpose of this study was to assess the association between interventricular delay and clinical outcomes in CRT patients implanted with quadripolar left ventricular (LV) leads. METHODS RALLY-X4 was a registry study of the Acuity X4 quadripolar LV leads. Interventricular delay was measured during unpaced basal rhythm from the right ventricular (RV) lead to the LV lead electrode (E1 to E4) chosen for CRT pacing. Patients were stratified by median RV-LV delay (80 ms) into short and long delay groups; they also were analyzed by multivariable modeling. The primary composite outcome measure was all-cause mortality and heart failure hospitalization (HFH) at 18 months. RESULTS A total of 581 patients had complete RV-LV delay data. Mean LV ejection fraction was 27%, and 73% had typical left bundle branch block. Predictors of long RV-LV delay included female sex, left bundle branch block, and QRS duration >150 ms. Survival free of the primary outcome at 18-month follow-up was 87% in the long activation delay group compared with 77% in the short delay group (P = .0042). Multivariate analysis showed that RV-LV delay was an independent predictor of survival free of HFH (P = .028). CONCLUSION Among CRT patients with quadripolar LV pacing leads, longer baseline interventricular activation delay was significantly associated with the composite endpoint of all-cause mortality and HFH.
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Affiliation(s)
- Haris M Haqqani
- Department of Cardiology, The Prince Charles Hospital, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Haran Burri
- Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | | | | | - Michael R Gold
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.
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9
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Gautam N, Ghanta SN, Clausen A, Saluja P, Sivakumar K, Dhar G, Chang Q, DeMazumder D, Rabbat MG, Greene SJ, Fudim M, Al'Aref SJ. Contemporary Applications of Machine Learning for Device Therapy in Heart Failure. JACC. HEART FAILURE 2022; 10:603-622. [PMID: 36049812 DOI: 10.1016/j.jchf.2022.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 05/31/2022] [Accepted: 06/16/2022] [Indexed: 06/15/2023]
Abstract
Despite a better understanding of the underlying pathogenesis of heart failure (HF), pharmacotherapy, surgical, and percutaneous interventions do not prevent disease progression in all patients, and a significant proportion of patients end up requiring advanced therapies. Machine learning (ML) is gaining wider acceptance in cardiovascular medicine because of its ability to incorporate large, complex, and multidimensional data and to potentially facilitate the creation of predictive models not constrained by many of the limitations of traditional statistical approaches. With the coexistence of "big data" and novel advanced analytic techniques using ML, there is ever-increasing research into applying ML in the context of HF with the goal of improving patient outcomes. Through this review, the authors describe the basics of ML and summarize the existing published reports regarding contemporary applications of ML in device therapy for HF while highlighting the limitations to widespread implementation and its future promises.
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Affiliation(s)
- Nitesh Gautam
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Sai Nikhila Ghanta
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Alex Clausen
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Prachi Saluja
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Kalai Sivakumar
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Gaurav Dhar
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Qi Chang
- Department of Computer Science, Rutgers University, The State University of New Jersey, Newark, New Jersey, USA
| | | | - Mark G Rabbat
- Department of Cardiology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Stephen J Greene
- Department of Cardiology, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Marat Fudim
- Department of Cardiology, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Subhi J Al'Aref
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
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10
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Gowani ZS, Tomashitis B, Vo CN, Field ME, Gold MR. Role of Electrical Delay in Cardiac Resynchronization Therapy Response. Card Electrophysiol Clin 2022; 14:233-241. [PMID: 35715081 DOI: 10.1016/j.ccep.2021.12.013] [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: 10/18/2022]
Abstract
Traditionally, left ventricular (LV) lead position was guided by anatomic criteria of pacing from the lateral wall of the LV. However, large trials showed little effect of LV lead position on outcomes, other than noting worse outcomes with apical positions. Given the poor correlation of cardiac resynchronization therapy (CRT) outcomes with anatomically guided LV lead placement, focus shifted toward more physiologic predictors such as targeting the areas of delayed mechanical and electrical activation. Measures of left ventricular delay and interventricular delay are strong predictors of CRT response.
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Affiliation(s)
- Zain S Gowani
- Department of Medicine, Medical University of South Carolina, 25 Courtenay Drive, MS-492, Charleston, SC 29425, USA
| | - Brett Tomashitis
- Department of Medicine, Medical University of South Carolina, 25 Courtenay Drive, MS-492, Charleston, SC 29425, USA
| | - Chau N Vo
- Department of Medicine, Medical University of South Carolina, 25 Courtenay Drive, MS-492, Charleston, SC 29425, USA
| | - Michael E Field
- Department of Medicine, Medical University of South Carolina, 25 Courtenay Drive, MS-492, Charleston, SC 29425, USA
| | - Michael R Gold
- Department of Medicine, Medical University of South Carolina, 25 Courtenay Drive, MS-492, Charleston, SC 29425, USA.
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11
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Electrocardiographic and echocardiographic dyssynchrony parameters that might better predict the response to cardiac resynchronization therapy than QRS morphology and duration. J Geriatr Cardiol 2022; 19:98-100. [PMID: 35317395 PMCID: PMC8915425 DOI: 10.11909/j.issn.1671-5411.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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12
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Novel electrocardiographic dyssynchrony criteria that may improve patient selection for cardiac resynchronization therapy. J Geriatr Cardiol 2022; 19:31-43. [PMID: 35233221 PMCID: PMC8832041 DOI: 10.11909/j.issn.1671-5411.2022.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is an evidence-based effective therapy of symptomatic heart failure with reduced ejection fraction refractory to optimal medical treatment associated with intraventricular conduction disturbance, that results in electrical dyssynchrony and further deterioration of systolic ventricular function. However, the non-response rate to CRT is still 20%−40%, which can be decreased by better patient selection. The main determinant of CRT outcome is the presence or absence of significant ventricular dyssynchrony and the ability of the applied CRT technique to eliminate it. The current guidelines recommend the determination of QRS morphology and QRS duration and the measurement of left ventricular ejection fraction for patient selection for CRT. However, QRS morphology and QRS duration are not perfect indicators of electrical dyssynchrony, which is the cause of the not negligible non-response rate to CRT and the missed CRT implantation in a significant number of patients who have the appropriate substrate for CRT. Using imaging modalities, many ventricular dyssynchrony criteria were devised for the detection of mechanical dyssynchrony, but their utility in patient selection for CRT is not yet proven, therefore their use is not recommended for this purpose. Moreover, CRT can eliminate only mechanical dyssynchrony due to underlying electrical dyssynchrony, for this reason ECG has a greater role in the detection of ventricular dyssynchrony than imaging modalities. To improve assessment of electrical dyssynchrony, we devised two novel ECG dyssynchrony criteria, which can estimate interventricular and left ventricular intraventricular dyssynchrony in order to improve patient selection for CRT. Here we discuss the results achieved by the application of these new ECG dyssynchrony criteria, which proved to be useful in predicting the CRT response in patients with nonspecific intraventricular conduction disturbance pattern (the second greatest group of CRT candidates), and the significance of other new ECG dyssynchrony criteria in the potential improvement of CRT outcome.
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13
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Fyenbo DB, Sommer A, Nørgaard BL, Kronborg MB, Kristensen J, Gerdes C, Jensen HK, Jensen JM, Nielsen JC. Long-term outcomes in a randomized controlled trial of multimodality imaging-guided left ventricular lead placement in cardiac resynchronization therapy. Europace 2022; 24:828-834. [PMID: 35041000 DOI: 10.1093/europace/euab314] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 12/08/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS This study aims to investigate the long-term occurrence of the composite endpoint of heart failure (HF) hospitalization or all-cause death (primary endpoint) in patients randomized to cardiac resynchronization therapy (CRT) using individualized multimodality imaging-guided left ventricular (LV) lead placement compared with a routine fluoroscopic approach. Furthermore, this study aims to evaluate whether inter-lead electrical delay (IED) is associated with improved response rate of this endpoint. METHODS AND RESULTS We reviewed follow-up data until November 2020 for all 182 patients included in the ImagingCRT trial for the occurrence of HF hospitalization and all-cause death. During median (inter-quartile range) time to primary endpoint/censuring of 6.7 (3.3-7.9) years, the rate of the primary endpoint was 60% (n = 53) in the imaging group compared with 52% (n = 48) in the control group [hazard ratio (HR) 1.22, 95% confidence interval (CI) 0.83-1.81, P = 0.31]. Neither the risk of HF hospitalization (HR 1.11, 95% CI 0.62-1.99, P = 0.72) nor of all-cause death differed between treatment groups (HR 1.23, 95% CI 0.82-1.85, P = 0.32). The risk of the primary endpoint was significantly reduced among those with IED ≥100 ms when compared with those with IED <100 ms (HR 0.62, 95% CI 0.39-0.98, P = 0.04). CONCLUSIONS In this study, an individualized multimodality imaging-guided strategy targeting LV lead placement towards the latest mechanically activated non-scarred myocardial segment during CRT implantation did not reduce HF hospitalization or all-cause death when compared with routine LV lead placement during long-term follow-up. Targeting the latest electrical activation should be studied as an alternative individualized strategy for optimizing LV lead placement in CRT recipients.
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Affiliation(s)
- Daniel Benjamin Fyenbo
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anders Sommer
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Bjarne Linde Nørgaard
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Mads Brix Kronborg
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Kristensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Christian Gerdes
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Henrik Kjærulf Jensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jesper Møller Jensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Soejima K, Kondo Y, Sasaki S, Adachi K, Kato R, Hagiwara N, Harada T, Kusano K, Miura F, Morishima I, Yoshitani K, Yotsukura A, Fujimoto M, Nishii N, Shimeno K, Ohe M, Tasaka H, Sasaki H, Schrader J, Ando K. Intracardiac conduction time as a predictor of cardiac resynchronization therapy response: Results of the BIO|SELECT pilot study. Heart Rhythm O2 2022; 2:588-596. [PMID: 34988503 PMCID: PMC8703154 DOI: 10.1016/j.hroo.2021.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Quadripolar left ventricular (LV) leads are capable of sensing and pacing the left ventricle from 4 different electrodes, which may potentially improve patient response to cardiac resynchronization therapy (CRT). Objective We measured 3 different time intervals: right ventricular (RV)-sensed to LV-sensed during intrinsic rhythm (RVs-LVs), RV-paced to LV-sensed (RVp-LVs), and LV-paced to LV-sensed (LVp-LVs, between distal [LV1] and proximal pole on a quadripolar LV lead), and assessed their association with CRT response in terms of LV end-systolic volume (LVESV) and a composite benefit index (CBI) comprising LVESV, LV ejection fraction (LVEF), brain natriuretic peptide level, and NYHA class. Methods A CRT-defibrillator system with quadripolar LV lead was implanted in 196 patients (mean age 69 years, mean LVEF 30%, left bundle-branch block [LBBB] 58%). Conduction intervals were measured before hospital discharge. At baseline and 7-month follow-up, echocardiographic and other components of CBI were determined. Results The mean RVs-LV1s, RVp-LV1s, and LVp-LVs delays were 68 ± 38 ms, 132 ± 34 ms, and 99 ± 31 ms, respectively. From baseline to 7 months, LVESV decreased by 17.3% ± 28.6%. The RVs-LV1s interval correlated stronger with CBI (R2 = 0.12, P < .00001) than with LVESV change (R2 = 0.05, P = .006). In contrast, RVp-LV1s did not correlate and LVp-LVs correlated only weakly with CRT response. The subgroup of patients (44%) with LBBB and RVs-LV1s above the lower quartile (≥34 ms) showed the greatest response to CRT. Conclusion The RVs-LVs interval during intrinsic rhythm is relevant for CRT success, whereas RVp-LVs and LVp-LVs intervals did not predict CRT response.
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Affiliation(s)
| | - Yusuke Kondo
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shingo Sasaki
- Department of Cardiology and Nephrology, Hirosaki University, Graduate School of Medicine, Aomori, Japan
| | | | | | | | - Tomoo Harada
- St. Marianna University School of Medicine, Kanagawa, Japan
| | - Kengo Kusano
- National Cerebral and Cardiovascular Center, Osaka, Japan
| | | | | | | | | | | | | | | | | | | | | | | | - Kenji Ando
- Kokura Memorial Hospital, Fukuoka, Japan
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15
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Howell S, Stivland TM, Stein K, Ellenbogen K, Tereshchenko LG. Response to cardiac resynchronisation therapy in men and women: a secondary analysis of the SMART-AV randomised controlled trial. BMJ Open 2021; 11:e049017. [PMID: 34706949 PMCID: PMC8552143 DOI: 10.1136/bmjopen-2021-049017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES There is a controversy about whether both sexes' response to cardiac resynchronisation therapy (CRT) is similar. We aimed to assess a causal effect of sex on CRT response. DESIGN Secondary analysis of a randomised controlled trial (RCT) data. Doubly robust augmented-inverse-probability-weighted (AIPW) estimation of sex effect on CRT response. SETTING The SmartDelay Determined Atrioventricular (AV) Optimisation (SMART-AV) RCT. PARTICIPANTS The SMART-AV RCT enrolled New York Heart Association class III-IV patients with heart failure (HF) with left ventricular ejection fraction (LVEF) ≤35% despite optimal medical therapy and QRS duration ≥120 ms, in sinus rhythm. After exclusion of those with missing outcome or covariates, 741 participants (age 66±11 years; 33% female; 78% white; LVEF 28%±9%; 58% ischaemic cardiomyopathy; 75% left bundle branch block; left ventricular end-systolic volume index (LVESVI) 65±30 mL/m2) were included. INTERVENTIONS Implanted CRT defibrillator with randomly assigned AV delay as either (1) fixed at 120 ms, or (2) echocardiography-determined, or (3) SmartDelay algorithm-programmed. OUTCOME A composite of freedom from death and HF hospitalisation and a >15% reduction in LVESVI at 6 month post-CRT was the endpoint. RESULTS The primary endpoint was met by 337 patients (45.5%); 134 were women (55.6% response) and 203 were men (40.6% response); p<0.0001. After conditioning for 33 covariates that included baseline demographic, clinical, ECG, echocardiographic and biomarker characteristics, known predictors of CRT response, logistic regression showed a higher probability for composite CRT response for women versus men (OR 1.79; 95% CI 1.08 to 2.98; p<0.0001), whereas AIPW estimation showed no difference in CRT response (average treatment effect 0.88; 95% CI 0.41 to 1.89; p=0.739). After removing colliders from the model, both logistic regression (OR 1.00; 95% CI 0.69 to 1.44) and AIPW (ATE 1.06; 95% CI 0.96 to 1.16) reported similar results. CONCLUSIONS Both sexes' response to CRT is similar. Sex differences in HF substrate, treatment and comorbidities explain sex disparities in CRT outcomes. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier; NCT00677014.
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Affiliation(s)
- Stacey Howell
- Department of Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | | | - Kenneth Stein
- Boston Scientific Corp, Marlborough, Massachusetts, USA
| | - Kenneth Ellenbogen
- Department of Medicine, Medical College of Virginia, Richmond, Virginia, USA
| | - Larisa G Tereshchenko
- Department of Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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16
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Gold MR, Siejko KZ, Yu Y, Auricchio A. Estimating Left Ventricular Electrical Delay From the Right Ventricular Lead Electrogram. JACC Clin Electrophysiol 2021; 7:1195-1196. [PMID: 34454882 DOI: 10.1016/j.jacep.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
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17
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Using Machine-Learning for Prediction of the Response to Cardiac Resynchronization Therapy: The SMART-AV Study. JACC Clin Electrophysiol 2021; 7:1505-1515. [PMID: 34454883 DOI: 10.1016/j.jacep.2021.06.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/17/2021] [Accepted: 06/17/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVES This study aimed to apply machine learning (ML) to develop a prediction model for short-term cardiac resynchronization therapy (CRT) response to identifying CRT candidates for early multidisciplinary CRT heart failure (HF) care. BACKGROUND Multidisciplinary optimization of cardiac resynchronization therapy (CRT) delivery can improve long-term CRT outcomes but requires substantial staff resources. METHODS Participants from the SMART-AV (SmartDelay-Determined AV Optimization: Comparison of AV Optimization Methods Used in Cardiac Resynchronization Therapy [CRT]) trial (n = 741; age: 66 ± 11 years; 33% female; 100% New York Heart Association HF class III-IV; 100% ejection fraction ≤35%) were randomly split into training/testing (80%; n = 593) and validation (20%; n = 148) samples. Baseline clinical, electrocardiographic, echocardiographic, and biomarker characteristics, and left ventricular (LV) lead position (43 variables) were included in 8 ML models (random forests, convolutional neural network, lasso, adaptive lasso, plugin lasso, elastic net, ridge, and logistic regression). A composite of freedom from death and HF hospitalization and a >15% reduction in LV end-systolic volume index at 6 months after CRT was the end point. RESULTS The primary end point was met by 337 patients (45.5%). The adaptive lasso model was the most more accurate (area under the receiver operating characteristic curve: 0.759; 95% confidence interval [CI]: 0.678-0.840), well calibrated, and parsimonious (19 predictors; nearly half potentially modifiable). Participants in the 5th quintile compared with those in the 1st quintile of the prediction model had 14-fold higher odds of composite CRT response (odds ratio: 14.0; 95% CI: 8.0-14.4). The model predicted CRT response with 70% accuracy, 70% sensitivity, and 70% specificity, and should be further validated in prospective studies. CONCLUSIONS ML predicts short-term CRT response and thus may help with CRT procedure and early post-CRT care planning. (SmartDelay-Determined AV Optimization: A Comparison of AV Optimization Methods Used in Cardiac Resynchronization Therapy [CRT] [SMART-AV]; NCT00677014).
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18
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O'Donnell D, Manyam H, Pappone C, Park SJ, Leclercq C, Lunati M, Lercher P, Rordorf R, Landolina M, Badie N, McSpadden LC, Ryu K, Mangual JO, Singh JP, Varma N, Niazi IK. Ventricular activation patterns during intrinsic conduction and right ventricular pacing in cardiac resynchronization therapy patients. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1663-1670. [PMID: 34319603 DOI: 10.1111/pace.14329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/10/2021] [Accepted: 07/18/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) involves stimulation of both right ventricle (RV) and left ventricle (LV). LV pacing from the sites of delayed electrical activation improves CRT response. The RV-LV conduction is typically measured in intrinsic rhythm. The differences in RV-LV conduction patterns and timing between intrinsic rhythm and during paced RV activation, these differences are not fully understood. METHODS Enrolled patients were implanted with a de novo CRT device and quadripolar LV lead, with lead implant locations at the implanting physician's discretion. QRS duration and conduction delay between the RV lead and each of the four LV electrodes (D1, M2, M3, and P4) were measured during intrinsic conduction and RV pacing. RESULTS Conduction measurements were collected from 275 patients across 14 international centers (68 ± 13 years of age, 73% male, 45% ischemic, 158 ± 22 ms QRS duration). Mean RV-LV conduction time was shorter during intrinsic conduction versus RV pacing by 59.6 ms (106.5 ± 36.5 versus 166.1 ± 32.1 ms, p < 0.001). The intra-LV activation delay between the latest and earliest activating LV electrode was also shorter during intrinsic conduction versus RV pacing by 6.6 ms (20.6 ± 13.1 vs. 27.2 ± 21.2 ms, p < 0.001). Intrinsic conduction and RV pacing resulted in a different activation order in 72.7% of patients, and the same LV activation order in 27.3%. CONCLUSIONS Differences in RV-LV conduction time, intra-LV conduction time, and activation pattern were observed between intrinsic conduction and RV pacing. These findings highlight the importance of evaluating intrinsic versus paced ventricular activation to guide LV pacing site selection in CRT patients.
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Affiliation(s)
- David O'Donnell
- Cardiology, GenesisCare, Wellington Parade, Melbourne, Australia
| | - Harish Manyam
- Department of Cardiology, Erlanger Hospital University of Tennessee, Chattanooga, Tennessee, USA
| | - Carlo Pappone
- Department of Arrhythmology, I.R.C.C.S. Policlinico San Donato, San Donato Milanese, Italy
| | - Seung-Jung Park
- Samsung Medical Center, Sungkyunkwan School of Medicine, Seoul, Korea
| | | | - Maurizio Lunati
- Cardiac Department, Niguarda Ca' Granda, Granda Hospital, Milan, Italy
| | - Peter Lercher
- Department of Cardiology, Medical University Graz, Graz, Austria
| | - Roberto Rordorf
- Coronay Care Unit, Department of Cardiology, Fondazione Policlinico San Matteo, Pavia, Italy
| | - Maurizio Landolina
- Coronay Care Unit, Department of Cardiology, Fondazione Policlinico San Matteo, Pavia, Italy.,Cardiology Department, Ospedale Maggiore di Crema, Crema, Italy
| | | | | | | | | | - Jagmeet P Singh
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Niraj Varma
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Imran K Niazi
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Milwaukee, Wisconsin, USA
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19
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Gardner RS, D'Onofrio A, Mark G, Gras D, Hu Y, Veraghtert S, Garcia‐Bolao I. Real-world outcomes in cardiac resynchronization therapy patients: design and baseline demographics of the SMART- Registry. ESC Heart Fail 2021; 8:1675-1680. [PMID: 33465287 PMCID: PMC8006707 DOI: 10.1002/ehf2.13192] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/22/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS The SMART (Strategic MAnagement to optimize response to cardiac Resynchronization Therapy) Registry was designed to assess real-world outcomes for patients receiving a cardiac resynchronization therapy defibrillator (CRT-D) and to better understand which programming and optimization techniques are used and how effective they are. METHODS AND RESULTS The SMART Registry is a global, multicentre, prospective, observational, post-market CRT-D registry with a planned enrolment of 2000 subjects from a maximum of 200 sites in Europe, North America, and Asia-Pacific region. Each subject will be followed up for a minimum of 12 months. The primary endpoint of CRT response rate at 12 months is defined by a clinical composite score of all-cause mortality, heart failure events, New York Heart Association Class, and quality of life as assessed by a patient global assessment instrument. A subgroup composed of the first 103 consecutive European subjects implanted with an NG4 device will have left ventricular multisite pacing feature enabled at any time during the initial 12 months of follow-up. The primary endpoint for this sub-analysis will be the NG4 PG-related complication-free rate at 36 months. CONCLUSIONS The SMART Registry achieved its recruitment target in August 2019, with 2014 patients enrolled. The baseline demographics demonstrated that patients were generally older, with greater co-morbidity, and on more contemporary medical therapy than in the key CRT trials. The results of the SMART Registry will determine which programming and optimization techniques are effective in this real-world population.
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Affiliation(s)
- Roy S. Gardner
- Scottish National Advanced Heart Failure ServiceGolden Jubilee National HospitalClydebankG81 4DYUK
| | - Antonio D'Onofrio
- Department of CardiologyAzienda Ospedaliera dei Colli – MonaldiNaplesItaly
| | - George Mark
- Cardiology Associates of the Delaware Valley, PAHaddon HeightsNJUSA
| | | | - Yan Hu
- Boston Scientific CorporationSt. PaulMNUSA
| | | | - Ignacio Garcia‐Bolao
- Clinica Universidad de NavarraPamplonaSpain
- IdiSNANavarra Institute for Health ResearchPamplonaSpain
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20
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Moubarak G, Sebag FA, Socie P, Villejoubert O, Louembe J, Ferchaud V. Interrelationships between interventricular electrical delays in cardiac resynchronization therapy. J Cardiovasc Electrophysiol 2020; 31:2405-2414. [PMID: 32562444 DOI: 10.1111/jce.14629] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/07/2020] [Accepted: 06/14/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION In cardiac resynchronization therapy, pacing the left ventricle (LV) at sites of prolonged electrical delay is associated with better outcomes. We sought to characterize the interrelationships between intrinsic, right-ventricular (RV)-paced, and LV-paced interventricular delays. METHODS AND RESULTS The following electrical timings were measured at implantation for all electrodes of the LV quadripolar leads: QLV, interventricular delay in intrinsic rhythm (RVs-LVs), in RV-paced rhythm (RVp-LVs), and in LV-paced rhythm (LVp-RVs). We included 32 patients (78% men, age 72 years, LV ejection fraction 29%, left bundle branch block 84%). QLV and RVs-LVs were correlated (R2 = .72, p < .0001), as were RVs-LVs and RVp-LVs (R2 = .27, p = .002) and RVp-LVs and LVp-RVs (R2 = .60, p < .001). Direction of activation along the four LV lead electrodes was concordant between RVs-LVs and RVp-LVs in only 17 (53%) patients. The latest-activated electrodes in RVs-LVs and RVp-LVs were concordant in 26 (81%) patients, adjacent in 3 (9%) patients, and remote in 3 (9%) patients. Biventricular-paced QRS duration varied by more than 10 ms between the two electrodes in half of the patients with dissimilar latest electrodes. Among the seven echocardiographic nonresponders at 6 months, the programmed electrode was remote from the latest electrode in RVs-LVs in five patients and in RVp-LVs in three patients. CONCLUSION Intrinsic and RV-paced interventricular electrical delays are correlated, but there is substantial heterogeneity between patients. The latest-activated electrode may be different between RVs-LVs and RVp-LVs, and this might have important implications in selecting the optimal LV vector.
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Affiliation(s)
- Ghassan Moubarak
- Department of Electrophysiology and Pacing, Centre Médico-Chirurgical Ambroise Paré, Neuilly-sur-Seine, France
| | - Frédéric A Sebag
- Département de Cardiologie Médicale, Institut Mutualiste Montsouris, Paris, France
| | - Pierre Socie
- Department of Cardiology, Centre Hospitalier de Chartres, Chartres, France
| | - Olivier Villejoubert
- Département de Cardiologie Médicale, Institut Mutualiste Montsouris, Paris, France
| | - Jules Louembe
- Department of Cardiology, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Virginie Ferchaud
- Department of Electrophysiology and Pacing, Centre Médico-Chirurgical Ambroise Paré, Neuilly-sur-Seine, France.,Department of Cardiology, Centre Hospitalier Universitaire de Caen Normandie, Caen, France
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