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Gold MR, Auricchio A, Leclercq C, Wold N, Stein KM, Ellenbogen KA. Atrioventricular optimization improves cardiac resynchronization response in patients with long interventricular electrical delays: A pooled analysis of the SMART-AV and SMART-CRT trials. Heart Rhythm 2024; 21:1686-1694. [PMID: 38604592 DOI: 10.1016/j.hrthm.2024.03.1783] [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: 03/07/2024] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND The utility of atrioventricular (AV) optimization (AVO) algorithms remains in question. A substudy of the SMART-AV trial found that patients with prolonged interventricular delays ≥70 ms were more likely to benefit from cardiac resynchronization therapy (CRT) with AVO. The SMART-CRT trial evaluated AVO on the basis of these results, but the study was underpowered. OBJECTIVE To increase statistical power, data from SMART-AV patients meeting the inclusion criterion of interventricular delay ≥70 ms were pooled with data from SMART-CRT to reassess AVO. METHODS SMART-CRT and SMART-AV were prospective, randomized, multicenter clinical trials. Patients in both studies were randomized to be programmed with an AVO algorithm (SmartDelay) or fixed AV delay (120 ms). Paired echocardiograms obtained at baseline and 6 months were compared, with CRT response defined as ≥15% reduction in left ventricular end-systolic volume. RESULTS A total of 451 complete patient data sets were pooled and analyzed. The baseline demographics between studies did not differ statistically in terms of age, sex, left ventricular ejection fraction, or left ventricular end-systolic volume. The AVO group had a greater proportion of CRT responders (SmartDelay, 73.9%; fixed, 63.1%; P = .014) and greater changes in measures of reverse remodeling. SmartDelay patients with a recommended sensed AV delay outside the nominal range (100-120 ms) had 2.3 greater odds of CRT response than fixed AV delay patients. CONCLUSION Greater CRT response and measures of reverse remodeling were observed in patients with SmartDelay enabled vs a fixed AV delay. This study supports the use of SmartDelay in patients with a CRT indication and interventricular delay ≥70 ms.
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Affiliation(s)
- Michael R Gold
- Medical University of South Carolina, Charleston, South Carolina.
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Khalid SN, Mansoor T, Bilal MI, Ijaz SH, Fudim M, Greene SJ, Nambi V, Virani SS, Fonarow GC, Abramov D, Minhas AMK. Ongoing and future clinical trials of device therapies for patients with heart failure. Curr Probl Cardiol 2024; 49:102805. [PMID: 39159710 DOI: 10.1016/j.cpcardiol.2024.102805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2024] [Accepted: 08/16/2024] [Indexed: 08/21/2024]
Abstract
Heart failure continues to pose a significant burden in terms of morbidity, mortality, and healthcare costs worldwide despite the implementation of guideline-directed medical therapy. Addressing this challenge and improving clinical outcomes for this patient population remains an urgent priority. Recognizing the limitations in current medical approaches and exploring strategies to overcome these limitations are crucial steps toward improving future outcomes. Various device-based interventions, such as Cardiac Resynchronization Therapy devices and Left Ventricular Assist Devices, have demonstrated notable benefits for individuals with heart failure. Our review is aimed at summarizing the ongoing research into new device therapies for heart failure, emphasizing their potential to overcome the current challenges in treatment. By utilizing Clinicaltrials.gov, an online repository, we conducted a comprehensive search for trials investigating emerging device therapies for patients dealing with heart failure.
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Affiliation(s)
| | - Taha Mansoor
- Department of Internal Medicine, Western Michigan University Homer Stryker M.D. School of Medicine.
| | | | | | - Marat Fudim
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Vijay Nambi
- Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX, USA; Michael E. DeBakey Veterans Affair Medical Center
| | - Salim S Virani
- Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX, USA; Department of Medicine, Aga Khan University, Karachi; Texas Heart Institute, Houston, TX, Pakistan
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles CA, USA
| | - Dmitry Abramov
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA, USA
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Ma X, Chen Z, Song Y, Wang J, Yang S, Yu S, Dong Z, Chen X, Wu S, Gao Y, Dai Y, Zhang S, Fan X, Hua W, Chen K, Zhao S. CMR feature tracking-based left atrial mechanics predicts response to cardiac resynchronization therapy and adverse outcomes. Heart Rhythm 2024; 21:1354-1362. [PMID: 38493992 DOI: 10.1016/j.hrthm.2024.03.028] [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: 11/21/2023] [Revised: 02/25/2024] [Accepted: 03/12/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is an established therapy for advanced heart failure (HF) with prolonged QRS duration. However, 30% of patients have shown no benefit from the treatment. OBJECTIVE This study aimed to examine the value of left atrial (LA) mechanics by cardiac magnetic resonance (CMR) to predict response to CRT and clinical outcomes. METHODS A total of 163 CRT recipients with preimplantation CMR examination were retrospectively recruited. CMR feature tracking was used to evaluate LA size and function. The end points include (1) improvement of at least 5% in left ventricular ejection fraction combined with a reduction of at least 1 New York Heart Association functional class at 6-month follow-up and (2) any all-cause death or HF hospitalization during follow-up. RESULTS Overall, 82 (50.3%) were CRT responders. CRT nonresponders had larger LA and worse LA reservoir and booster pump function than did responders (P < .001 for all). LA structural (maximum volume index < 47 mL/m2) and functional (booster pump strain > 8.5%) criteria were incremental to traditional indicators in detecting CRT response (χ2, 40.83 vs 9.98; P < .001). During follow-up (median 41 months), survival free from death or HF hospitalization increased with the number of positive LA criteria (log-rank, P < .001). After adjustment for clinical confounders, the absence of the 2 criteria remained associated with a considerably increased risk of death or HF hospitalization (adjusted hazard ratio 6.2; 95% confidence interval 2.15-17.88; P = .001). CONCLUSION The preprocedure LA mechanics evaluated using CMR may be useful to predict response to CRT and improve risk stratification in CRT recipients.
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Affiliation(s)
- Xuan Ma
- MR Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhongli Chen
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanyan Song
- MR Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiaxin Wang
- MR Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shujuan Yang
- MR Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shiqin Yu
- MR Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhixiang Dong
- MR Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiuyu Chen
- MR Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sijin Wu
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Gao
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Dai
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu Zhang
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaohan Fan
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Hua
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Keping Chen
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shihua Zhao
- MR Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Francisco-Pascual J, Adeliño R, Quesada A, Sainz Godoy I, Exposito V, Ferrando J, Fernadez Armenta J, Cabanas P, Pérez-Rodon J, Santos-Ortega A, Villuendas R, Trucco E, Benito B, Jordan-Marchite P, Rodríguez-Palomares JF, Ferreira-González I, Rivas-Gándara N. Cardiac resynchronization therapy with triple fusion using the SyncAV dynamic algorithm compared to conventionally optimized biventricular pacing: Results from the multicentric, randomized, double-blinded CRUSTY trial. Heart Rhythm 2024:S1547-5271(24)02696-1. [PMID: 38880204 DOI: 10.1016/j.hrthm.2024.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 06/01/2024] [Accepted: 06/08/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Jaume Francisco-Pascual
- Arrhythmia Unit, Cardiology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain; CIBER de Enfermedades Cardiovasculares (CIBER-CV), Instituto de Salud Carlos III, Madrid, Spain.
| | - Raquel Adeliño
- Arrhythmia Unit, Cardiology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain; CIBER de Enfermedades Cardiovasculares (CIBER-CV), Instituto de Salud Carlos III, Madrid, Spain; Unitat d'Arritmies, Servei de Cardiologia, Hospital Universitari Germans Tries i Pujol, Barcelona, Spain
| | | | | | - Victor Exposito
- Unidad de Arritmias, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | | | - Pilar Cabanas
- Unidad de Arritmias, Servicio de Cardiologia, Hospital Álvaro Cunqueiro, Pontevedra, Spain
| | - Jordi Pérez-Rodon
- Arrhythmia Unit, Cardiology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain; CIBER de Enfermedades Cardiovasculares (CIBER-CV), Instituto de Salud Carlos III, Madrid, Spain
| | - Alba Santos-Ortega
- Arrhythmia Unit, Cardiology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain; CIBER de Enfermedades Cardiovasculares (CIBER-CV), Instituto de Salud Carlos III, Madrid, Spain
| | - Roger Villuendas
- Unitat d'Arritmies, Servei de Cardiologia, Hospital Universitari Germans Tries i Pujol, Barcelona, Spain
| | - Emilce Trucco
- Arrythmia Unit, Cardiology Department, Hospital Universitari de Griona Dr Josep Trueta, Girona, Spain
| | - Begoña Benito
- Arrhythmia Unit, Cardiology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain; CIBER de Enfermedades Cardiovasculares (CIBER-CV), Instituto de Salud Carlos III, Madrid, Spain
| | - Pablo Jordan-Marchite
- Arrhythmia Unit, Cardiology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Jose Fernando Rodríguez-Palomares
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain; CIBER de Enfermedades Cardiovasculares (CIBER-CV), Instituto de Salud Carlos III, Madrid, Spain; Cardiology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Ignacio Ferreira-González
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain; Cardiology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBER-ESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Nuria Rivas-Gándara
- Arrhythmia Unit, Cardiology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain; CIBER de Enfermedades Cardiovasculares (CIBER-CV), Instituto de Salud Carlos III, Madrid, Spain
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Nguyên UC, Prinzen FW, Vernooy K. Left ventricular lead placement in cardiac resynchronization therapy: Current data and potential explanations for the lack of benefit. Heart Rhythm 2024; 21:197-205. [PMID: 37806647 DOI: 10.1016/j.hrthm.2023.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/22/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Abstract
The present article reviews the literature on image-guided cardiac resynchronization therapy (CRT) studies. Improved outcome to CRT has been associated with the placement of a left ventricular (LV) lead in the latest activated segment free from scar. The majority of randomized controlled trials investigating guided LV lead implantation did not show superiority over conventional implantation approaches. Several factors may contribute to this paradoxical observation, including inclusion criteria favoring patients with left bundle branch block who already respond well to conventional anatomical LV lead implantation, differences in activation wavefronts during simultaneous right ventricular and LV pacing, incorrect definition of target regions, and limitations in coronary venous anatomy that prevent access to target regions that are detected by imaging. It is imperative that exclusion of patients lacking access to target regions from these studies would lead to larger benefit of image-guided CRT.
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Affiliation(s)
- Uyên Châu Nguyên
- Department of Physiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands; Department of Cardiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.
| | - Frits W Prinzen
- Department of Physiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
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Vătășescu RG, Târtea GC, Iorgulescu C, Cojocaru C, Deaconu A, Badiul A, Goanță EV, Bogdan Ș, Cozma D. Predictors for Super-Responders in Cardiac Resynchronization Therapy. Am J Ther 2024; 31:e13-e23. [PMID: 38231577 DOI: 10.1097/mjt.0000000000001692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND Prediction of cardiac resynchronization therapy (CRT) response, particularly a super-response, is of great importance. STUDY QUESTION The aim of our study was to assess the predictors for super-responders in CRT. STUDY DESIGN We conducted a retrospective, observational study, which finally included 622 patients with heart failure treated with CRT between January 2008 and May 2020 who had a minimal follow-up of 6 months after CRT. MEASURES AND OUTCOMES A total of 192 super-responders, defined by a left ventricular ejection fraction (LVEF) of at least 45%, and/or minimum 15% increase in LVEF and an improvement of the New York Heart Association functional class by at least 2 degrees at the last follow-up, and the rest of 430 patients who did not fulfill the super-responder criteria. RESULTS The highest rate of super-responders (41.91%, n = 171) was at patients with left ventricle-only pacing with optimal fusion (OPT) compared with patients with biventricular (BiV) pacing (9.81%, n = 21, P < 0.000). In the OPT group, univariable analysis showed that nonischemic cardiomyopathy, a smaller degree of mitral regurgitation, and better left ventricle function at enrollment were predictors for super-response compared with the BiV group where a narrower QRS after implantation, nonischemic cardiomyopathy, and a better baseline LVEF were predictors for super-responders. In the multivariable analysis, both narrower QRS after implantation and nonischemic cardiomyopathy were independent predictors for super-response in the BiV group compared with OPT where nonischemic cardiomyopathy remained the only independent predictor for super-response. CONCLUSIONS In this retrospective study, OPT CRT programing was an additional predictor of super-response to CRT besides nonischemic cardiomyopathy.
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Affiliation(s)
- Radu Gabriel Vătășescu
- Department of Cardiology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Cardiology, Clinic Emergency Hospital of Bucharest, Bucharest, Romania
| | - Georgică Costinel Târtea
- Department of Physiology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
- Department of Cardiology, Emergency County Hospital of Craiova, Craiova, Romania
| | - Corneliu Iorgulescu
- Department of Cardiology, Clinic Emergency Hospital of Bucharest, Bucharest, Romania
| | - Cosmin Cojocaru
- Department of Cardiology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Cardiology, Clinic Emergency Hospital of Bucharest, Bucharest, Romania
| | - Alexandru Deaconu
- Department of Cardiology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Cardiology, Clinic Emergency Hospital of Bucharest, Bucharest, Romania
| | - Alexandru Badiul
- Department of Cardiology, Clinic Emergency Hospital of Bucharest, Bucharest, Romania
| | - Emilia-Violeta Goanță
- Department of Cardiology, Emergency County Hospital of Craiova, Craiova, Romania
- Department of Cardiology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Ștefan Bogdan
- Department of Cardiology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Cardiology, "Elias" University Emergency Hospital, Bucharest, Romania; and
| | - Dragoș Cozma
- Department of Cardiology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
- Institute of Cardiovascular Diseases Timisoara, Timisoara, Romania
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Knijnik L, Wang B, Cardoso R, Shanafelt C, Lloyd MS. Clinical outcomes of automatic algorithms in cardiac resynchronization therapy: Systematic review and meta-analysis. Heart Rhythm O2 2023; 4:618-624. [PMID: 37936674 PMCID: PMC10626183 DOI: 10.1016/j.hroo.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Background Algorithms to automatically adjust atrioventricular (AV) and interventricular (VV) intervals in cardiac resynchronization therapy (CRT) devices are common, but their clinical efficacy is unknown. Objective The purpose of this study was to evaluate automatic CRT algorithms in patients with heart failure for the reduction of mortality, heart failure hospitalizations, and clinical improvement. Methods We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) in patients with CRT using automatic algorithms that change AV and VV intervals dynamically without manual input, on a beat-to-beat basis. We performed a subgroup analysis including intracardiac electrogram-based (EGM) algorithms and contractility-based algorithms. Results Nine RCTs with 8531 participants were included, of whom 4275 (50.1%) were randomized to automatic algorithm. Seven of the 9 trials used EGM-based algorithms, and 2 used contractility sensors. There was no difference in all-cause mortality (10.3% vs 11.3%; odds ratio [OR] 0.90; 95% confidence interval [CI] 0.71-1.03; P = .13; I2 = 0%) or heart failure hospitalizations (15.0% vs 16.1%; OR 0.924; 95% CI 0.81-1.04; P = .194; I2 = 0%) between the automatic algorithm group and the control group. Study-defined clinical improvement was also not significantly different between groups (66.6% vs 63.3%; risk ratio 1.01; 95% CI 0.95-1.06; P = .82; I2 = 50%). In the contractility-based subgroup, there was a trend toward greater clinical improvement with the use of the automatic algorithm (75% vs 68.3%; OR 1.45; 95% CI 0.97-2.18; P = .07; I2 = 40%), which did not reach statistical significance. The overall risk of bias was low. Conclusion Automatic algorithms that change AV or VV intervals did not improve mortality, heart failure hospitalizations, or cardiovascular symptoms in patients with heart failure and CRT.
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Affiliation(s)
- Leonardo Knijnik
- Emory University Adult Congenital Heart Center, Atlanta, Georgia
| | - Bo Wang
- Emory University Adult Congenital Heart Center, Atlanta, Georgia
| | - Rhanderson Cardoso
- Heart and Vascular Center, Brigham and Women’s Hospital, Boston Massachusetts
| | - Colby Shanafelt
- Emory University Adult Congenital Heart Center, Atlanta, Georgia
| | - Michael S. Lloyd
- Emory University Adult Congenital Heart Center, Atlanta, Georgia
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Cafri G, Austin PC. Variance estimation of the risk difference when using propensity-score matching and weighting with time-to-event outcomes. Pharm Stat 2023; 22:880-902. [PMID: 37258420 DOI: 10.1002/pst.2317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 03/23/2023] [Accepted: 05/14/2023] [Indexed: 06/02/2023]
Abstract
Observational studies are increasingly being used in medicine to estimate the effects of treatments or exposures on outcomes. To minimize the potential for confounding when estimating treatment effects, propensity score methods are frequently implemented. Often outcomes are the time to event. While it is common to report the treatment effect as a relative effect, such as the hazard ratio, reporting the effect using an absolute measure of effect is also important. One commonly used absolute measure of effect is the risk difference or difference in probability of the occurrence of an event within a specified duration of follow-up between a treatment and comparison group. We first describe methods for point and variance estimation of the risk difference when using weighting or matching based on the propensity score when outcomes are time-to-event. Next, we conducted Monte Carlo simulations to compare the relative performance of these methods with respect to bias of the point estimate, accuracy of variance estimates, and coverage of estimated confidence intervals. The results of the simulation generally support the use of weighting methods (untrimmed ATT weights and IPTW) or caliper matching when the prevalence of treatment is low for point estimation. For standard error estimation the simulation results support the use of weighted robust standard errors, bootstrap methods, or matching with a naïve standard error (i.e., Greenwood method). The methods considered in the article are illustrated using a real-world example in which we estimate the effect of discharge prescribing of statins on patients hospitalized for acute myocardial infarction.
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Affiliation(s)
- Guy Cafri
- Medical Device Epidemiology and Real-World Data Sciences, J&J Medical Devices and Office of the Chief Medical Officer, New Jersey, USA
| | - Peter C Austin
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
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Westphal P, Luo H, Shahmohammadi M, Prinzen FW, Delhaas T, Cornelussen RN. Machine learning-powered, device-embedded heart sound measurement can optimize AV delay in patients with CRT. Heart Rhythm 2023; 20:1316-1324. [PMID: 37247684 DOI: 10.1016/j.hrthm.2023.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/28/2023] [Accepted: 05/17/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Continuous optimization of atrioventricular (AV) delay for cardiac resynchronization therapy (CRT) is mainly performed by electrical means. OBJECTIVE The purpose of this study was to develop an estimation model of cardiac function that uses a piezoelectric microphone embedded in a pulse generator to guide CRT optimization. METHODS Electrocardiogram, left ventricular pressure (LVP), and heart sounds were simultaneously collected during CRT device implantation procedures. A piezoelectric alarm transducer embedded in a modified CRT device facilitated recording of heart sounds in patients undergoing a pacing protocol with different AV delays. Machine learning (ML) was used to produce a decision-tree ensemble model capable of estimating absolute maximal LVP (LVPmax) and maximal rise of LVP (LVdP/dtmax) using 3 heart sound-based features. To gauge the applicability of ML in AV delay optimization, polynomial curves were fitted to measured and estimated values. RESULTS In the data set of ∼30,000 heartbeats, ML indicated S1 amplitude, S2 amplitude, and S1 integral (S1 energy for LVdP/dtmax) as most prominent features for AV delay optimization. ML resulted in single-beat estimation precision for absolute values of LVPmax and LVdP/dtmax of 67% and 64%, respectively. For 20-30 beat averages, cross-correlation between measured and estimated LVPmax and LVdP/dtmax was 0.999 for both. The estimated optimal AV delays were not significantly different from those measured using invasive LVP (difference -5.6 ± 17.1 ms for LVPmax and +5.1 ± 6.7 ms for LVdP/dtmax). The difference in function at estimated and measured optimal AV delays was not statiscally significant (1 ± 3 mm Hg for LVPmax and 9 ± 57 mm Hg/s for LVdP/dtmax). CONCLUSION Heart sound sensors embedded in a CRT device, powered by a ML algorithm, provide a reliable assessment of optimal AV delays and absolute LVPmax and LVdP/dtmax.
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Affiliation(s)
- Philip Westphal
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands; Bakken Research Center, Medtronic, plc, Maastricht, The Netherlands
| | - Hongxing Luo
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Mehrdad Shahmohammadi
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Tammo Delhaas
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Richard N Cornelussen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands; Bakken Research Center, Medtronic, plc, Maastricht, The Netherlands.
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10
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Chen Z, Zhou X, Ma X, Chen K. Recruitment of the cardiac conduction system for optimal resynchronization therapy in failing heart. Front Physiol 2022; 13:1045740. [PMID: 36589433 PMCID: PMC9798297 DOI: 10.3389/fphys.2022.1045740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
Heart failure (HF) is a leading health burden around the world. Although pharmacological development has dramatically advanced medication therapy in the field, hemodynamic disorders or mechanical desynchrony deteriorated by intra or interventricular conduction abnormalities remains a critical target beyond the scope of pharmacotherapy. In the past 2 decades, nonpharmacologic treatment for heart failure, such as cardiac resynchronization therapy (CRT) via biventricular pacing (BVP), has been playing an important role in improving the prognosis of heart failure. However, the response rate of BVP-CRT is variable, leaving one-third of patients not benefiting from the therapy as expected. Considering the non-physiological activation pattern of BVP-CRT, more efforts have been made to optimize resynchronization. The most extensively investigated approach is by stimulating the native conduction system, e.g., His-Purkinje conduction system pacing (CSP), including His bundle pacing (HBP) and left bundle branch area pacing (LBBAP). These emerging CRT approaches provide an alternative to traditional BVP-CRT, with multiple proof-of-concept studies indicating the safety and efficacy of its utilization in dyssynchronous heart failure. In this review, we summarize the mechanisms of dyssynchronous HF mediated by conduction disturbance, the rationale and acute effect of CSP for CRT, the recent advancement in clinical research, and possible future directions of CSP.
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Affiliation(s)
- Zhongli Chen
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | | | - Xuan Ma
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Keping Chen
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China,*Correspondence: Keping Chen,
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Corbisiero R, Muller D. The Gallant™ system heart rhythm management device: making a connection. Future Cardiol 2022; 18:605-614. [PMID: 35748496 DOI: 10.2217/fca-2021-0117] [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
Implantable cardiac defibrillators have revolutionized the way we prevent sudden cardiac death via arrhythmias. The addition of cardiac resynchronization pacing to defibrillators has broadened that treatment to include patients with heart failure and reduced ejection fraction. As with all technology, new devices and platforms expand the capabilities and interface with patients across the world. This review discusses the evolution from the initial modalities and methods of communication of implantable devices up to the most recent advances in implantable defibrillators and their integration into patient lives and clinical practice. This review is focused on the integration of Bluetooth communication into modern healthcare with the Gallant™ family of devices, the first branded launch by Abbott Laboratories.
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Affiliation(s)
| | - David Muller
- Abbott Laboratories, 15900 Valley View Ct, Sylmar, CA 91342, USA
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Programming Algorithms for Cardiac Resynchronization Therapy. Card Electrophysiol Clin 2022; 14:243-252. [PMID: 35715082 DOI: 10.1016/j.ccep.2021.12.018] [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]
Abstract
Current cardiac resynchronization therapy (CRT) implant guidelines emphasize the presence of electrical dyssynchrony (left bundle branch block (LBBB) and QRS > 150 ms) yet have modest predictive value for response and have not reduced the 30% nonresponse rate. Optimized programming to optimize CRT delivery has promised much but to date has largely been ineffective. What is missing is the understanding of LV paced effects (which are unpredictable) and optimal paced AV interval (that can be conserved during physiologic variations) that then can be incorporated into an individualized programming prescription. Automatic device-based algorithms that deliver electrical optimization and maintain this during ambulatory fluctuations in AV interval are discussed.
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Abstract
Left ventricular (LV) dP/dtmax provides a sensitive measure of the acute hemodynamic response to cardiac resynchronization therapy (CRT) and can predict reverse remodeling on echocardiography. Its use to guide LV lead placement has been shown to improve outcomes in a multicenter randomized trial. Given the invasive protocol required for measurement, it is unlikely to be universally beneficial for patients undergoing CRT but may be useful for patients who do not respond to conventional CRT, or in those who have borderline indications or risk factors for non-response. In such cases, LV dP/dtmax may help guide LV lead placement, optimize device programming, and select the best alternative method of delivering CRT, such endocardial LV pacing or conduction system pacing.
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Affiliation(s)
- Mark K Elliott
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Vishal S Mehta
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Chong L, Kipp R. Proarrhythmic effects of dynamic atrioventricular delay programming in a patient with cardiac resynchronization therapy and activity-induced atrioventricular node dysfunction. HeartRhythm Case Rep 2022; 8:296-300. [PMID: 35497482 PMCID: PMC9039094 DOI: 10.1016/j.hrcr.2022.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Ryan Kipp
- Address reprint requests and correspondence: Dr Ryan Kipp, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792.
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Park SJ. Device treatment of heart failure. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2022. [DOI: 10.5124/jkma.2022.65.1.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: The incidence of heart failure (HF) is rapidly increasing, introducing a significant burden and challenges in clinical practice. Non-pharmacological cardiac device therapy has been established as an essential component of optimal HF management, particularly for the prevention of sudden cardiac death and the improvement of HF symptoms, left ventricular (LV) systolic function, quality of life, and eventually survival.Current Concepts: Cardiac resynchronization therapy (CRT) can correct atrioventricular or inter/intraventricular dyssynchrony, thereby improving LV systolic function. Recently, the concept of CRT is being expanded, including His bundle (HB), HB-optimized LV, left bundle branch (LBB), and LBB optimized LV pacing CRTs. Newly introduced CRT approaches by stimulating the cardiac conduction system are expected to correct dyssynchrony better and consequently exhibit better CRT outcomes than the conventional biventricular pacing CRT. The current versions of implantable cardioverter-defibrillators (ICDs) or CRT devices can continuously monitor multiple biosignals. CRT/ICD can calculate a single index by combining these multiple bio-signal data for early detection of HF aggravation. Recently, subcutaneous and transvenous ICDs showed comparable safety and efficacy in HF patients. In drug-refractory HF patients without LV dyssynchrony, cardiac contractility modulation therapy provides some promising results.Discussion and Conclusion: Recent technological advancements have improved the efficacy and safety of cardiac device therapy. Therefore, cardiac device therapy should be used more actively to manage HF patients better.
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Elliott MK, Mehta VS, Martic D, Sidhu BS, Niederer S, Rinaldi CA. Atrial fibrillation in cardiac resynchronization therapy. Heart Rhythm O2 2021; 2:784-795. [PMID: 34988530 PMCID: PMC8710632 DOI: 10.1016/j.hroo.2021.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Patients with atrial fibrillation (AF) were largely excluded from the major clinical trials of cardiac resynchronization therapy (CRT), despite the presence of AF in up to 40% of patients receiving CRT in clinical practice. AF appears to attenuate the response to CRT, by the combination of a reduction in biventricular pacing and the loss of atrioventricular synchrony. In addition, remodeling secondary to CRT may influence the progression of AF. Management options for patients with AF and CRT include rate control, with drugs or atrioventricular node ablation, or rhythm control, with electrical cardioversion and antiarrhythmic therapy, or AF catheter ablation. The evidence for these therapies in patients with CRT is largely limited to observational studies or inferred from randomized studies in the general heart failure population. In this review, we explore the complex interaction between AF, heart failure, and CRT and discuss the evidence for the treatment options in this difficult patient cohort.
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Affiliation(s)
- Mark K. Elliott
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Vishal S. Mehta
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Dejana Martic
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Baldeep S. Sidhu
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
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CRT Efficacy in "Mid-Range" QRS Duration Among Asians Contrasted to Non-Asians, and Influence of Height. JACC Clin Electrophysiol 2021; 8:211-221. [PMID: 34838518 DOI: 10.1016/j.jacep.2021.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The purpose of this study was to test the hypotheses that cardiac resynchronization therapy (CRT) efficacy differed among Asians compared with non-Asian populations, differed between QRS duration (QRSd) ranges 120-149 and ≥150 ms, and was influenced by height in the multinational ADVANCE CRT trial. BACKGROUND CRT guidelines, derived from trials among U.S./European patients, assign weaker recommendations to those with midrange QRSd (QRSd <150 ms). Patient height may modulate CRT efficacy. Together, these may affect CRT prescription and efficacy in Asia. METHODS CRT response was assessed using the Clinical Composite Score 6 months postimplant (n = 934). Heart failure events and cardiac deaths were reported until 12 months. Asian and non-Asian patients were compared overall, by QRSd <150 ms (Asian n = 71 vs non-Asian n = 248), and QRSd ≥150 ms (Asian n = 180 vs non-Asian n = 435) and by height. RESULTS Asians comprised 27% (251 of 934) of the primary study population. More Asians had QRSd ≥150 ms (72% [180 of 251] vs 64% [435 of 683] in non-Asian patients; P = 0.022). Overall CRT response was better in Asians vs non-Asians (Clinical Composite Score 85% vs 65%; P <0.001), and following QRSd dichotomization (QRSd <150 ms: 80% vs 59%; P <0.001; QRS ≥150 ms: 86% vs 69%; P < 0.001). HF events and cardiac deaths were fewer in Asians irrespective of QRSd (P < 0.001). Stepwise multivariable analysis indicated that in group QRSd <150 ms, nonischemic cardiomyopathy, number of other comorbidities (0-1 vs ≥4), and atrial fibrillation influenced CRT response. The trend favoring Asian race (OR: 1.46; 95% CI: 0.72-2.95) was eliminated (OR: 1.00; 95% CI: 0.47-2.11) when height or QRSd/height were included (QRSd/height P = 0.006; OR: 1.64; 95% CI: 1.15-2.35). In QRSd <150 ms, probability of CRT response diminished as height increased, but increased with QRSd/height, in both Asians and non-Asians. In QRSd ≥150 ms, height or QRSd/height had minimal effect in Asians or non-Asians. CONCLUSIONS Height modulates CRT efficacy among patients with QRSd <150 ms and contributes to high probability of benefit from CRT among Asians. CRT should be encouraged among Asian patients with midrange QRSd. (Advance Cardiac Resynchronization Therapy [CRT] Registry; NCT01805154).
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Varma N. Intracardiac impedance to track cardiac volume status during cardiac resynchronization therapy - The quest for a heart failure sensor. Indian Pacing Electrophysiol J 2021; 21:219-220. [PMID: 34238434 PMCID: PMC8263328 DOI: 10.1016/j.ipej.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Niraj Varma
- Cleveland Clinic, 9500 Euclid Ave Desk J2-2, Cleveland, OH, 44195, USA.
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