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König S, Hilbert S, Bode K. Conduction System Pacing: Hope, Challenges, and the Journey Forward. Curr Cardiol Rep 2024; 26:801-814. [PMID: 38976199 DOI: 10.1007/s11886-024-02085-8] [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: 06/17/2024] [Indexed: 07/09/2024]
Abstract
PURPOSE OF THE REVIEW Cardiac pacing has evolved in recent years currently culminating in the specific stimulation of the cardiac conduction system (conduction system pacing, CSP). This review aims to provide a comprehensive overview of the available literature on CSP, focusing on a critical classification of studies comparing CSP with standard treatment in the two fields of pacing for bradycardia and cardiac resynchronization therapy in patients with heart failure. The article will also elaborate specific benefits and limitations associated with CSP modalities of His bundle pacing (HBP) and left bundle branch area pacing (LBBAP). RECENT FINDINGS Based on a growing number of observational studies for different indications of pacing therapy, both CSP modalities investigated are advantageous over standard treatment in terms of narrowing the paced QRS complex and preserving or improving left ventricular systolic function. Less consistent evidence exists with regard to the improvement of heart failure-related rehospitalization rates or mortality, and effect sizes vary between HBP and LBBAP. LBBAP is superior over HBP in terms of lead measurements and procedural duration. With regard to all reported outcomes, evidence from large scale randomized controlled clinical trials (RCT) is still scarce. CSP has the potential to sustainably improve patient care in cardiac pacing therapy if patients are appropriately selected and limitations are considered. With this review, we offer not only a summary of existing data, but also an outlook on probable future developments in the field, as well as a detailed summary of upcoming RCTs that provide insights into how the journey of CSP continues.
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Affiliation(s)
- S König
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany.
- Helios Health Institute, Real World Evidence and Health Technology Assessment, Berlin, Germany.
| | - S Hilbert
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - K Bode
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
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2
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Lou Y, Hua Y, Yang J, Shi J, Jiang L, Yang Y. A nomogram for predicting CRT response based on multi-parameter features. BMC Cardiovasc Disord 2024; 24:376. [PMID: 39030503 PMCID: PMC11264749 DOI: 10.1186/s12872-024-04033-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 07/08/2024] [Indexed: 07/21/2024] Open
Abstract
OBJECTIVE To construct a nomogram for predicting the responsiveness of cardiac resynchronization therapy (CRT) in patients with chronic heart failure and verify its predictive efficacy. METHOD A retrospective study was conducted including 109 patients with chronic heart failure who successfully received CRT from January 2018 to December 2022. According to patients after six months of the CRT preoperative improving acuity in the left ventricular ejection fraction is 5% or at least improve grade 1 NYHA heart function classification, divided into responsive group and non-responsive group. Clinical data of patients were collected, and LASSO regression analysis and multivariate logistic regression analysis were used to explore relative factors. A nomogram was constructed, and the predictive performance of the nomogram was evaluated using the calibration curve and decision curve analysis (DCA). RESULTS Among the 109 patients, 61 were assigned to the CRT-responsive group, while 48 were assigned to the non-responsive group. LASSO regression analysis showed that left ventricular end-systolic volume, diffuse fibrosis, and left bundle branch block (LBBB) were independent factors for CRT responsiveness in patients with heart failure (P < 0.05). Based on the above three predictive factors, a nomogram was constructed. The ROC curve analysis showed that the area under the curve (AUC) was 0.865 (95% CI 0.794-0.935). The calibration curve analysis showed that the predicted probability of the nomogram is consistent with the actual occurrence rate. DCA showed that the line graph model has an excellent clinical net benefit rate. CONCLUSION The nomogram constructed based on clinical features, laboratory, and imaging examinations in this study has high discrimination and calibration in predicting CRT responsiveness in patients with chronic heart failure.
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Affiliation(s)
- Yuxuan Lou
- Southeast University, Nanjing, 210009, Jiangsu, China
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Yang Hua
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Jiaming Yang
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Jing Shi
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Lei Jiang
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Yang Yang
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, Jiangsu, China.
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3
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Yuecel G, Stoesslein K, Gaasch L, Kodeih A, Oeztuerk ON, Hetjens S, Yazdani B, Pfleger S, Liebe V, Rudic B, Behnes M, Langer H, Duerschmied D, Akin I, Kuschyk J. Long-term outcomes from upgrade to cardiac resynchronisation therapy in ischaemic versus non-ischaemic heart disease. Acta Cardiol 2024; 79:327-337. [PMID: 37961770 DOI: 10.1080/00015385.2023.2277624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Cardiac resynchronisation therapy (CRT) can be necessary in patients with chronic heart failure, who have already been provided with transvenous cardiac implantable electrical devices. Upgrade procedures revealed controversial results, while long-term outcomes regarding underlying Ischaemic- (ICM) or Non-Ischaemic heart disease (NICM) have yet to be described. METHODS The Mannheim Cardiac Resynchronisation Therapy Registry (MARACANA) was designed as a retrospective observational single-centre registry, including all CRT implantations from 2013-2021 (n = 459). CRT upgrades (n = 136) were retrospectively grouped to either ICM (n = 84) or NICM (n = 52) and compared for New York Heart Association classification (NYHA), paced QRS-width, left ventricular ejection fraction (LVEF), tricuspid annular plane systolic excursion (TAPSE) and other heart failure modification aspects in the long-term (59.3 ± 5 months). RESULTS Baseline-characteristics including paced QRS-width, upgrade indications or NYHA-classification were comparable for both groups (group comparison p>.05). The CRT upgrade improved NYHA (ICM: 2.98 ± 0.4 to 2.29 ± 0.7, NICM: 2.94 ± 0.5 to 2.08 ± 0.5) and the LVEF (ICM: 27.2 ± 6.6 to 38.25 ± 8.8, NICM: 30.2 ± 9.4 to 38.7 ± 13.8%) after five years, irrespective of underlying heart disease (each group p < .05, group comparison p>.05). Only ICM revealed significant improvements in TAPSE (15.9 ± 4.1 to 18.9 ± 4.1 mm) and narrowing of the paced QRS-width (185.4 ± 29 to 147.2 ± 16.3 ms) after five years (each p < .05). CONCLUSIONS Upgrade to CRT might improve heart failure symptoms and left-ventricular systolic function in the long-term, irrespective of underlying ischaemic or non-ischaemic heart disease.
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Affiliation(s)
- Goekhan Yuecel
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Karolina Stoesslein
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Leo Gaasch
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Abbass Kodeih
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Oezge Nur Oeztuerk
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Svetlana Hetjens
- Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Mannheim
| | - Babak Yazdani
- Fifth Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany
| | - Stefan Pfleger
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Volker Liebe
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Boris Rudic
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Harald Langer
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Daniel Duerschmied
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Juergen Kuschyk
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
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Zeitler EP, Dalgaard F, Abraham WT, Cleland JGF, Curtis AB, Friedman DJ, Gold MR, Kutyifa V, Linde C, Tang AS, Olivas-Martinez A, Inoue LYT, Sanders GD, Al-Khatib SM. Benefit of cardiac resynchronization therapy among older patients: A patient-level meta-analysis. Am Heart J 2024; 267:81-90. [PMID: 37984672 PMCID: PMC10842211 DOI: 10.1016/j.ahj.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) reduces heart failure hospitalizations (HFH) and mortality for guideline-indicated patients with heart failure (HF). Most patients with HF are aged ≥70 years but such patients are often under-represented in randomized trials. METHODS Patient-level data were combined from 8 randomized trials published 2002-2013 comparing CRT to no CRT (n = 6,369). The effect of CRT was estimated using an adjusted Bayesian survival model. Using age as a categorical (<70 vs ≥70 years) or continuous variable, the interaction between age and CRT on the composite end point of HFH or all-cause mortality or all-cause mortality alone was assessed. RESULTS The median age was 67 years with 2436 (38%) being 70+; 1,554 (24%) were women; 2,586 (41%) had nonischemic cardiomyopathy and median QRS duration was 160 ms. Overall, CRT was associated with a delay in time to the composite end point (adjusted hazard ratio [aHR] 0.75, 95% credible interval [CI] 0.66-0.85, P = .002) and all-cause mortality alone (aHR of 0.80, 95% CI 0.69-0.96, P = .017). When age was treated as a categorical variable, there was no interaction between age and the effect of CRT for either end point (P > .1). When age was treated as a continuous variable, older patients appeared to obtain greater benefit with CRT for the composite end point (P for interaction = .027) with a similar but nonsignificant trend for mortality (P for interaction = .35). CONCLUSION Reductions in HFH and mortality with CRT are as great or greater in appropriately indicated older patients. Age should not be a limiting factor for the provision of CRT.
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Affiliation(s)
| | - Frederik Dalgaard
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Nykøbing Falster Sygehus, Nykøbing and Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH
| | - John G F Cleland
- National Heart and Lung Institute, Royal Brompton & Harefield Hospitals, Imperial College, London, United Kingdom; British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom
| | | | - Daniel J Friedman
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Valentina Kutyifa
- Division of Cardiology, Department of Medicine, University of Rochester Medical Center, NY
| | - Cecilia Linde
- Karolinska Institutet and Department of Cardiology, Karolinska University, Stockholm, Sweden
| | - Anthony S Tang
- Department of Medicine, Western University, Ontario, Canada
| | | | - Lurdes Y T Inoue
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Gillian D Sanders
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Population Health Sciences, Duke-Margolis Center for Health Policy, Duke University School of Medicine, Durham, NC
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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Karpawich PP, Chubb H. Indications for Cardiac Resynchronization Therapy in Patients with Congenital Heart Disease. Card Electrophysiol Clin 2023; 15:433-445. [PMID: 37865517 DOI: 10.1016/j.ccep.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
Heart failure in patients with congenital heart disease (CHD) stems from unique causes compared with the elderly. Patients with CHD face structural abnormalities and malformations present from birth, leading to altered cardiac function and potential complications. In contrast, elderly individuals primarily experience heart failure due to age-related changes and underlying cardiovascular conditions. Cardiac resynchronization therapy (CRT) can benefit patients with CHD, although it presents numerous challenges. The complexities of CHD anatomy and limited access to appropriate venous sites for lead placement make CRT implantation demanding.
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Affiliation(s)
- Peter P Karpawich
- Department of Pediatrics, Central Michigan University College of Medicine, Cardiac Electrophysiology, The Children's Hospital of Michigan, Detroit, MI, USA.
| | - Henry Chubb
- Stanford University School of Medicine, Stanford Medicine Children's Health, Palo Alto, CA, USA; Pediatric Heart Center, 725 Welch Road, Suite 120, MC 5912, Palo Alto, CA 94304, USA
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6
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Wilczek J, Jadczyk T, Wojakowski W, Gołba KS. Time-related factors predicting a positive response to cardiac resynchronisation therapy in patients with heart failure. Sci Rep 2023; 13:8524. [PMID: 37237039 PMCID: PMC10219980 DOI: 10.1038/s41598-023-35174-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/14/2023] [Indexed: 05/28/2023] Open
Abstract
This study aimed to identify time parameters predicting favourable CRT response. A total of 38 patients with ischemic cardiomyopathy, qualified for CRT implantation, were enrolled in the study. A 15% reduction in indexed end-systolic volume after 6 months was a criterion for a positive response to CRT. We evaluated QRS duration, measured from a standard ECG before and after CRT implantation and obtained from mapping with NOGA XP system (AEMM); and the delay, measured with the implanted device algorithm (DCD) and its change after 6 months (ΔDCD); and selected delay parameters between the left and right ventricles based on AEMM data. A total of 24 patients presented with a positive response to CRT versus 9 non-responders. After CRT implantation, we observed differences between responders and non-responders group in the reduction of QRS duration (31 ms vs. 16 ms), duration of paced QRS (123 ms vs. 142 ms), and the change of ΔDCDMaximum (4.9 ms vs. 0.44 ms) and ΔDCDMean (7.7 ms vs. 0.9 ms). The difference in selected parameters obtained during AEMM in both groups was related to interventricular delay (40.3 ms vs. 18.6 ms). Concerning local activation time and left ventricular activation time, we analysed the delays in individual left ventricular segments. Predominant activation delay of the posterior wall middle segment was associated with a better response to CRT. Some AEMM parameters, paced QRS time of less than 120 ms and reduction of QRS duration greater than 20 ms predict the response to CRT. ΔDCD is associated with favourable electrical and structural remodelling.Clinical trial registration: SUM No. KNW/0022/KB1/17/15.
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Affiliation(s)
- Jacek Wilczek
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland.
- Electrocardiology Department, Upper Silesian Medical Center, Katowice, Poland.
| | - Tomasz Jadczyk
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
- Third Department of Cardiology, Upper Silesian Medical Center, Katowice, Poland
- Interventional Cardiac Electrophysiology Group, International Clinical Research Center, St. Anne's University Hospital in Brno, Brno, Czech Republic
| | - Wojciech Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
- Third Department of Cardiology, Upper Silesian Medical Center, Katowice, Poland
| | - Krzysztof S Gołba
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
- Electrocardiology Department, Upper Silesian Medical Center, Katowice, Poland
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7
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Gin J, Chow CL, Voskoboinik A, Nalliah C, Wong C, Van Gaal W, Farouque O, Mohamed U, Lim HS, Kalman JM, Wong GR. Improved Outcomes of Conduction System Pacing in Heart Failure with Reduced Ejection Fraction - A Systematic Review and Meta-analysis. Heart Rhythm 2023:S1547-5271(23)02226-9. [PMID: 37172670 DOI: 10.1016/j.hrthm.2023.05.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/25/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023]
Abstract
Conduction system pacing (CSP) - His bundle pacing (HBP) and Left bundle branch area pacing (LBBAP) - are emerging alternatives to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT) in heart failure. However, evidence is largely limited to small and observational studies. We conducted a meta-analysis including a total of 15 randomized control trials (RCTs) and non-RCTs that compare CSP (HBP & LBBAP) with BVP in patients with CRT indications. We assessed the mean differences in QRS duration (QRSd), pacing threshold, left ventricular ejection fraction (LVEF), and New York Heart Association (NYHA) class score. CSP resulted in a pooled mean QRSd improvement of -20.3 ms (95% CI -26.1 - -14.5, p<0.05, I2=87.1%) versus BVP. For LVEF, a weighted mean increase of 5.2% (95% CI 3.5-6.9, p<0.05, I2=55.6) was observed following CSP versus BVP. The mean NYHA score was reduced by -0.40 (95% CI -0.6 - -0.2, p<0.05, I2=61.7) post-CSP versus BVP. Subgroup analysis of outcomes by LBBAP and HBP demonstrated statistically significant weighted mean improvements from both CSP modalities for QRSd and LVEF compared to BVP. LBBAP resulted in NYHA improvement compared to BVP without differences between CSP subgroups. LBBAP is associated with a significantly lowered mean pacing threshold of -0.51V (95% CI -0.68 - -0.38) whilst HBP had increased the mean threshold (0.62V, 95% CI -0.03 - 1.26) compared to BVP, however, this was associated with significant heterogeneity. Overall, both CSP techniques are feasible and effective CRT alternatives for heart failure. Further RCTs are needed to establish long-term efficacy and safety.
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Affiliation(s)
- Julian Gin
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Chee Loong Chow
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia; Department of Cardiology, Northern Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Alex Voskoboinik
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Chrishan Nalliah
- Department of Cardiology, Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Chiew Wong
- Department of Cardiology, Northern Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - William Van Gaal
- Department of Cardiology, Northern Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Uwais Mohamed
- Department of Cardiology, St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Han S Lim
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia; Department of Cardiology, Northern Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Jonathan M Kalman
- Department of Cardiac Electrophysiology, Royal Melbourne Hospital, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Geoffrey R Wong
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia; Department of Cardiology, Northern Health, Melbourne, Victoria, Australia.
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8
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Rickard J, Gold MR, Patel D, Wilkoff BL, Varma N, Sinha S, Albert C, Finet JE, Tang WHW, Marine J, Spragg D. Long-term outcomes in nonprogressors to cardiac resynchronization therapy. Heart Rhythm 2023; 20:165-170. [PMID: 36356725 DOI: 10.1016/j.hrthm.2022.10.029] [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: 07/10/2022] [Revised: 10/22/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Among patients with heart failure undergoing cardiac resynchronization therapy (CRT), patients with a minimal change in left ventricular ejection fraction (LVEF) have recently been defined as "nonprogressors" rather than as "nonresponders." Little is known regarding long-term outcomes of nonprogressors. OBJECTIVE We sought to evaluate outcomes in patients undergoing CRT on the basis of echocardiographically determined response status. METHODS We reviewed the medical charts of patients with an LVEF of ≤35% and a QRS duration of ≥120 ms undergoing CRT at the Cleveland Clinic, Johns Hopkins Hospital, and Johns Hopkins Bayview Medical Center between 2003 and 2014. Response to CRT was defined on the basis of LVEF change as follows: super-responders ≥20%, responders 6%-19%, nonprogressors 0%-5%, and progressors <0%. Survival free of left ventricular assist device (LVAD) implantation and heart transplantation was compared on the basis of response classification. RESULTS A total of 1058 patients were included and had a mean follow-up 8.7 ± 5.4 years, over which time there were 606 end points (37 LVAD implants, 32 heart transplants, and 537 deaths). Survival free of LVAD and heart transplant differed significantly between response groups after CRT both in the mid-term (4 years) and in the long-term (8.7 ± 5.4 years), with super-responders achieving the best outcomes and progressors the worst (P < .001). In multivariate analysis, nonprogressors had superior outcomes to progressors (P = .02) at 4 years of follow-up. Over the duration of follow-up (8.7 ± 5.4 years), there was no significant difference in survival between those 2 groups (P = .18). CONCLUSION Nonprogressors to CRT have superior medium-term outcomes but similar long-term outcomes to progressors and inferior outcomes to responders and super-responders.
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Affiliation(s)
- John Rickard
- Cleveland Clinic Heart and Vascular Institute, Cleveland, Ohio.
| | - Michael R Gold
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Divyang Patel
- Cleveland Clinic Heart and Vascular Institute, Cleveland, Ohio
| | - Bruce L Wilkoff
- Cleveland Clinic Heart and Vascular Institute, Cleveland, Ohio
| | - Niraj Varma
- Cleveland Clinic Heart and Vascular Institute, Cleveland, Ohio
| | - Sunil Sinha
- Division of Cardiology, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Chonyang Albert
- Cleveland Clinic Heart and Vascular Institute, Cleveland, Ohio
| | - J Emanuel Finet
- Cleveland Clinic Heart and Vascular Institute, Cleveland, Ohio
| | - W H Wilson Tang
- Cleveland Clinic Heart and Vascular Institute, Cleveland, Ohio
| | - Joe Marine
- Division of Cardiology, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - David Spragg
- Division of Cardiology, Johns Hopkins University Medical Center, Baltimore, Maryland
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9
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Boros AM, Perge P, Merkely B, Széplaki G. Risk scores in cardiac resynchronization therapy-A review of the literature. Front Cardiovasc Med 2023; 9:1048673. [PMID: 36733831 PMCID: PMC9886679 DOI: 10.3389/fcvm.2022.1048673] [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: 09/19/2022] [Accepted: 12/28/2022] [Indexed: 01/18/2023] Open
Abstract
Cardiac resynchronization therapy (CRT) for selected heart failure (HF) patients improves symptoms and reduces morbidity and mortality; however, the prognosis of HF is still poor. There is an emerging need for tools that might help in optimal patient selection and provide prognostic information for patients and their families. Several risk scores have been created in recent years; although, no literature review is available that would list the possible scores for the clinicians. We identified forty-eight risk scores in CRT and provided the calculation methods and formulas in a ready-to-use format. The reviewed score systems can predict the prognosis of CRT patients; some of them have even provided an online calculation tool. Significant heterogeneity is present between the various risk scores in terms of the variables incorporated and some variables are not yet used in daily clinical practice. The lack of cross-validation of the risk scores limits their routine use and objective selection. As the number of prognostic markers of CRT is overwhelming, further studies might be required to analyze and cross-validate the data.
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Affiliation(s)
| | - Péter Perge
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Gábor Széplaki
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary,Heart and Vascular Centre, Mater Private Hospital, Dublin, Ireland,Royal College of Surgeons in Ireland, Dublin, Ireland,*Correspondence: Gábor Széplaki,
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10
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Rickard J, Jackson K, Gold M, Biffi M, Ziacchi M, Silverstein J, Ramza B, Metzl M, Grubman E, Abben R, Varma N, Tabbal G, Jensen C, Wouters G, Ghosh S, Vernooy K. Electrocardiogram Belt guidance for left ventricular lead placement and biventricular pacing optimization. Heart Rhythm 2022; 20:537-544. [PMID: 36442824 DOI: 10.1016/j.hrthm.2022.11.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/07/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with ischemic cardiomyopathy, non-left bundle branch block, or QRS duration <150 ms have a lower response rate to cardiac resynchronization therapy (CRT) than did other indicated patients. The ECG Belt system (EBS) is a novel surface mapping system designed to measure electrical dyssynchrony via the standard deviation of the activation times of the left ventricle. OBJECTIVES The objectives of this study were to evaluate the efficacy of the EBS in patients less likely to respond to CRT and to determine whether EBS use in lead placement guidance and device programming was superior to standard CRT care. METHODS This was a prospective randomized trial of patients with heart failure and EBS-guided CRT implantation and programming vs standard CRT care. The primary end point was relative change in left ventricular end-systolic volume from baseline to 6 months postimplantation. RESULTS A total of 408 patients from centers in Europe and North America were randomized. Although both patients with EBS and control patients had a mean improvement in left ventricular end-systolic volume, there was no significant difference in relative change from baseline (P = .26). While patients with a higher baseline standard deviation of the activation times derived greater left ventricular reverse remodeling, improvement in electrical dyssynchrony did not correlate with the extent of reverse remodeling. CONCLUSION The findings of the present study do not support EBS-guided therapy for CRT management of heart failure with reduced ejection fraction.
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Affiliation(s)
- John Rickard
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Kevin Jackson
- Section of Cardiac Electrophysiology, Division of Cardiovascular Disease, Duke University Medical Center, Durham, North Carolina
| | - Michael Gold
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Mauro Biffi
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Ziacchi
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Brian Ramza
- Division of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Mark Metzl
- Department of Medicine, NorthShore University HealthSystem, Evanston, Illinois
| | - Eric Grubman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Richard Abben
- Cardiac Interventions and Cardiac Arrythmia Center, Cardiovascular Institute of the South, Houma, Louisiana
| | - Niraj Varma
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ghiyath Tabbal
- Cardiac Interventions and Cardiac Arrythmia Center, Cardiovascular Institute of the South, Houma, Louisiana
| | - Cory Jensen
- Department of Cardiac Electrophysiology, Heartland Cardiology, Wichita, Kansas
| | - Griet Wouters
- Department of Cardiac Rhythm Management, Medtronic Inc., Mounds View, Minnesota
| | - Subham Ghosh
- Department of Cardiac Rhythm Management, Medtronic Inc., Maastricht, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
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11
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Chung ES, Rickard J, Lu X, DerSarkissian M, Zichlin ML, Cheung HC, Swartz N, Greatsinger A, Duh MS. Real-world clinical burden among patients with and without heart failure worsening after cardiac resynchronization therapy. Curr Med Res Opin 2022; 38:1489-1498. [PMID: 35727103 DOI: 10.1080/03007995.2022.2092374] [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] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Cardiac resynchronization therapy (CRT) can improve cardiac function in patients with heart failure (HF); however, in some patients, HF worsens despite CRT. This study characterized the long-term clinical burden of patients with and without HF worsening (HFW) within 6 months post CRT implantation. METHODS A claims database (2007-2018) was used to identify two cohorts of adults: those with HFW within 180 days post-CRT and those with no HFW (NHFW). The evaluated clinical outcomes were cardiovascular events/complications, HF-related interventions, hospice enrollment, and all-cause mortality. Inverse probability of treatment weighting (IPTW) was used to adjust for confounders; adjusted comparisons were assessed using weighted Cox proportional hazard ratios (HRs). RESULTS Among the 12,753 adults analyzed (HFW: N = 4,785; NHFW: N = 7,968), the mean age was 72 years and the mean duration of follow-up was approximately 2 years. The clinical burden was greater for HFW than for NHFW in terms of all-cause mortality (19.7% vs. 12.1%) and occurrence of atrial fibrillation (57.4% vs. 51.2%). In the IPTW-adjusted Cox proportional hazard analyses, patients with HFW had a 54% higher average hazard of experiencing all-cause mortality compared to NHFW (adjusted average HR = 1.54, 95% confidence interval [CI]: 1.41-1.70; p < .001). Of the clinical events experienced by ≥5% of patients, the greatest differences in average hazard were for HF decompensation (adjusted average HR = 1.83, 95% CI: 1.60-2.09) and HF decompensation or death (HR = 1.63, 95%CI: 1.50-1.77). CONCLUSION Patients with early HFW post-CRT experienced a significantly higher clinical burden than those without HFW. Vigilance for signs of worsening HF in the first 6 months post-CRT is warranted.
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Affiliation(s)
- Eugene S Chung
- The Lindner Clinical Research Center at The Christ Hospital, Cincinnati, OH, USA
| | | | - Xiaoxiao Lu
- Medtronic Global CRHF Headquarters, Mounds View, MN, USA
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12
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Green PG, Herring N, Betts TR. What Have We Learned in the Last 20 Years About CRT Non-Responders? Card Electrophysiol Clin 2022; 14:283-296. [PMID: 35715086 DOI: 10.1016/j.ccep.2021.12.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Although cardiac resynchronization therapy (CRT) has become well established in the treatment of heart failure, the management of patients who do not respond after CRT remains a key challenge. This review will summarize what we have learned about non-responders over the last 20 years and discuss methods for optimizing response, including the introduction of novel therapies.
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Affiliation(s)
- Peregrine G Green
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK; Oxford Centre for Clinical Magnetic Resonance Research (OCMR), University of Oxford, Level 0 John Radcliffe Hospital, Oxford, OX3 9DU, UK; Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Neil Herring
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK; Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Timothy R Betts
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK; Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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13
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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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14
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Rickard J. Case Studies of Cardiac Resynchronization Therapy "Nonresponders". Card Electrophysiol Clin 2022; 14:273-282. [PMID: 35715085 DOI: 10.1016/j.ccep.2021.12.014] [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: 11/25/2022]
Abstract
Outcomes following cardiac resynchronization therapy (CRT) vary widely, with some patients experiencing normalization of left ventricular function to some who seem to be harmed by biventricular pacing. The care of CRT patients postoperatively is complex and requires input from physicians specializing in electrophysiology, heart failure, and often cardiac imaging. In this section, cases of apparent CRT suboptimal response from a dedicated CRT optimization clinic are presented.
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Affiliation(s)
- John Rickard
- Section of Cardiac Electrophysiology, Department of Cardiovascular Medicine, Heart, and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue/J2-2, Cleveland, OH 44195, USA.
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15
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Martins R, António N, Donato H, Oliveiros B. Predictors of echocardiographic response to cardiac resynchronization therapy: A systematic review with Meta-Analysis. IJC HEART & VASCULATURE 2022; 39:100979. [PMID: 35252540 PMCID: PMC8891947 DOI: 10.1016/j.ijcha.2022.100979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 01/30/2022] [Accepted: 02/20/2022] [Indexed: 11/17/2022]
Abstract
NYHA class II seems to predict response to CRT. We should not delay CRT, trying medical management first, even in mildly symptomatic patients. Atrial fibrillation patients must have the same indication for CRT as those in sinus rhythm.
Background At least 30% of the patients do not respond to cardiac resynchronization therapy (CRT). We performed a systematic review and meta-analysis of real-world studies trying to identify predictors of response to CRT. Methods PubMed, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for observational prospective studies, referring the evaluation of response to CRT, defined as a decrease in left ventricle end-systolic volume (LVESV) ≥ 15% at 6-month follow-up, via two-dimensional echocardiography. Results A total of 24 studies were included. The meta-analysis showed that female gender (p = 0.018), non-ischemic cardiomyopathy (NICM) (p < 0.001), left bundle branch morphology (LBBB) (p = 0.001), longer QRS (p < 0.001) and New York Heart Association (NYHA) class II (p = 0.014) appear to favor response to CRT. After ROC analysis and logistic regression procedures, female gender (kappa = 0.450; p < 0.001), NICM (kappa = 0.636; p < 0.001), LBBB (kappa = 0.935; p < 0.001), and NYHA class II (kappa = 0.647; p < 0.001) were identified as independent predictors of response to CRT, being LBBB the most reliable one (sensitivity = 97.24%; specificity = 98.86%). Conclusions Female gender, NICM, LBBB and NYHA class II are baseline variables with an apparent capability to independently predict response to CRT, being LBBB the most reliable one.
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Affiliation(s)
- Rodrigo Martins
- Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - Natália António
- Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Corresponding author.
| | - Helena Donato
- Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
- Serviço de Documentação, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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16
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Cardiac computed tomography-verified right ventricular lead position and outcomes in cardiac resynchronization therapy. J Interv Card Electrophysiol 2022; 64:783-792. [DOI: 10.1007/s10840-022-01193-1] [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: 10/31/2021] [Accepted: 03/20/2022] [Indexed: 10/18/2022]
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17
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Zhang C, Wang XY, Lou L, Zhang X, Chen LL, Chen YX, Yang J. Pacemaker and Atrioventricular Junction Ablation in Patients With Atrial Fibrillation—A Systematic Review of Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 8:587297. [PMID: 35127840 PMCID: PMC8810654 DOI: 10.3389/fcvm.2021.587297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 12/20/2021] [Indexed: 11/25/2022] Open
Abstract
Background Cardiac resynchronization therapy (CRT) could be considered for heart failure (HF) patients with atrial fibrillation (AF) unless a potent ventricular capture strategy is conducted. However, the benefit of a pacemaker (PM; as part of CRT) in patients with AF and whether atrioventricular junction (or nodal) ablation (AVAB) can improve the prognosis of these patients compared with those treated medically to support ventricular capture are unclear. Methods and Results Systematic reviews and meta-analyses investigating the roles of PMs and AVAB in patients with AF were obtained in a search of the PubMed, Embase, and Medline databases and then analyzed with respect to the following outcomes: mortality, left ventricular ejection fraction, and clinical findings including the New York Heart Association class, 6-min walk distance (6MWD), quality of life as assessed in a specific questionnaire, and response to CRT. The quality of the included reviews was assessed using the Assessing the Methodological Quality of Systematic Reviews 2 tool, which includes 16 items. This study was finally based on 13 systematic reviews or meta-analyses. The results showed that patients with AF have higher all-cause mortality rates compared with patients with sinus rhythm and that AVAB can reduce all-cause mortality in patients with AF. Although the functional improvement was better in sinus rhythm than in patients with AF, in the latter, AVAB increased the 6MWD and reduced the CRT nonresponse rate in patients with AF. Conclusion Atrial fibrillation is associated with a higher all-cause mortality rate in patients with CRT implantation. AVAB, by increasing the 6MWD and survival, can improve the prognosis of these patients.
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18
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Hwang M, Uhm JS, Park MC, Shim EB, Lee CJ, Oh J, Yu HT, Kim TH, Joung B, Pak HN, Kang SM, Lee MH. In silico screening method for non-responders to cardiac resynchronization therapy in patients with heart failure: a pilot study. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2022. [DOI: 10.1186/s42444-021-00052-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Cardiac resynchronization therapy (CRT) is an effective treatment option for patients with heart failure (HF) and left ventricular (LV) dyssynchrony. However, the problem of some patients not responding to CRT remains unresolved. This study aimed to propose a novel in silico method for CRT simulation.
Methods
Three-dimensional heart geometry was constructed from computed tomography images. The finite element method was used to elucidate the electric wave propagation in the heart. The electric excitation and mechanical contraction were coupled with vascular hemodynamics by the lumped parameter model. The model parameters for three-dimensional (3D) heart and vascular mechanics were estimated by matching computed variables with measured physiological parameters. CRT effects were simulated in a patient with HF and left bundle branch block (LBBB). LV end-diastolic (LVEDV) and end-systolic volumes (LVESV), LV ejection fraction (LVEF), and CRT responsiveness measured from the in silico simulation model were compared with those from clinical observation. A CRT responder was defined as absolute increase in LVEF ≥ 5% or relative increase in LVEF ≥ 15%.
Results
A 68-year-old female with nonischemic HF and LBBB was retrospectively included. The in silico CRT simulation modeling revealed that changes in LVEDV, LVESV, and LVEF by CRT were from 174 to 173 mL, 116 to 104 mL, and 33 to 40%, respectively. Absolute and relative ΔLVEF were 7% and 18%, respectively, signifying a CRT responder. In clinical observation, echocardiography showed that changes in LVEDV, LVESV, and LVEF by CRT were from 162 to 119 mL, 114 to 69 mL, and 29 to 42%, respectively. Absolute and relative ΔLVESV were 13% and 31%, respectively, also signifying a CRT responder. CRT responsiveness from the in silico CRT simulation model was concordant with that in the clinical observation.
Conclusion
This in silico CRT simulation method is a feasible technique to screen for CRT non-responders in patients with HF and LBBB.
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19
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Gu H, Sidhu BS, Fang L, Webb J, Jackson T, Claridge S, Einarsen E, Razavi R, Papageorgiou N, Chow A, Bhattacharyya S, Chowienczyk P, Rinaldi CA. First-Phase Ejection Fraction Predicts Response to Cardiac Resynchronization Therapy and Adverse Outcomes. JACC Cardiovasc Imaging 2021; 14:2275-2285. [PMID: 34886993 DOI: 10.1016/j.jcmg.2021.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 05/04/2021] [Accepted: 05/14/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to examine the value of first-phase ejection fraction (EF1), to predict response to cardiac resynchronization therapy (CRT) and clinical outcomes after CRT. BACKGROUND CRT is an important treatment for patients with chronic heart failure. However, even in carefully selected cases, up to 40% of patients fail to respond. EF1, the ejection fraction up to the time of maximal ventricular contraction, is a novel sensitive echocardiographic measure of early systolic function and might relate to response to CRT. METHODS An initial retrospective study was performed in 197 patients who underwent CRT between 2009 and 2018 and were followed to determine clinical outcomes at King's Health Partners in London. A validation study (n = 100) was performed in patients undergoing CRT at Barts Heart Centre in London. RESULTS Volumetric response rate (reduction in end-systolic volume ≥15%) was 92.3% and 12.1% for those with EF1 in the highest and lowest tertiles (P < 0.001). A cutoff value of 11.9% for EF1 had >85% sensitivity and specificity for prediction of response to CRT; on multivariate binary logistic regression analysis incorporating previously defined predictors, EF1 was the strongest predictor of response (odds ratio [OR]: 1.56 per 1% change in EF1; 95% CI: 1.37-1.78; P < 0.001). EF1 was also the strongest predictor of improvement in clinical composite score (OR: 1.11; 95% CI: 1.04-1.19; P = 0.001). Improvement in EF1 at 6 months after CRT implantation (6.5% ± 5.8% vs 1.8% ± 4.3% in responders vs nonresponders; P < 0.001) was the best predictor of heart failure rehospitalization and death after median follow-up period of 20.3 months (HR: 0.81; 95% CI: 0.73-0.90; P < 0.001). In the validation cohort, EF1 was a similarly 1strong predictor of response (OR: 1.45; 95% CI: 1.23-1.70; P < 0.001) as in the original cohort. CONCLUSIONS EF1 is a promising marker to identify patients likely to respond to CRT.
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Affiliation(s)
- Haotian Gu
- British Heart Foundation Centre, King's College London, London, United Kingdom
| | - Baldeep S Sidhu
- Cardiology Department, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Lingyun Fang
- British Heart Foundation Centre, King's College London, London, United Kingdom
| | - Jessica Webb
- Cardiology Department, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Tom Jackson
- Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Simon Claridge
- Cardiology Department, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Eigir Einarsen
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Reza Razavi
- Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | | | - Anthony Chow
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | | | - Phil Chowienczyk
- British Heart Foundation Centre, King's College London, London, United Kingdom.
| | - Christopher A Rinaldi
- Cardiology Department, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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20
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Östenson B, Ostenfeld E, Werther-Evaldsson A, Roijer A, Bakos Z, Kanski M, Heiberg E, Arheden H, Borgquist R, Carlsson M. Regional contributions to left ventricular stroke volume determined by cardiac magnetic resonance imaging in cardiac resynchronization therapy. BMC Cardiovasc Disord 2021; 21:519. [PMID: 34702172 PMCID: PMC8549254 DOI: 10.1186/s12872-021-02325-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) restores ventricular synchrony and induces left ventricular (LV) reverse remodeling in patients with heart failure (HF) and dyssynchrony. However, 30% of treated patients are non-responders despite all efforts. Cardiac magnetic resonance imaging (CMR) can be used to quantify regional contributions to stroke volume (SV) as potential CRT predictors. The aim of this study was to determine if LV longitudinal (SVlong%), lateral (SVlat%), and septal (SVsept%) contributions to SV differ from healthy controls and investigate if these parameters can predict CRT response. METHODS Sixty-five patients (19 women, 67 ± 9 years) with symptomatic HF (LVEF ≤ 35%) and broadened QRS (≥ 120 ms) underwent CMR. SVlong% was calculated as the volume encompassed by the atrioventricular plane displacement (AVPD) from end diastole (ED) to end systole (ES) divided by total SV. SVlat%, and SVsept% were calculated as the volume encompassed by radial contraction from ED to ES. Twenty age- and sex-matched healthy volunteers were used as controls. The regional measures were compared to outcome response defined as ≥ 15% decrease in echocardiographic LV end-systolic volume (LVESV) from pre- to 6-months post CRT (delta, Δ). RESULTS AVPD and SVlong% were lower in patients compared to controls (8.3 ± 3.2 mm vs 15.3 ± 1.6 mm, P < 0.001; and 53 ± 18% vs 64 ± 8%, P < 0.01). SVsept% was lower (0 ± 15% vs 10 ± 4%, P < 0.01) with a higher SVlat% in the patient group (42 ± 16% vs 29 ± 7%, P < 0.01). There were no differences between responders and non-responders in neither SVlong% (P = 0.87), SVlat% (P = 0.09), nor SVsept% (P = 0.65). In patients with septal net motion towards the right ventricle (n = 28) ΔLVESV was - 18 ± 22% and with septal net motion towards the LV (n = 37) ΔLVESV was - 19 ± 23% (P = 0.96). CONCLUSIONS Longitudinal function, expressed as AVPD and longitudinal contribution to SV, is decreased in patients with HF scheduled for CRT. A larger lateral contribution to SV compensates for the abnormal septal systolic net movement. However, LV reverse remodeling could not be predicted by these regional contributors to SV.
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Affiliation(s)
- Björn Östenson
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Ellen Ostenfeld
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Anna Werther-Evaldsson
- Section for Heart Failure and Valvular Disease, Department of Clinical Sciences Lund, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Anders Roijer
- Section for Heart Failure and Valvular Disease, Department of Clinical Sciences Lund, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Zoltan Bakos
- Section of Arrhythmia, Department of Clinical Sciences Lund, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Mikael Kanski
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Department of Radiology, New York University School of Medicine, New York, NY, USA
| | - Einar Heiberg
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
| | - Håkan Arheden
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Rasmus Borgquist
- Section of Arrhythmia, Department of Clinical Sciences Lund, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marcus Carlsson
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden.
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21
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Stühlinger M, Metzler B. Do we need machine learning to predict CRT response? Int J Cardiol 2021; 342:41-42. [PMID: 34375707 DOI: 10.1016/j.ijcard.2021.07.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/30/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Markus Stühlinger
- University Clinic of Internal Medicine III/Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria.
| | - Bernhard Metzler
- University Clinic of Internal Medicine III/Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
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22
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Koerber SM, Field ME, Cobb DB, Gregoski MJ, Sturdivant JL, Gold MR. Electrical delays in quadripolar leads with cardiac resynchronization therapy. J Cardiovasc Electrophysiol 2021; 32:2498-2503. [PMID: 34245479 DOI: 10.1111/jce.15156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/17/2021] [Accepted: 06/07/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Pacing at sites of late intraventricular activation (QLV) or long interventricular conduction (right ventricle [RV]-left ventricular [LV]) have been associated with improved cardiac resynchronization therapy (CRT) outcomes. Quadripolar leads improve CRT outcomes by allowing for electrical repositioning to optimize pacing sites. However, little is known regarding the effect of such repositioning on electrical delay. OBJECTIVE Determine the relationship between different electrical bipoles from a quadripolar lead and measures of electrical delay. METHODS Forty-six patients underwent CRT with a quadripolar lead. The RV-LV and QLV intervals were measured for both the proximal and distal bipoles and the difference (Δ) between bipoles for each measure were calculated. Multivariate analyses were performed to identify predictors of electrical delays. RESULTS This was a typical CRT population with a mean age of 65 years and ejection fraction of 27%, with left bundle branch block (LBBB) present in 70%. The regression model for ΔQLV was significant (p = .05), with both gender (p = .008) and LBBB status (p = .020) significant predictors. The overall regression model for ΔRV-LV was not significant. ΔQLV and ΔRV-LV were significant among LBBB patients. Among non-LBBB, only ΔRV-LV was significant (mean: 7.2 ms, p = .006). ΔRV-LV versus ΔQLV were strongly correlated in LBBB (R2 = .92) but not non-LBBB (R2 = .06). CONCLUSION In LBBB, ΔRV-LV and ΔQLV are closely correlated suggesting that the proximal bipole and thus basal LV pacing sites should be selected when feasible. Greater variation in activation pattern is present in non-LBBB, so pacing sites should be individualized.
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Affiliation(s)
- Scott M Koerber
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael E Field
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Daniel B Cobb
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mathew J Gregoski
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John L Sturdivant
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael R Gold
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
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Bazoukis G, Naka KK, Alsheikh-Ali A, Tse G, Letsas KP, Korantzopoulos P, Liu T, Yeung C, Efremidis M, Tsioufis K, Baranchuk A, Stavrakis S. Association of QRS narrowing with response to cardiac resynchronization therapy-a systematic review and meta-analysis of observational studies. Heart Fail Rev 2021; 25:745-756. [PMID: 31392534 DOI: 10.1007/s10741-019-09839-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Prolonged QRS duration, which reflects a higher degree of mechanical dysynchrony, is a predictor of response to CRT. However, the association of QRS narrowing after biventricular pacing with CRT response rates is not clear. Our aim was to conduct a systematic review and meta-analysis on the association between QRS narrowing after cardiac resynchronization therapy (CRT) and clinical and echocardiographic response to CRT in patients with heart failure. Two independent investigators searched MedLine and EMBASE databases through July 2018 without any limitations. Studies providing estimates (continuous data) on the association of QRS shortening with either clinical (defined as New York Heart Association (NYHA) reduction ≥ 1) or echocardiographic (defined as left ventricular end-systolic volume (LVESV) reduction ≥ 15%) response to CRT were finally included in the quantitative synthesis. We included 32 studies (14 studies (1274 patients mean age 64 years old, males 79.3%) using clinical CRT response and 18 studies (1270 patients, mean age 64 years old, males 69.1%) using echocardiographic CRT response). A significant association between QRS narrowing and shorter attained QRS duration with clinical and echocardiographic CRT response was observed. The observed association was independent of the timing of QRS width measurement after CRT implantation. Acute and late improvement of electrical dysynchrony as depicted by QRS narrowing following biventricular pacing is associated with clinical and echocardiographic response to CRT. However, large prospective studies are needed to further examine our findings.
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Affiliation(s)
- George Bazoukis
- Second Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece. .,The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | - Katerina K Naka
- Second Department of Cardiology, University of Ioannina, GR 45110, Ioannina, Greece
| | - Alawi Alsheikh-Ali
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China.,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China
| | - Konstantinos P Letsas
- Second Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece
| | | | - Tong Liu
- Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, People's Republic of China
| | - Cynthia Yeung
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Michael Efremidis
- Second Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Konstantinos Tsioufis
- First Cardiology Clinic, Medical School, Hippokration Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Adrian Baranchuk
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Stavros Stavrakis
- The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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24
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Nejadeh M, Bayat P, Kheirkhah J, Moladoust H. Predicting the response to cardiac resynchronization therapy (CRT) using the deep learning approach. Biocybern Biomed Eng 2021. [DOI: 10.1016/j.bbe.2021.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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25
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Bazoukis G, Thomopoulos C, Tse G, Tsioufis K, Nihoyannopoulos P. Global longitudinal strain predicts responders after cardiac resynchronization therapy-a systematic review and meta-analysis. Heart Fail Rev 2021; 27:827-836. [PMID: 33782788 DOI: 10.1007/s10741-021-10094-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 11/28/2022]
Abstract
To evaluate the association between baseline global longitudinal strain (GLS) and ΔGLS (difference of baseline GLS and follow-up) and cardiac resynchronization therapy (CRT) response defined either with clinical or with echocardiographic characteristics. This meta-analysis was performed in accordance to both the Meta-Analysis of Observational Studies in Epidemiology and Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Two independent investigators performed a comprehensive systematic search in MedLine, EMBASE and Cochrane databases through September 2019 without limitations. Data analysis was performed by using the Review Manager software (RevMan), version 5.3, and Stata 13 software. A p value of less than 0.05 (two-tailed) was considered statistically significant. Twelve studies (1004 patients, mean age 63.8 years old, males 69.4%) provided data on the association of baseline GLS with the response to CRT therapy. We found that CRT responders had significantly better resting GLS values compared with non-responders [GLS mean difference -2.13 (-3.03, -1.23), p < 0.001, I2 78%]. Furthermore, CRT responders had significantly greater improvement of GLS at follow-up compared with non-responders [ΔGLS mean difference -3.20 (-4.95, -1.45), p < 0.001, I2 66%]. These associations remained significant in a subgroup analysis including only studies with similar CRT response definition. In this meta-analysis, we found that CRT responders had a baseline and ΔGLS significantly higher than the non-responders strengthening the central role of GLS as a tool for selecting candidates for CRT. Furthermore, improved GLS values after CRT may be used to better define CRT responders.
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Affiliation(s)
- George Bazoukis
- Second Department of Cardiology, General Hospital of Athens "Evangelismos", Athens, Greece
| | | | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, 300211, Tianjin, P. R. China
| | - Konstantinos Tsioufis
- First Cardiology Clinic, Hippokration Hospital, University of Athens, Athens, Greece
| | - Petros Nihoyannopoulos
- Imperial College London, NHLI, National Heart & Lung Institute, London, UK. .,Imperial College London, NHLI, Hammersmith Hospital, Du Cane Road, London, W12 0NN, UK.
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26
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Abstract
Cardiac resynchronization therapy (CRT) is an important and effective therapy for end-stage heart failure. Non-response to CRT is one of the main obstacles to its application in clinical practice. There is no uniform consensus or definition of CRT “response.” Clinical symptoms, ventricular remodeling indices, and cardiovascular events have been reported to be associated with non-responders. To prevent non-response to CRT, three aspects should be thoroughly considered: preoperative patient selection, electrode implantation, and postoperative management. Preoperative selection of appropriate patients for CRT treatment is an important step in preventing non-response. Currently, the CRT inclusion criteria are mainly based on the morphology of QRS waves in deciding ventricular dyssynchrony. Echocardiography and cardiac magnetic resonance are being explored to predict nonresponse to CRT. The location of left ventricular electrode implantation is a current hot spot of research; it is important to identify the location of the latest exciting ventricular segment and avoid scars. Cardiac magnetic resonance and ultrasonic spot tracking are being progressively developed in this field. Some new techniques such as His Bundle pacing, endocardial electrodes, and novel sensors are also being investigated. Postoperative management of patients is another essential step towards preventing non-response; it mainly focuses on the treatment of the disease itself and CRT program control optimization. CRT treatment is just one part of the overall treatment of heart failure, and multidisciplinary efforts are needed to improve the overall outcome.
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27
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Hejjel L, Németh M, Melczer L, Kónyi A. Cardiac resynchronization therapy with intraoperative epicardial mapping via minithoracotomy: 10 years' experience. Pacing Clin Electrophysiol 2021; 44:101-109. [PMID: 33184900 PMCID: PMC7898599 DOI: 10.1111/pace.14123] [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] [Received: 07/14/2020] [Revised: 10/19/2020] [Accepted: 11/09/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is considered an efficient method to improve the left ventricular (LV) dysfunction with left bundle branch block. However, coronary venous anatomy is not appropriate in about 10% of the cases; thus other alternatives, such as epicardial lead implantation via minithoracotomy are needed. METHODS During the period 2007-2017, a total of 57 patients were operated at our institute via left anterior minithoracotomy after an unsuccessful transvenous CRT. The best position of the LV epicardial electrode was determined by intraoperative epicardial mapping, that is locating the latest activation spot relative to the right ventricular (RV) electrode. The authors analyzed the survival by Kaplan-Meier estimator with Tarone-Ware equality test and multiple Cox regression analysis, the changes of the LV ejection fraction (LVEF) and dimensions, the development of the impedance and threshold of the LV epicardial electrode, the possible associations between the survival and intraoperative sensed RV-LV activation delay. RESULTS The intraoperative RV-LV activation delay was 92.250 ± 26.538 milliseconds. There were no intraoperative complications except ventricular fibrillation in three patients. Within 30 days there were neither wound healing complications nor pocket hematoma. There was no significant difference in survival with regard to gender or etiology, but significantly better survival was found in the cohort with intraoperative sensed RV-LV activation delay >86 milliseconds. The LVEF and dimensions improved following the operation and continued to be improved in the survivors. CONCLUSION CRT via minithoracotomy with epicardial mapping is a safe, efficient, simple, and reproducible second-line alternative to the transvenous method.
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Affiliation(s)
- László Hejjel
- Heart Institute, Medical SchoolUniversity of PécsPécsHungary
| | - Marianna Németh
- Heart Institute, Medical SchoolUniversity of PécsPécsHungary
| | - László Melczer
- Heart Institute, Medical SchoolUniversity of PécsPécsHungary
| | - Attila Kónyi
- Heart Institute, Medical SchoolUniversity of PécsPécsHungary
- Szentágothai Research CentreUniversity of PécsPécsHungary
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28
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Rath B, Willy K, Wolfes J, Ellermann C, Reinke F, Köbe J, Eckardt L, Frommeyer G. Predictors of response to cardiac resynchronization therapy in patients with chronic right ventricular pacing. Clin Res Cardiol 2020; 110:877-883. [PMID: 33320290 PMCID: PMC8166655 DOI: 10.1007/s00392-020-01785-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/23/2020] [Indexed: 01/20/2023]
Abstract
Background The benefits of de novo cardiac resynchronization therapy (CRT) in patients with QRS-prolongation and impaired left-ventricular function (LVEF) are well established. Current guidelines also recommend CRT-upgrade in patients requiring permanent or frequent right ventricular pacing (RVP) with symptomatic heart failure and reduced LVEF. Whereas several predictors of response to de novo CRT-implantation such as female gender, QRS-duration, non-ischemic cardiomyopathy (NICM) are known due to large prospective trials, similar factors regarding CRT-upgrade are currently lacking. Methods and results We examine 114 patients 3–6 months after CRT-upgrade due to frequent RVP (> 50%) and symptomatic heart failure. Response to CRT was evaluated by improvement in NYHA class referring to the Minnesota Living With Heart Failure Questionnaire. Only cardiomyopathy type and use of Angiotensin-converting-enzyme (ACE) inhibitor had an impact on response to CRT-upgrade in a linear regression model. Patients with NICM presented a greater responder rate than patients with ischemic cardiomyopathy (ICM) (80.4 vs. 60.3%, p < 0.05). Other traditional response predictors in de novo CRT recipients (e.g. QRS-width, female gender) showed no effect on CRT-response in this cohort. Conclusion Only underlying heart disease (NICM vs. ICM) and the use of ACE inhibitor were significant predictors of response to CRT-upgrade. In contrast to de novo CRT-recipients, where pre-implant QRS-duration is a key predictor, QRS-duration during RV-pacing has no significant impact on CRT-response in this cohort. Graphic abstract ![]()
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Affiliation(s)
- Benjamin Rath
- Department of Cardiology II (Electrophysiology), University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
| | - Kevin Willy
- Department of Cardiology II (Electrophysiology), University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Julian Wolfes
- Department of Cardiology II (Electrophysiology), University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Christian Ellermann
- Department of Cardiology II (Electrophysiology), University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Florian Reinke
- Department of Cardiology II (Electrophysiology), University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Julia Köbe
- Department of Cardiology II (Electrophysiology), University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Lars Eckardt
- Department of Cardiology II (Electrophysiology), University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Gerrit Frommeyer
- Department of Cardiology II (Electrophysiology), University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
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29
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Zou F, Brar V, Worley SJ. Interventional device implantation, Part I: Basic techniques to avoid complications: A hands-on approach. J Cardiovasc Electrophysiol 2020; 32:523-532. [PMID: 32945053 PMCID: PMC7894320 DOI: 10.1111/jce.14748] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/31/2020] [Accepted: 09/08/2020] [Indexed: 01/30/2023]
Abstract
Introduction The essence of cardiac resynchronization therapy (CRT) is biventricular (BiV) pacing, which involves implanting pacing leads in both the right ventricle (RV) and left ventricle (LV). Unlike traditional RV pacing, many hurdles lie ahead of successful LV lead implantation. Methods and Results In this review, we first highlight the importance of optimizing the patient and the tools. Next, we describe the CRT tools developed over several decades, to facilitate successful implantation. Thereafter, we provide a streamlined step‐by‐step summary of the basic BiV implantation procedure. Lastly, we discuss some commonly encountered challenges during implantation and the techniques to tackle them. Conclusion A systematic approach to every step of the implantation process can reduce procedure time, decrease patient exposure to radiation and contrast, and minimize complications. The use of right tools and techniques can enable all implanters to become more successful with BiV implantation.
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Affiliation(s)
- Fengwei Zou
- School of Medicine, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Vijaywant Brar
- Division of Cardiac Electrophysiology, MedStar Heart and Vascular Institute, Washington, District of Columbia, USA
| | - Seth J Worley
- Division of Cardiac Electrophysiology, MedStar Heart and Vascular Institute, Washington, District of Columbia, USA
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30
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Rickard J, Jackson K, Biffi M, Vernooy K, Bank A, Cerkvenik J, Ghosh S, Gold MR. The ECG Belt for CRT response trial: Design and clinical protocol. Pacing Clin Electrophysiol 2020; 43:1063-1071. [PMID: 32537740 DOI: 10.1111/pace.13985] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/17/2020] [Accepted: 05/10/2020] [Indexed: 11/29/2022]
Abstract
The ECG Belt for CRT response trial is designed to test the hypothesis that in patients traditionally less likely to respond to cardiac resynchronization therapy (CRT), an individualized approach utilizing the electrocardiogram (ECG) Belt to guide lead placement, vector selection, and device programming is superior to current standard of care. The ECG Belt is a noninvasive mapping technology designed to measure beat by beat electrical activation of the left ventricle by utilizing unipolar measurements from multiple ECG electrodes on the body surface. The ECG Belt for CRT response trial is a multicenter, prospective, randomized, investigational pre-market research study conducted at 48 centers in the United States, Canada, and Europe and will randomize approximately 400 subjects. The trial has three arms (enrollment will be 2:1:1, respectively): utilization of the Belt to guide implant as well as postimplant programming, utilizing the Belt to guide postimplant programming alone, and a non-Belt control arm. AdaptivCRT will be an option in the treatment arm but not the control arms. The primary endpoint is change in left ventricular end-systolic volume between preimplant and at 6 months. This paper describes the design and analytic plan for the trial.
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Affiliation(s)
| | - Kevin Jackson
- Duke University Medical Center, Durham, North Carolina
| | - Mauro Biffi
- Policlinico Sant'Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Kevin Vernooy
- Department of Cardiology, Maastricht Universitair Medisch Centrum, Maastricht, The Netherlands
| | - Alan Bank
- United Heart and Vascular Clinic, St Paul, Minnesota
| | | | | | - Michael R Gold
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
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31
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Left ventricular mechanical dyssynchrony analzyed by Tc-99m sestamibi SPECT and F-18 FDG PET in patients with ischemic cardiomyopathy and the prognostic value. Int J Cardiovasc Imaging 2020; 36:2063-2071. [DOI: 10.1007/s10554-020-01904-7] [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: 03/28/2020] [Accepted: 05/29/2020] [Indexed: 10/24/2022]
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32
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Verdonschot JAJ, Merken JJ, van Stipdonk AMW, Pliger P, Derks KWJ, Wang P, Henkens MTHM, van Paassen P, Abdul Hamid MA, van Empel VPM, Knackstedt C, Luermans JGLM, Crijns HJGM, Brunner-La Rocca HP, Brunner HG, Poelzl G, Vernooy K, Heymans SRB, Hazebroek MR. Cardiac Inflammation Impedes Response to Cardiac Resynchronization Therapy in Patients With Idiopathic Dilated Cardiomyopathy. Circ Arrhythm Electrophysiol 2020; 13:e008727. [PMID: 32997547 DOI: 10.1161/circep.120.008727] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is an established therapy in patients with dilated cardiomyopathy (DCM) and conduction disorders. Still, one-third of the patients with DCM do not respond to CRT. This study aims to depict the underlying cardiac pathophysiological processes of nonresponse to CRT in patients with DCM using endomyocardial biopsies. METHODS Within the Maastricht and Innsbruck registries of patients with DCM, 99 patients underwent endomyocardial biopsies before CRT implantation, with histological quantification of fibrosis and inflammation, where inflammation was defined as >14 infiltrating cells/mm2. Echocardiographic left ventricular end-systolic volume reduction ≥15% after 6 months was defined as response to CRT. RNA was isolated from cardiac biopsies of a representative subset of responders and nonresponders. RESULTS Sixty-seven patients responded (68%), whereas 32 (32%) did not respond to CRT. Cardiac inflammation before implantation was negatively associated with response to CRT (25% of responders, 47% of nonresponders; odds ratio 0.3 [0.12-0.76]; P=0.01). Endomyocardial biopsies fibrosis did not relate to CRT response. Cardiac inflammation improved the robustness of prediction beyond well-known clinical predictors of CRT response (likelihood ratio test P<0.001). Cardiac transcriptomic profiling of endomyocardial biopsies reveals a strong proinflammatory and profibrotic signature in the hearts of nonresponders compared with responders. In particular, COL1A1, COL1A2, COL3A1, COL5A1, POSTN, CTGF, LOX, TGFβ1, PDGFRA, TNC, BGN, and TSP2 were significantly higher expressed in the hearts of nonresponders. CONCLUSIONS Cardiac inflammation along with a transcriptomic profile of high expression of combined proinflammatory and profibrotic genes are associated with a poor response to CRT in patients with DCM.
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Affiliation(s)
- Job A J Verdonschot
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands.,Clinical Genetics (J.A.J.V., K.W.J.D., P.W., H.G.B.), Maastricht University Medical Center, the Netherlands
| | - Jort J Merken
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Antonius M W van Stipdonk
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Philipp Pliger
- Clinical Division of Cardiology and Angiology, Innsbruck Medical University, Austria (P.P., G.P.)
| | - Kasper W J Derks
- Clinical Genetics (J.A.J.V., K.W.J.D., P.W., H.G.B.), Maastricht University Medical Center, the Netherlands
| | - Ping Wang
- Clinical Genetics (J.A.J.V., K.W.J.D., P.W., H.G.B.), Maastricht University Medical Center, the Netherlands
| | - Michiel T H M Henkens
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Pieter van Paassen
- Immunology (P.v.P.), Maastricht University Medical Center, the Netherlands
| | | | - Vanessa P M van Empel
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Christian Knackstedt
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Justin G L M Luermans
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Harry J G M Crijns
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Hans-Peter Brunner-La Rocca
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Han G Brunner
- Clinical Genetics (J.A.J.V., K.W.J.D., P.W., H.G.B.), Maastricht University Medical Center, the Netherlands.,GROW Institute for Developmental Biology and Cancer (H.G.B.), Maastricht University Medical Center, the Netherlands.,Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour (H.G.B.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gerhard Poelzl
- Clinical Division of Cardiology and Angiology, Innsbruck Medical University, Austria (P.P., G.P.)
| | - Kevin Vernooy
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands.,Department of Cardiology (K.V.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stephane R B Heymans
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands.,Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology, KU Leuven, Belgium (S.R.B.H.).,The Netherlands Heart Institute, Nl-HI, Utrecht (S.R.B.H.)
| | - Mark R Hazebroek
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
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Myocardial Scar on Surface ECG: Selvester Score, but Not Fragmentation, Predicts Response to CRT. Cardiol Res Pract 2020; 2020:2036545. [PMID: 33014454 PMCID: PMC7525300 DOI: 10.1155/2020/2036545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 11/18/2022] Open
Abstract
Purpose Myocardial scar is directly related to the response to CRT after implantation. The extent of myocardial scar can be detected not only by cardiac magnetic resonance but also by two electrocardiographic scores: fragmented QRS (fQRS) and Selvester score (SSc). The aim of our study is to compare the role of baseline SSc and fQRS in predicting response to CRT in a cohort of heart failure patients with true left bundle branch block (LBBB). As a secondary endpoint, we assessed the association of both scores with overall and cardiac mortality, heart failure hospitalizations, ventricular arrhythmias requiring ICD intervention, and major adverse cardiovascular event (MACE). Methods We evaluated fQRS and SSc of 178 consecutive HF patients with severe systolic dysfunction (LVEF ≤ 35%), NYHA class II-III despite optimal medical treatment, and true-LBBB. Response to CRT was defined as the improvement of LVEF of at least 10% or as the reduction of LVESV of at least 15% at a 6-month follow-up. Each endpoint was related to fQRS and SSc. Results SSc ≥7 was significantly associated with the absence of echocardiographic response to CRT (OR: 0.327; 95% C.I. 0.155–0.689; p=0.003), while the presence of fQRS at baseline ECG was not (OR: 1.133; 95% C.I. 0.539–2.381; p=0.742). No correlation was found between SSc and overall mortality, cardiac death, ventricular arrhythmias, hospitalizations due to heart failure, or for MACE. Similar results were observed between fQRS and all secondary endpoints. Conclusion In HF patients with true-LBBB and LVEF ≤35% eligible for CRT, myocardial scar assessed by calculating the SSc on preimplant ECG is an independent predictor of nonresponse after multiple adjustments. Neither SSc nor fQRS is associated with overall and cardiac death, ventricular arrhythmias, or hospitalization for heart failure at a 24-month follow-up.
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Cardiac Resynchronization Therapy in Patients With Nonischemic Cardiomyopathy Using Left Bundle Branch Pacing. JACC Clin Electrophysiol 2020; 6:849-858. [DOI: 10.1016/j.jacep.2020.04.011] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 04/02/2020] [Accepted: 04/03/2020] [Indexed: 11/23/2022]
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Coksevim M, Akcay M, Yuksel S, Yenercag M, Cerik B, Gedikli O, Gulel O, Sahin M. The effect of cardiac resynchronization therapy on arterial stiffness and central hemodynamic parameters. J Arrhythm 2020; 36:498-507. [PMID: 32528578 PMCID: PMC7279984 DOI: 10.1002/joa3.12331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 02/24/2020] [Accepted: 02/28/2020] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Cardiac resynchronization therapy (CRT) is a device-based method of treatment which decreases morbidity and mortality in heart failure with reduced ejection fraction (HFrEF). This study was aimed to investigate the effects of CRT on hemodynamic and arterial stiffness parameters evaluated by noninvasive method, and determine whether there is a correlation between the changes after CRT in these parameters and the clinical response to CRT or not. METHODS The study included 46 patients with HFrEF who were planned to undergo CRT implantation. Before the CRT implantation, clinical and demographic data were recorded from all patients. Hemodynamic and arterial stiffness parameters were measured oscillometrically by an arteriograph before CRT implantation. The patients were re-evaluated minimum three months after CRT; the above-mentioned parameters were measured again and compared to the pre-CRT period. RESULTS Compared to the period before CRT, mean systolic blood pressure (SBP) (116.8 ± 19.1 mm Hg vs 127.7 ± 20.9 mm Hg, P = .005), central SBP (cSBP) (106.2 ± 17.3 mm Hg vs 116.8 ± 18.7 mm Hg, P = .015), cardiac output (CO) (4.6 ± 0.8 lt/min vs 5.1 ± 0.8 lt/min, P = .002), stroke volume (65.6 ± 16.3 mL vs 72.0 ± 14.9 mL), and pulse wave velocity (PWV) (10 ± 1.6 m/sec vs 10.4 ± 1.8 m/sec, P = .004) increased significantly in post-CRT period. In addition, the same parameters were significantly increased post-CRT period in patients with clinical response. However, there was not any similar increase in nonresponder patients. CONCLUSION This study demonstrated that SBP, CO, and PWV increased significantly after CRT. The modest increases in these parameters were observed to be associated with positive clinical outcomes.
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Affiliation(s)
- Metin Coksevim
- School of MedicineDepartment of CardiologyOndokuz Mayis UniversitySamsunTurkey
| | - Murat Akcay
- School of MedicineDepartment of CardiologyOndokuz Mayis UniversitySamsunTurkey
| | - Serkan Yuksel
- Department of CardiologySamsun Training and Research HospitalSamsunTurkey
| | - Mustafa Yenercag
- Department of CardiologySamsun Training and Research HospitalSamsunTurkey
| | - Bugra Cerik
- School of MedicineDepartment of CardiologySivas Cumhuriyet UniversitySivasTurkey
| | - Omer Gedikli
- School of MedicineDepartment of CardiologyOndokuz Mayis UniversitySamsunTurkey
| | - Okan Gulel
- School of MedicineDepartment of CardiologyOndokuz Mayis UniversitySamsunTurkey
| | - Mahmut Sahin
- School of MedicineDepartment of CardiologyOndokuz Mayis UniversitySamsunTurkey
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Combination of Left Ventricular End-Diastolic Diameter and QRS Duration Strongly Predicts Good Response to and Prognosis of Cardiac Resynchronization Therapy. Cardiol Res Pract 2020; 2020:1257578. [PMID: 32411441 PMCID: PMC7201746 DOI: 10.1155/2020/1257578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 12/26/2019] [Indexed: 11/17/2022] Open
Abstract
Background Approximately 20–40% of recipients of cardiac resynchronization therapy (CRT) do not respond to it based on the current patient selection criteria. The purpose of this study was to identify baseline parameters that can predict CRT response and to evaluate the effect of those predictive parameters on long-term prognosis. Methods This was a retrospective, nonrandomized, noncontrolled cohort study. Patients who received CRT in our centre were divided into responders and nonresponders by the definition of CRT response (an increase in left ventricular ejection fraction (LVEF) of ≥5% and improvement of ≥1 New York Heart Association (NYHA) class from baseline to the 6-month follow-up). Results Of the 101 patients, 68 were responders and 33 were nonresponders. Left ventricular end-diastolic diameter (LVEDD; OR: 0.88, 95% CI: 0.81–0.95, P=0.001) and QRS duration (OR: 1.07, 95% CI: 1.04–1.10, P < 0.001) were independent predictors of CRT response. The combination of LVEDD and QRS duration was more valuable for predicting CRT response (AUC 0.836; 95% CI: 0.76–0.91; P < 0.001). Moreover, the combination of LVEDD ≤ 71 mm and QRS duration ≥ 170 ms had a low incidence of all-cause mortality, HF hospitalisation, and the composite endpoint. In addition, baseline LVEDD had a positive correlation with QRS duration (R=0.199, P=0.046). Responders to CRT had better LV reverse remodeling. Conclusion The combination of LVEDD and QRS duration provided more robust prediction of CRT response. Moreover, the combination of LVEDD ≤ 71 mm and QRS duration ≥ 170 ms was associated with a low incidence of all-cause mortality, HF hospitalisation, and the composite endpoint. Our results may be useful to provide individualized patient selection for CRT.
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Wang J, Wang Y, Yang M, Shao S, Tian Y, Shao X, Fan S, Zhang F, Yang W, Xin W, Tang H, Xu M, Yang L, Wang X, Zhou W. Mechanical contraction to guide CRT left-ventricular lead placement instead of electrical activation in myocardial infarction with left ventricular dysfunction: An experimental study based on non-invasive gated myocardial perfusion imaging and invasive electroanatomic mapping. J Nucl Cardiol 2020; 27:419-430. [PMID: 30972718 PMCID: PMC10961107 DOI: 10.1007/s12350-019-01710-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 03/29/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Whether the region of the latest electrical activation (LEA) corresponds with the segment of the latest mechanical contraction (LMC) in ischemic cardiomyopathy (ICM) is uncertain. We aimed to investigate the relationship between the left-ventricular (LV) viable segments with LEA and with LMC after myocardial infarction (MI) and analyze the acute hemodynamic responses (dP/dtmax) after cardiac resynchronization therapy (CRT) pacing at different LV sites. METHODS AND RESULTS Bama suckling pigs (n = 6) were subjected to create MI models. Both gated myocardial perfusion imaging (GMPI) and electroanatomic mapping (EAM) were performed successfully before MI and 4 weeks after MI. LMC was assessed by phase analysis of GMPI, while LEA was evaluated by EAM. The dP/dtmax was measured before CRT and when the CRT LV electrode was implanted in viable segments of LMC, viable segments of lateral wall and scar, respectively. The viable segments of LEA were consistent with the sites of LMC for five in six cases. The dP/dtmax increased significantly compared with that before CRT when the CRT LV electrode was implanted in viable segments of LMC (1103.33 ± 195.76 vs 717.83 ± 80.74 mmHg·s-1, P = .001), which was also significantly higher than in viable segments of lateral wall (751.17 ± 105.62 mmHg·s-1, P = .000) and scar (679.50 ± 60.87 mmHg·s-1, P = .001). CONCLUSIONS Non-invasive GMPI may be a better option than invasive EAM for guiding LV electrode implantation for CRT in ICM.
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Affiliation(s)
- Jianfeng Wang
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Yuetao Wang
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China.
| | - Minfu Yang
- Department of Nuclear Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100000, China
| | - Shan Shao
- Department of Cardiology, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Yi Tian
- Department of Nuclear Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Xiaoliang Shao
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Shengdeng Fan
- Department of Anesthesiology, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Feifei Zhang
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Wei Yang
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Wenchong Xin
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Haipeng Tang
- School of Computing, University of Southern Mississippi, Long Beach, MS, 39560, USA
| | - Min Xu
- Department of Echocardiogram, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Ling Yang
- Department of Cardiology, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Xiaosong Wang
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
| | - Weihua Zhou
- School of Computing, University of Southern Mississippi, Long Beach, MS, 39560, USA
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Baseline Right Ventricular Dysfunction Predicts Worse Outcomes in Patients Undergoing Cardiac Resynchronization Therapy Implantation. J Card Fail 2020; 26:227-232. [DOI: 10.1016/j.cardfail.2019.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 12/16/2019] [Accepted: 12/18/2019] [Indexed: 02/02/2023]
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Chubb H, Motonaga KS. Cardiac resynchronization and implantable defibrillators in adults with congenital heart disease. Heart Fail Rev 2019; 25:657-670. [PMID: 31754907 DOI: 10.1007/s10741-019-09886-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillators (ICDs) are well-established therapies for adult patients with heart failure that have been shown to improve morbidity and mortality. However, the benefits and indications for use in adults with congenital heart disease (ACHD) are less defined with no significant large prospective studies in this population. There are, however, multiple retrospective studies that demonstrate the efficacy of these devices in the ACHD population. These indicate a role for both CRT and ICDs in select patients with ACHD. The clinician and patient must balance the risks and benefits, summarized in complex evidence that reflects the heterogeneity of the ACHD patient group, and apply them in a patient-specific manner to optimize the utility of CRT and ICDs.
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Affiliation(s)
- Henry Chubb
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Palo Alto, CA, USA. .,Division of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Palo Alto, CA, USA. .,Heart Center Research Core, Stanford University, 780 Welch Road, Palo Alto, CA, 94304-5701, USA.
| | - Kara S Motonaga
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Palo Alto, CA, USA
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Mascia G, Paoletti Perini A, Cartei S, Binazzi B, Gigliotti F, Solimene F, Mascioli G, Giaccardi M. Sleep-disordered breathing and effectiveness of cardiac resynchronization therapy in heart failure patients: gender differences? Sleep Med 2019; 64:106-111. [PMID: 31678699 DOI: 10.1016/j.sleep.2019.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/17/2019] [Accepted: 06/12/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVES This study evaluated heart failure (HF) patients who underwent cardiac resynchronization therapy (CRT) and who had device-documented sleep-disordered breathing (SDB). We found gender differences in acute changes in SDB due to CRT impact. BACKGROUND SDB typically occurs in HF patients. However, the role of SDB and its response to CRT in HF patients, as well as the relation with gender are currently not fully researched. METHODS Among 63 consecutive patients who received CRT with an SDB algorithm, 23 patients documented SDB at one-month cardiac device interrogation and represented our population. We defined a Sleep apnoea Severity SCore(SSSC), and consequently, patients were categorized to have mild, moderate, and severe sleep apnoea syndrome divided into two groups: Group-1: 18 males (78%); Group-2: 5 females (22%). We evaluated the variation of apnoea burden and CRT response based on gender differences. RESULTS A significantly higher proportion of patients in the male group were non-responders to CRT at 12-months follow-up (p = 0.076) while in the female population 5/5 patients (100%) were responders to CRT at the same follow-up time (p = 0.021). Among Group-2 subjects, we documented a significant linear decrease in SSSC(p > 0,01) while in Group-1 the CRT effect on SSSC was variable. At 12-months follow-up, the difference in SSSC between the two groups was statistically significant (p < 0.001). CONCLUSIONS Our study reports a correlation between CRT response and sleep apnoea burden considering gender differences. In particular, HF-women responders to CRT demonstrate a significant linear decrease in sleep apnoea burden determined through a device algorithm, when compared to a similar male population. Further research is needed to confirm these findings.
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Affiliation(s)
- Giuseppe Mascia
- Cardiology and Electrophysiology Unit, Azienda USL Toscana Centro, Florence, Italy.
| | | | - Stella Cartei
- Cardiology and Electrophysiology Unit, Azienda USL Toscana Centro, Florence, Italy
| | - Barbara Binazzi
- Rehabilitative Pneumology IRCCS Fondazione Don Gnocchi Hospital, Florence, Italy
| | - Francesco Gigliotti
- Rehabilitative Pneumology IRCCS Fondazione Don Gnocchi Hospital, Florence, Italy
| | - Francesco Solimene
- Electrophysiology Unit, Clinica Montevergine, Mercogliano, Avellino, Italy
| | - Giosue Mascioli
- Cardiology and Electrophysiology Unit, Cliniche Gavazzeni, Bergamo, Italy
| | - Marzia Giaccardi
- Cardiology and Electrophysiology Unit, Azienda USL Toscana Centro, Florence, Italy
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Chang HY, Chen KC, Fong MC, Feng AN, Fu HN, Huang KC, Chong E, Yin WH. Recovery of left ventricular dysfunction after sacubitril/valsartan: predictors and management. J Cardiol 2019; 75:233-241. [PMID: 31563433 DOI: 10.1016/j.jjcc.2019.08.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/29/2019] [Accepted: 08/08/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Literature describing recovery of left ventricular (LV) function post sacubitril/valsartan treatment and the optimal management of heart failure (HF) patients receiving sacubitril/valsartan remain sparse. METHODS We recruited 437 consecutive chronic HF patients with baseline left ventricular ejection fraction (LVEF) less than 40%, who were treated with sacubitril/valsartan. All patients underwent routine echocardiographic measurement. RESULTS During treatment period, recovery of LVEF to 50% or greater was observed in 77 (17.6%) patients. After multivariate analysis, recovery of LV dysfunction was associated with non-ischemic etiology of HF, smaller baseline LV end-diastolic diameter (LVEDD), and higher initial dosage of sacubitril/valsartan. Compared to those without recovery of LV dysfunction, death from cardiovascular causes or first unplanned hospitalization for HF (CVD/HFH) were significantly lower in patients with LVEF recovery [11.7% vs. 24.4%, hazard ratio (HR) 0.42, p = 0.014]. Among patients with recovery of LVEF, 51 patients continued to receive the same dosage of sacubitril/valsartan had higher LVEF and were less likely to have deterioration of LVEF than the other 26 patients who received either tapering dose of sacubitril/valsartan or switching from sacubitril/valsartan to renin-angiotensin-system blockers (LVEF 56.4 ± 5.3% vs. 45.0 ± 12.8%, p < 0.001; ΔLVEF 1.2 ± 5.1% vs. -9.3 ± 12.0%, p < 0.001). CVD/HFH occurred more frequently in the taper group than the maintenance group (23.1% vs. 5.9%, HR 0.22, p = 0.035). CONCLUSIONS Non-ischemic etiology of HF, smaller baseline LVEDD, and higher initial dosage of sacubitril/valsartan could predict better recovery of LV function. Among patients with functional recovery, tapering sacubitril/valsartan dose was associated with deterioration of recovered heart function and had less favorable prognosis during follow-up.
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Affiliation(s)
- Hung-Yu Chang
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Kuan-Chun Chen
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan; National Defense Medical Center, Taipei, Taiwan; Institute of Emergency and Critical Care Medicine, National Yang Ming University, Taipei, Taiwan
| | - Man-Cai Fong
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan; National Defense Medical Center, Taipei, Taiwan
| | - An-Ning Feng
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Hao-Neng Fu
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | | | - Eric Chong
- Division of Cardiology, Farrer Park Hospital, Singapore
| | - Wei-Hsian Yin
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan.
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Abstract
With the growing obesity epidemic, the global burden of AF and obstructive sleep apnoea (OSA) is increasing at an alarming rate. Obesity, age, male gender, alcohol consumption, smoking and heart failure are common risk factors for both AF and OSA and they are independently associated with adverse cardiovascular outcomes. Weak evidence from observational studies link OSA to the development of AF. Hypoxia/hypercapnia, systemic inflammation and autonomic nervous system modulation are biological mechanisms that link OSA to AF. Patients with OSA have a poor response to catheter ablation of AF and often suffer recurrences. Observational data shows that continuous positive airway pressure is associated with a reduction in AF burden and a better response to catheter ablation of AF. However, prospective randomised studies are needed to confirm the usefulness of continuous positive airway pressure in the treatment of AF in patients with OSA.
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Affiliation(s)
- Ghanshyam Shantha
- Clinical Cardiac Electrophysiology, University of Michigan Ann Arbor, MI, US
| | - Frank Pelosi
- Clinical Cardiac Electrophysiology, University of Michigan Ann Arbor, MI, US
| | - Fred Morady
- Clinical Cardiac Electrophysiology, University of Michigan Ann Arbor, MI, US
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Yaman B, Kemal HS, Dönmez Y, Cerit L, Usalp S, Yüksek Ü, Günsel A, Duygu H, Akpınar O. Improvement of abnormal systolic motion of the interventricular septum with cardiac resynchronization therapy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:1213-1218. [PMID: 31390077 DOI: 10.1111/pace.13772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/18/2019] [Accepted: 08/04/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is no consensus in the literature regarding what is the responsible mechanism of left ventricular dyssynchrony; septal dyskinesia or late movement of left ventricle (LV) lateral wall. We aim to evaluate the abnormal systolic motion in each myocardial segment and the improvement of LV systolic function with pulsed tissue Doppler imaging (TDI) in patients undergoing cardiac resynchronization therapy (CRT) with left bundle branch block (LBBB). METHODS A total of 26 patients undergoing CRT implantation with LBBB, wide QRS duration (≥120 ms), and low ejection fraction (EF) (<35%) were included. Pulsed TDI was taken from apical 4-chamber view and parasternal short axis view (PSAX). All echocardiographic parameters were measured when CRT is on and off. RESULTS Systolic ejection time (ET) of anteroseptal and posterolateral wall of LV in PSAX was statistically significantly longer in CRT on group (321.6 ± 62.7 vs 237.5 ± 59.3 ms, P < .001; 323.9 ± 58.0 vs 289.4 ± 43.7 ms, P = .015, respectively). In apical 4-chamber view, septal annulus systolic ET is significantly longer in CRT on group than CRT off group (315.8 ± 57.2 vs 287.3 ± 42.2, P = .014). Also, there was a strong correlation between systolic ET of the septum in PSAX with aortic velocity time integral (VTI), QRS duration and EF (r = .587, P = .002; r = .479, P = .013; r = .440, P = .025; respectively). CONCLUSION Circumferential contraction of septal myocardial fibers is improved with CRT and it is strongly correlated with increase of aortic VTI and shortening of QRS duration. These findings predict the deterioration of septal contraction as the main mechanism in patients with LBBB pattern and, CRT may improves myocardial contraction by correcting septal systolic motion.
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Affiliation(s)
- Belma Yaman
- Department of Cardiology, Near East University Faculty of Medicine, Nicosia, Cyprus
| | - Hatice S Kemal
- Department of Cardiology, Near East University Faculty of Medicine, Nicosia, Cyprus
| | - Yurdaer Dönmez
- Department of Cardiology, Adana City Training and Research Hospital, Adana, Turkey
| | - Levent Cerit
- Department of Cardiology, Near East University Faculty of Medicine, Nicosia, Cyprus
| | - Songül Usalp
- Department of Cardiology, Near East University Faculty of Medicine, Nicosia, Cyprus
| | - Ümit Yüksek
- Department of Cardiology, Near East University Faculty of Medicine, Nicosia, Cyprus
| | - Aziz Günsel
- Department of Cardiology, Near East University Faculty of Medicine, Nicosia, Cyprus
| | - Hamza Duygu
- Department of Cardiology, Near East University Faculty of Medicine, Nicosia, Cyprus
| | - Onur Akpınar
- Department of Cardiology, Near East University Faculty of Medicine, Nicosia, Cyprus
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Feeny AK, Rickard J, Patel D, Toro S, Trulock KM, Park CJ, LaBarbera MA, Varma N, Niebauer MJ, Sinha S, Gorodeski EZ, Grimm RA, Ji X, Barnard J, Madabhushi A, Spragg DD, Chung MK. Machine Learning Prediction of Response to Cardiac Resynchronization Therapy: Improvement Versus Current Guidelines. Circ Arrhythm Electrophysiol 2019; 12:e007316. [PMID: 31216884 DOI: 10.1161/circep.119.007316] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) has significant nonresponse rates. We assessed whether machine learning (ML) could predict CRT response beyond current guidelines. METHODS We analyzed CRT patients from Cleveland Clinic and Johns Hopkins. A training cohort was created from all Johns Hopkins patients and an equal number of randomly sampled Cleveland Clinic patients. All remaining patients comprised the testing cohort. Response was defined as ≥10% increase in left ventricular ejection fraction. ML models were developed to predict CRT response using different combinations of classification algorithms and clinical variable sets on the training cohort. The model with the highest area under the curve was evaluated on the testing cohort. Probability of response was used to predict survival free from a composite end point of death, heart transplant, or placement of left ventricular assist device. Predictions were compared with current guidelines. RESULTS Nine hundred twenty-five patients were included. On the training cohort (n=470: 235, Johns Hopkins; 235, Cleveland Clinic), the best ML model was a naive Bayes classifier including 9 variables (QRS morphology, QRS duration, New York Heart Association classification, left ventricular ejection fraction and end-diastolic diameter, sex, ischemic cardiomyopathy, atrial fibrillation, and epicardial left ventricular lead). On the testing cohort (n=455, Cleveland Clinic), ML demonstrated better response prediction than guidelines (area under the curve, 0.70 versus 0.65; P=0.012) and greater discrimination of event-free survival (concordance index, 0.61 versus 0.56; P<0.001). The fourth quartile of the ML model had the greatest risk of reaching the composite end point, whereas the first quartile had the least (hazard ratio, 0.34; P<0.001). CONCLUSIONS ML with 9 variables incrementally improved prediction of echocardiographic CRT response and survival beyond guidelines. Performance was not improved by incorporating more variables. The model offers potential for improved shared decision-making in CRT (online calculator: http://riskcalc.org:3838/CRTResponseScore ). Significant remaining limitations confirm the need to identify better variables to predict CRT response.
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Affiliation(s)
- Albert K Feeny
- Cleveland Clinic Lerner College of Medicine (A.K.F., M.A.L.), Case Western Reserve University, OH
| | - John Rickard
- Department of Cardiovascular Medicine, Heart and Vascular Institute (J.R., D.P., S.T., K.M.T., N.V., M.J.N., E.Z.G., R.A.G., M.K.C.), Cleveland Clinic, OH
| | - Divyang Patel
- Department of Cardiovascular Medicine, Heart and Vascular Institute (J.R., D.P., S.T., K.M.T., N.V., M.J.N., E.Z.G., R.A.G., M.K.C.), Cleveland Clinic, OH
| | - Saleem Toro
- Department of Cardiovascular Medicine, Heart and Vascular Institute (J.R., D.P., S.T., K.M.T., N.V., M.J.N., E.Z.G., R.A.G., M.K.C.), Cleveland Clinic, OH
| | - Kevin M Trulock
- Department of Cardiovascular Medicine, Heart and Vascular Institute (J.R., D.P., S.T., K.M.T., N.V., M.J.N., E.Z.G., R.A.G., M.K.C.), Cleveland Clinic, OH
| | - Carolyn J Park
- Division of Cardiology, The Johns Hopkins Hospital, Baltimore, MD (C.J.P., S.S., D.D.S.)
| | - Michael A LaBarbera
- Cleveland Clinic Lerner College of Medicine (A.K.F., M.A.L.), Case Western Reserve University, OH
| | - Niraj Varma
- Department of Cardiovascular Medicine, Heart and Vascular Institute (J.R., D.P., S.T., K.M.T., N.V., M.J.N., E.Z.G., R.A.G., M.K.C.), Cleveland Clinic, OH
| | - Mark J Niebauer
- Department of Cardiovascular Medicine, Heart and Vascular Institute (J.R., D.P., S.T., K.M.T., N.V., M.J.N., E.Z.G., R.A.G., M.K.C.), Cleveland Clinic, OH
| | - Sunil Sinha
- Division of Cardiology, The Johns Hopkins Hospital, Baltimore, MD (C.J.P., S.S., D.D.S.)
| | - Eiran Z Gorodeski
- Department of Cardiovascular Medicine, Heart and Vascular Institute (J.R., D.P., S.T., K.M.T., N.V., M.J.N., E.Z.G., R.A.G., M.K.C.), Cleveland Clinic, OH
| | - Richard A Grimm
- Department of Cardiovascular Medicine, Heart and Vascular Institute (J.R., D.P., S.T., K.M.T., N.V., M.J.N., E.Z.G., R.A.G., M.K.C.), Cleveland Clinic, OH
| | - Xinge Ji
- Department of Quantitative Health Sciences, Lerner Research Institute (X.J., J.B.), Cleveland Clinic, OH
| | - John Barnard
- Department of Quantitative Health Sciences, Lerner Research Institute (X.J., J.B.), Cleveland Clinic, OH
| | - Anant Madabhushi
- Department of Biomedical Engineering (A.M.), Case Western Reserve University, OH.,Louis Stokes Cleveland Veterans Administration Medical Center, OH (A.M.)
| | - David D Spragg
- Division of Cardiology, The Johns Hopkins Hospital, Baltimore, MD (C.J.P., S.S., D.D.S.)
| | - Mina K Chung
- Department of Cardiovascular Medicine, Heart and Vascular Institute (J.R., D.P., S.T., K.M.T., N.V., M.J.N., E.Z.G., R.A.G., M.K.C.), Cleveland Clinic, OH
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Cruz MC, Abreu A, Portugal G, Santa-Clara H, Cunha PS, Oliveira MM, Santos V, Oliveira L, Rio P, Rodrigues I, Morais LA, Ferreira RC, Carmo MM. Relationship of left ventricular global longitudinal strain with cardiac autonomic denervation as assessed by 123I-mIBG scintigraphy in patients with heart failure with reduced ejection fraction submitted to cardiac resynchronization therapy : Assessment of cardiac autonomic denervation by GLS in patients with heart failure with reduced ejection fraction submitted to CRT. J Nucl Cardiol 2019; 26:869-879. [PMID: 29209951 DOI: 10.1007/s12350-017-1148-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 10/24/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Heart failure (HF) is associated with cardiac autonomic denervation (AD), which can be non-invasively assessed by 123I-metaiodobenzylguanidine (123I-mIBG) scintigraphy and has prognostic implications. We aimed to study the relationship between myocardial contractility assessed by global longitudinal strain (GLS) and AD assessed by 123I-mIBG scintigraphy in advanced HF. METHODS/RESULTS BETTER-HF is a prospective randomized clinical trial including HF patients (pts) submitted to cardiac resynchronization therapy (CRT) who are submitted to a clinical, echocardiographic, and scintigraphic assessment before and 6 months after CRT. 81 pts were included. An echocardiographic response (absolute increase in left ventricular ejection fraction ≥ 10%) was observed in 73.7% of pts. A higher baseline late heart-to-mediastinum ratio (HMR) was associated with a better echocardiographic response. There was a significant association between late HMR and GLS at baseline and 6 months. At baseline, GLS had an AUC of 0.715 for discrimination for a late HMR < 1.6. A GLS cut-off of - 9% maximized the likelihood of correctly classifying a pt as having severe AD (HMR < 1.6). CONCLUSION Myocardial contractility as assessed by GLS is moderately correlated with AD as assessed by 123I-mIBG scintigraphy and has a good discrimination for the identification of severe cardiac denervation. GLS may allow for a more readily accessible estimation of the degree of AD in advanced HF pts.
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Affiliation(s)
- Madalena Coutinho Cruz
- Serviço de Cardiologia, Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, EPE, Rua de Santa Marta, 50, 1169-024, Lisbon, Portugal.
| | - Ana Abreu
- Serviço de Cardiologia, Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, EPE, Rua de Santa Marta, 50, 1169-024, Lisbon, Portugal
| | - Guilherme Portugal
- Serviço de Cardiologia, Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, EPE, Rua de Santa Marta, 50, 1169-024, Lisbon, Portugal
| | | | - Pedro S Cunha
- Serviço de Cardiologia, Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, EPE, Rua de Santa Marta, 50, 1169-024, Lisbon, Portugal
| | - Mario M Oliveira
- Serviço de Cardiologia, Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, EPE, Rua de Santa Marta, 50, 1169-024, Lisbon, Portugal
| | - Vanessa Santos
- CIPER, Human Kinetics Faculty, University of Lisbon, Lisbon, Portugal
| | - Luís Oliveira
- Nuclear Medicine Department, Medical and Diagnosis Clinic Quadrantes, Lisbon, Portugal
| | - Pedro Rio
- Serviço de Cardiologia, Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, EPE, Rua de Santa Marta, 50, 1169-024, Lisbon, Portugal
| | - Inês Rodrigues
- Serviço de Cardiologia, Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, EPE, Rua de Santa Marta, 50, 1169-024, Lisbon, Portugal
| | - Luís A Morais
- Serviço de Cardiologia, Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, EPE, Rua de Santa Marta, 50, 1169-024, Lisbon, Portugal
| | - Rui C Ferreira
- Serviço de Cardiologia, Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, EPE, Rua de Santa Marta, 50, 1169-024, Lisbon, Portugal
| | - Miguel M Carmo
- Serviço de Cardiologia, Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, EPE, Rua de Santa Marta, 50, 1169-024, Lisbon, Portugal
- NOVA Medical School, New University of Lisbon, Lisbon, Portugal
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Role of obstructive sleep apnea on the response to cardiac resynchronization therapy and all-cause mortality. Heart Rhythm 2019; 15:1283-1288. [PMID: 30170662 DOI: 10.1016/j.hrthm.2018.06.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND The role of obstructive sleep apnea (OSA) on the response to cardiac resynchronization therapy (CRT) and all-cause mortality in patients with advanced heart failure (HF) is unknown. OBJECTIVE We assessed the association between OSA, response to CRT, and all-cause mortality in patients with HF. METHODS We analyzed records of 548 consecutive patients (mean age 65 ± 13 years; 216 (39%) women; mean follow-up period 76 ± 17 months) who received a CRT-defibrillator device from January 15, 2007 to March 30, 2016 at our tertiary care referral center. RESULTS A total of 180 patients (33%) had OSA. Fewer patients in the OSA group (109 [61%]) had improvement in left ventricular ejection fraction (EF) than did those in the non-OSA group (253 [69%]) (P = .001). A total of 144 patients (27%) died by the end of follow-up (OSA group: 61 [33%]; non-OSA group 83 [23%]; P < .001). OSA diagnosis was associated with a lower chance of improvement in EF (hazard ratio 0.71; 95% confidence interval 0.60-0.89) and a higher risk of all-cause mortality (hazard ratio 3.7; 95% confidence interval 2.5-6.8). This was true in continuous positive airway pressure-compliant patients and in patients with nonischemic cardiomyopathy. However, among patients with ischemic cardiomyopathy, the chance of improvement in EF and all-cause mortality was similar in patients with OSA and those without OSA. CONCLUSION OSA is associated with a decreased response to CRT and an increase in all-cause mortality in patients with HF. The differential effect of OSA on CRT response in patients with ischemic cardiomyopathy and nonischemic cardiomyopathy needs further study.
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Terricabras M, Khaykin Y. Speckle Tracking for Cardiac Resynchronization Therapy Implantation: Have We Found the Perfect Match? Can J Cardiol 2019; 35:12-14. [PMID: 30595175 DOI: 10.1016/j.cjca.2018.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 11/28/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- Maria Terricabras
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Yaariv Khaykin
- Southlake Regional Health Centre, Newmarket, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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48
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Optimization of coronary sinus lead placement targeted to right-to-left delay in patients undergoing cardiac resynchronization therapy. Europace 2018; 21:502-510. [DOI: 10.1093/europace/euy275] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 10/18/2018] [Indexed: 11/14/2022] Open
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49
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Niu HX, Gold MR. Predicting cardiac resynchronization therapy outcomes: It is more than just left bundle branch block. Heart Rhythm 2018; 15:1673-1674. [DOI: 10.1016/j.hrthm.2018.06.012] [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: 06/05/2018] [Indexed: 11/16/2022]
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50
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Rattanawong P, Prasitlumkum N, Riangwiwat T, Kanjanahattakij N, Vutthikraivit W, Chongsathidkiet P, Simpson RJ. Baseline Prolonged PR Interval and Outcome of Cardiac Resynchronization Therapy: A Systematic Review and Meta-analysis. Arq Bras Cardiol 2018; 111:710-719. [PMID: 30328947 PMCID: PMC6248241 DOI: 10.5935/abc.20180198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 05/09/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Recent studies suggest that baseline prolonged PR interval is associated with worse outcome in cardiac resynchronization therapy (CRT). However, a systematic review and meta-analysis of the literature have not been made. OBJECTIVE To assess the association between baseline prolonged PR interval and adverse outcomes of CRT by a systematic review of the literature and a meta-analysis. METHODS We comprehensively searched the databases of MEDLINE and EMBASE from inception to March 2017. The included studies were published prospective or retrospective cohort studies that compared all-cause mortality, HF hospitalization, and composite outcome of CRT with baseline prolonged PR (> 200 msec) versus normal PR interval. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate the risk ratios and 95% confidence intervals. RESULTS Six studies from January 1991 to May 2017 were included in this meta-analysis. All-cause mortality rate is available in four studies involving 17,432 normal PR and 4,278 prolonged PR. Heart failure hospitalization is available in two studies involving 16,152 normal PR and 3,031 prolonged PR. Composite outcome is available in four studies involving 17,001 normal PR and 3,866 prolonged PR. Prolonged PR interval was associated with increased risk of all-cause mortality (pooled risk ratio = 1.34, 95 % confidence interval: 1.08-1.67, p < 0.01, I2= 57.0%), heart failure hospitalization (pooled risk ratio = 1.30, 95 % confidence interval: 1.16-1.45, p < 0.01, I2= 6.6%) and composite outcome (pooled risk ratio = 1.21, 95% confidence interval: 1.13-1.30, p < 0.01, I2= 0%). CONCLUSIONS Our systematic review and meta-analysis support the hypothesis that baseline prolonged PR interval is a predictor of all-cause mortality, heart failure hospitalization, and composite outcome in CRT patients.
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Affiliation(s)
- Pattara Rattanawong
- University of Hawaii Internal Medicine Residency Program, Honolulu, Havaí - EUA
| | - Narut Prasitlumkum
- University of Hawaii Internal Medicine Residency Program, Honolulu, Havaí - EUA
| | - Tanawan Riangwiwat
- University of Hawaii Internal Medicine Residency Program, Honolulu, Havaí - EUA
| | | | | | | | - Ross J Simpson
- The University of North Carolina, Chapel Hill, Carolina do Norte - EUA
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