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Santos MR, Silva MS, Guerreiro SL, Gomes DA, Rocha BM, Cunha GL, Freitas PN, Abecasis JM, Santos AC, Saraiva CC, Mendes M, Ferreira AM. Assessment of myocardial strain patterns in patients with left bundle branch block using cardiac magnetic resonance. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024:10.1007/s10554-024-03049-3. [PMID: 38376720 DOI: 10.1007/s10554-024-03049-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/05/2024] [Indexed: 02/21/2024]
Abstract
Recently, a classification with four types of septal longitudinal strain patterns was described using echocardiography, suggesting a pathophysiological continuum of left bundle branch block (LBBB)-induced left ventricle (LV) remodeling. The aim of this study was to assess the feasibility of classifying these strain patterns using cardiovascular magnetic resonance (CMR), and to evaluate their association with LV remodeling and myocardial scar. Single center registry included LBBB patients with septal flash (SF) referred to CMR to assess the cause of LV systolic dysfunction. Semi-automated feature-tracking cardiac resonance (FT-CMR) was used to quantify myocardial strain and detect the four strain patterns. A total of 115 patients were studied (age 66 ± 11 years, 57% men, 28% with ischemic heart disease). In longitudinal strain analysis, 23 patients (20%) were classified in stage LBBB-1, 37 (32.1%) in LBBB-2, 25 (21.7%) in LBBB-3, and 30 (26%) in LBBB-4. Patients at higher stages had more prominent septal flash, higher LV volumes, lower LV ejection fraction, and lower absolute strain values (p < 0.05 for all). Late gadolinium enhancement (LGE) was found in 55% of the patients (n = 63). No differences were found between the strain patterns regarding the presence, distribution or location of LGE. Among patients with LBBB, there was a good association between strain patterns assessed by FT-CMR analysis and the degree of LV remodeling and LV dysfunction. This association seems to be independent from the presence and distribution of LGE.
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Affiliation(s)
- Marina Raquel Santos
- Hospital Dr. Nélio Mendonça, Funchal, Portugal.
- CHLO - Hospital de Santa Cruz, Lisbon, Portugal.
| | - Mariana Santos Silva
- CHLO - Hospital de Santa Cruz, Lisbon, Portugal
- Centro Hospitalar Barreiro/Montijo, Setúbal, Portugal
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Skeete J, Huang HD, Mazur A, Sharma PS, Engelstein E, Trohman RG, Larsen TR. Evolving Concepts in Cardiac Physiologic Pacing in the Era of Conduction System Pacing. Am J Cardiol 2024; 212:51-66. [PMID: 38012990 DOI: 10.1016/j.amjcard.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/22/2023] [Accepted: 11/11/2023] [Indexed: 11/29/2023]
Abstract
Cardiac physiologic pacing (CPP) has become a well-established therapy for patients with cardiomyopathy (left ventricular ejection fraction <35%) in the presence of a left bundle branch block. In addition, CPP can be highly beneficial in patients with pacing-induced cardiomyopathy and patients with existing cardiomyopathy expected to have a right ventricular pacing burden of >40%. The benefits of CPP with traditional biventricular pacing are only realized if adequate resynchronization can be achieved. However, left ventricular lead implantation can be limited by individual anatomic variation within the coronary venous system and can be adversely affected by underlying abnormal myocardial substrate (i.e., scar tissue), especially if located within the basal lateral wall. In the last 7 years the investigation of conduction system pacing (CSP) and its potential salutary benefits are being realized and have led to a rapid evolution in the field of cardiac resynchronization pacing. However, supportive evidence for CSP for patients eligible for cardiac resynchronization remains limited compared with data available for biventricular cardiac resynchronization, mostly derived from leading CSP investigative centers. In this review, we perform an up-to-date comprehensive review of the available literature on CPP.
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Affiliation(s)
- Jamario Skeete
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Henry D Huang
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Alex Mazur
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Parikshit S Sharma
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Erica Engelstein
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Richard G Trohman
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Timothy R Larsen
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois.
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Butcher CJT, Cantor E, Sohaib A, Shun-Shin MJ, Haynes R, Khan H, Kyriacou A, Shi R, Chen Z, Haldar S, Cleland JGF, Hussain W, Markides V, Jones DG, Lane RE, Mason MJ, Whinnett ZI, Francis DP, Wong T. Variation in optimal hemodynamic atrio-ventricular delay of biventricular pacing with different endocardial left ventricular lead locations using precision hemodynamics. J Cardiovasc Electrophysiol 2023; 34:1431-1440. [PMID: 36786511 DOI: 10.1111/jce.15862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 01/11/2023] [Accepted: 02/05/2023] [Indexed: 02/15/2023]
Abstract
INTRODUCTION It is not known whether the optimal atrioventricular (AVopt ) delay varies between left ventricular (LV) pacing site during endocardial biventricular pacing (BiVP) and may therefore needs consideration. METHODS We assessed the hemodynamic AVopt in patients with chronic heart failure undergoing endocardial LV lead implantation. AVopt was assessed during atrio-BiVP with a "roving LV lead." Up to four locations were studied: mid-lateral wall, mid-septum (or a close alternative), site of greatest hemodynamic improvement, and LV lead implant site. The AVopt was compared to a fixed AV delay of 180 ms. RESULTS Seventeen patients were included (12 male, aged 66.5 ± 12.8 years, ejection fraction 26 ± 7%, 16 left bundle branch block or high percentage of right ventricular pacing [RVP], QRS duration 167 ± 27 ms). In most locations (62/63), AVopt increased systolic blood pressure during BiVP compared with RVP (relative improvement 6 mmHg, interquartile range [IQR] 4-9 mmHg). Compared to a fixed AV delay, the hemodynamic improvement at AVopt was higher (1 mmHg, IQR 0.2-2.6 mmHg, p < .001). Within most patients (16/17), we observed a difference in AVopt between pacing sites (median paced AVopt 209 ms, IQR 117-250). Within this range, the hemodynamic impact of these differences was small (median loss 0.6 mmHg, IQR 0.1-2.6 mmHg). CONCLUSION Within a patient, different endocardial LV lead locations have slightly different hemodynamic AVopt which are superior to a fixed AV delay. The hemodynamic consequence of applying an optimum from a different lead location is small.
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Affiliation(s)
- Charles J T Butcher
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
- NHLI, Imperial College London, London, UK
| | - Emily Cantor
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
- NHLI, Imperial College London, London, UK
| | - Afzal Sohaib
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
- NHLI, Imperial College London, London, UK
| | - Matthew J Shun-Shin
- NHLI, Imperial College London, London, UK
- International Centre for Circulatory Health, Imperial College London, London, UK
| | - Ross Haynes
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Habib Khan
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
- NHLI, Imperial College London, London, UK
| | - Adreas Kyriacou
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rui Shi
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Zhong Chen
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Shouvik Haldar
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Wajid Hussain
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Vias Markides
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David G Jones
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rebecca E Lane
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mark J Mason
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Zachary I Whinnett
- NHLI, Imperial College London, London, UK
- International Centre for Circulatory Health, Imperial College London, London, UK
| | - Darrel P Francis
- NHLI, Imperial College London, London, UK
- International Centre for Circulatory Health, Imperial College London, London, UK
| | - Tom Wong
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
- NHLI, Imperial College London, London, UK
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Galli E, Baritussio A, Sitges M, Donnellan E, Jaber WA, Gimelli A. Multi-modality imaging to guide the implantation of cardiac electronic devices in heart failure: is the sum greater than the individual components? Eur Heart J Cardiovasc Imaging 2023; 24:163-176. [PMID: 36458875 DOI: 10.1093/ehjci/jeac237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/03/2022] [Indexed: 12/05/2022] Open
Abstract
Heart failure is a clinical syndrome with an increasing prevalence and incidence worldwide that impacts patients' quality of life, morbidity, and mortality. Implantable cardioverter-defibrillator and cardiac resynchronization therapy are pillars of managing patients with HF and reduced left ventricular ejection fraction. Despite the advances in cardiac imaging, the assessment of patients needing cardiac implantable electronic devices relies essentially on the measure of left ventricular ejection fraction. However, multi-modality imaging can provide important information concerning the aetiology of heart failure, the extent and localization of myocardial scar, and the pathophysiological mechanisms of left ventricular conduction delay. This paper aims to highlight the main novelties and progress in the field of multi-modality imaging to identify patients who will benefit from cardiac resynchronization therapy and/or implantable cardioverter-defibrillator. We also want to underscore the boundaries that prevent the application of imaging-derived parameters to patients who will benefit from cardiac implantable electronic devices and orient the choice of the device. Finally, we aim at providing some reflections for future research in this field.
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Affiliation(s)
- Elena Galli
- Department of Cardiology, University Hospital of Rennes, 35000 Rue Henri Le Guilloux, Rennes, France
| | - Anna Baritussio
- Cardiology, Department of Cardiac, Vascular, Thoracic Sciences and Public Health, University Hospital of Padua, 35121 Via Nicolò Giustiniani, Padua, Italy
| | - Marta Sitges
- Cardiovascular Institute, Hospital Clínic, Universitat de Barcelona, 08036 C. de Villarroel, Barcelona, Spain
| | - Eoin Donnellan
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Wael A Jaber
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Alessia Gimelli
- Fondazione Toscana G. Monasterio, 56124 Via Giuseppe Moruzzi, Pisa, Italy
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Barone A, Grieco D, Gizzi A, Molinari L, Zaltieri M, Massaroni C, Loppini A, Schena E, Bressi E, de Ruvo E, Caló L, Filippi S. A Simulation Study of the Effects of His Bundle Pacing in Left Bundle Branch Block. Med Eng Phys 2022; 107:103847. [DOI: 10.1016/j.medengphy.2022.103847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/30/2022] [Accepted: 07/09/2022] [Indexed: 11/28/2022]
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Bordachar P, Strik M, Ploux S. Left Ventricular Endocardial Pacing: Update and State of the Art. Card Electrophysiol Clin 2022; 14:263-271. [PMID: 35715084 DOI: 10.1016/j.ccep.2021.12.004] [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: 06/15/2023]
Abstract
Initially, left ventricular (LV) endocardial pacing was performed as a bailout procedure after unsuccessful transvenous cardiac resynchronization therapy implantation in the presence of surgical contraindications. Additional possible advantages of endocardial LV pacing are a more physiologic activation, being less arrhythmogenic, more effective on the hemodynamic level, with better thresholds, and without the risk of phrenic stimulation. Different techniques have been proposed to stimulate the LV endocardium in humans, with feasibility and safety studies involving limited numbers of patients. In this review, we will describe the different techniques proposed to allow LV endocardial pacing, the results observed, and then we will discuss the reasons why LV endocardial pacing seems to be out of fashion today and what are the possible perspectives for development.
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Affiliation(s)
- Pierre Bordachar
- Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Avenue Magellan, 33600 Pessac, France; IHU Liryc, Electrophysiology and Heart Modeling Institute, Avenue Haut Lévêque, 33600 Pessac, France
| | - Marc Strik
- Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Avenue Magellan, 33600 Pessac, France; IHU Liryc, Electrophysiology and Heart Modeling Institute, Avenue Haut Lévêque, 33600 Pessac, France.
| | - Sylvain Ploux
- Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Avenue Magellan, 33600 Pessac, France; IHU Liryc, Electrophysiology and Heart Modeling Institute, Avenue Haut Lévêque, 33600 Pessac, France
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Abstract
Left ventricular (LV) dP/dtmax provides a sensitive measure of the acute hemodynamic response to cardiac resynchronization therapy (CRT) and can predict reverse remodeling on echocardiography. Its use to guide LV lead placement has been shown to improve outcomes in a multicenter randomized trial. Given the invasive protocol required for measurement, it is unlikely to be universally beneficial for patients undergoing CRT but may be useful for patients who do not respond to conventional CRT, or in those who have borderline indications or risk factors for non-response. In such cases, LV dP/dtmax may help guide LV lead placement, optimize device programming, and select the best alternative method of delivering CRT, such endocardial LV pacing or conduction system pacing.
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Affiliation(s)
- Mark K Elliott
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Vishal S Mehta
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Fan L, Choy JS, Raissi F, Kassab GS, Lee LC. Optimization of cardiac resynchronization therapy based on a cardiac electromechanics-perfusion computational model. Comput Biol Med 2022; 141:105050. [PMID: 34823858 PMCID: PMC8810745 DOI: 10.1016/j.compbiomed.2021.105050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/10/2021] [Accepted: 11/15/2021] [Indexed: 02/03/2023]
Abstract
Cardiac resynchronization therapy (CRT) is an established treatment for left bundle branch block (LBBB) resulting in mechanical dyssynchrony. Approximately 1/3 of patients with CRT, however, are non-responders. To understand factors affecting CRT response, an electromechanics-perfusion computational model based on animal-specific left ventricular (LV) geometry and coronary vascular networks located in the septum and LV free wall is developed. The model considers contractility-flow and preload-activation time relationships, and is calibrated to simultaneously match the experimental measurements in terms of the LV pressure, volume waveforms and total coronary flow in the left anterior descending and left circumflex territories from 2 swine models under right atrium and right ventricular pacing. The model is then applied to investigate the responses of CRT indexed by peak LV pressure and (dP/dt)max at multiple pacing sites with different degrees of perfusion in the LV free wall. Without the presence of ischemia, the model predicts that basal-lateral endocardial region is the optimal pacing site that can best improve (dP/dt)max by 20%, and is associated with the shortest activation time. In the presence of ischemia, a non-ischemic region becomes the optimal pacing site when coronary flow in the ischemic region fell below 30% of its original value. Pacing at the ischemic region produces little response at that perfusion level. The optimal pacing site is associated with one that optimizes the LV activation time. These findings suggest that CRT response is affected by both pacing site and coronary perfusion, which may have clinical implication in improving CRT responder rates.
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Affiliation(s)
- Lei Fan
- Department of Mechanical Engineering, Michigan State University, East Lansing, MI, USA.
| | - Jenny S Choy
- California Medical Innovations Institute, San Diego, CA, USA
| | - Farshad Raissi
- Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | | | - Lik Chuan Lee
- Department of Mechanical Engineering, Michigan State University, East Lansing, MI, USA
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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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Elliott MK, Mehta VS, Sidhu BS, Niederer S, Rinaldi CA. Endocardial left ventricular pacing. Herz 2021; 46:526-532. [PMID: 34694427 PMCID: PMC8543431 DOI: 10.1007/s00059-021-05074-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 11/23/2022]
Abstract
Cardiac resynchronization therapy (CRT) is an effective treatment for dyssynchronous heart failure; however, 30–50% of patients fail to improve after implant. Endocardial left ventricular (LV) pacing is an alternative therapy for patients who do not respond to conventional CRT or in whom placement of a lead via the coronary sinus is not possible. It enables pacing at a wide variety of sites, without restrictions due to coronary sinus anatomy, and there is evidence of superior electrical resynchronization and hemodynamic response compared with conventional epicardial CRT. In this article, we discuss the potential advantages and disadvantages of endocardial LV pacing compared with conventional CRT, review the evidence for the delivery of endocardial LV pacing using both lead-based and leadless systems, and explore possible future directions of this novel technology.
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Affiliation(s)
- Mark K Elliott
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, SE1 7EH, London, UK. .,Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Vishal S Mehta
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, SE1 7EH, London, UK
| | - Baldeep Singh Sidhu
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, SE1 7EH, London, UK.,Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, SE1 7EH, London, UK
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, SE1 7EH, London, UK.,Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Butter C, Georgi C, Stockburger M. Optimal CRT Implantation-Where and How To Place the Left-Ventricular Lead? Curr Heart Fail Rep 2021; 18:329-344. [PMID: 34495452 PMCID: PMC8484220 DOI: 10.1007/s11897-021-00528-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 12/28/2022]
Abstract
Purpose of Review Cardiac resynchronization therapy (CRT) represents a well-established and effective non-pharmaceutical heart failure (HF) treatment in selected patients. Still, a significant number of patients remain CRT non-responders. An optimal placement of the left ventricular (LV) lead appears crucial for the intended hemodynamic and hence clinical improvement. A well-localized target area and tools that help to achieve successful lead implantation seem to be of utmost importance to reach an optimal CRT effect. Recent Findings Recent studies suggest previous multimodal imaging (CT/cMRI/ECG torso) to guide intraprocedural LV lead placement. Relevant benefit compared to empirical lead optimization is still a matter of debate. Technical improvements in leads and algorithms (e.g., multipoint pacing (MPP), adaptive algorithms) promise higher procedural success. Recently emerging alternatives for ventricular synchronization such as conduction system pacing (CSP), LV endocardial pacing, or leadless pacing challenge classical biventricular pacing. Summary This article reviews current strategies for a successful planning, implementation, and validation of the optimal CRT implantation. Pre-implant imaging modalities offer promising assistance for complex cases; empirical lead positioning and intraoperative testing remain the cornerstone in most cases and ensure a successful CRT effect.
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Affiliation(s)
- Christian Butter
- Department of Cardiology, Heart Center Brandenburg, University Hospital Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany
| | - Christian Georgi
- Department of Cardiology, Heart Center Brandenburg, University Hospital Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany
| | - Martin Stockburger
- Department of Internal Medicine/Cardiology, Havelland Kliniken GmbH, Nauen, Germany
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Kheiri B, Przybylowicz R, Simpson TF, Merrill M, Osman M, Dalouk K, Rahmouni H, Stecker E, Nazer B, Henrikson CA. Imaging-guided cardiac resynchronization therapy: A meta-analysis of randomized controlled trials. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1570-1576. [PMID: 34255376 DOI: 10.1111/pace.14316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/07/2021] [Accepted: 07/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Among patients with heart failure and left ventricular (LV) dysfunction despite guideline directed medical therapy, cardiac resynchronization (CRT) is an effective technology to reverse LV remodeling. Given that a large portion of patients are non-responders, alternatives to traditional LV-lead placement have been explored. A promising alternative is image targeted placement of an LV-lead to latest mechanically activated segment without scar. METHODS Electronic database search for randomized controlled trials (RCTs) that evaluated the imaging-guided LV-lead placement on clinical, echocardiographic, and functional outcomes. The primary outcome was a composite of mortality and heart failure hospitalization. The secondary outcomes included CRT responders, New York Heart Association (NYHA), 6-minute walk test, Minnesota Living with Heart Failure Questionnaire (MLHFQ), and ejection fraction (EF) changes. RESULTS Analysis included 4 RCTs of 691 patients with an average follow-up of 2 years (age 69.5 ± 10.3 years, 76% males, 54% ischemic cardiomyopathy, 81% with NYHA classes III/IV, and EF of 24.4% ± 8). The most common site for LV-lead paced segment was the anterolateral segment (45%) and at mid-LV (49%). Compared with the control, imaging-guided LV-lead placement was associated with a significant reduction of the primary outcome (hazard ratio [HR] = 0.60; 95% CI = 0.40-0.88; p = .01), higher CRT responders (odd ratio [OR] = 2.10; p < .01), more NYHA improvements by ≥1 (OR = 1.89; p = .01), increased 6MWT (mean difference [MD] = 25.78 feet; p < .01), and lower MLHFQ (MD = -4.04; p = .04), without significant differences in the LVEF (p = .08). CONCLUSIONS In patients undergoing CRT, imaging-guided LV-lead placement was associated with improved clinical, echocardiographic, and functional status.
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Affiliation(s)
- Babikir Kheiri
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Ryle Przybylowicz
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Timothy F Simpson
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Miranda Merrill
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Mohammed Osman
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA.,Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Khidir Dalouk
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Hind Rahmouni
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Eric Stecker
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Babak Nazer
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Charles A Henrikson
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
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13
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Sohal M, Hamid S, Perego G, Della Bella P, Adhya S, Paisey J, Betts T, Kamdar R, Lambiase P, Leyva F, McComb JM, Behar J, Jackson T, Claridge S, Mehta V, Elliott M, Niederer S, Razavi R, Rinaldi CA. A multicenter prospective randomized controlled trial of cardiac resynchronization therapy guided by invasive dP/dt. Heart Rhythm O2 2021; 2:19-27. [PMID: 34113901 PMCID: PMC8183864 DOI: 10.1016/j.hroo.2021.01.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background No periprocedural metric has demonstrated improved cardiac resynchronization therapy (CRT) outcomes in a multicenter setting. Objective We sought to determine if left ventricular (LV) lead placement targeted to the coronary sinus (CS) branch generating the best acute hemodynamic response (AHR) results in improved outcomes at 6 months. Methods In this multicenter randomized controlled trial, patients were randomized to guided CRT or conventional CRT. Patients in the guided arm had LV dP/dtmax measured during biventricular (BIV) pacing. Target CS branches were identified and the final LV lead position was the branch with the best AHR and acceptable threshold values. The primary endpoint was the proportion of patients with a reduction in LV end-systolic volume (LVESV) of ≥15% at 6 months. Results A total of 281 patients were recruited across 12 centers. Mean age was 70.8 ± 10.9 years and 54% had ischemic etiology. Seventy-three percent of patients in the guided arm demonstrated a reduction in LVESV of ≥15% at 6 months vs 60% in the conventional arm (P = .02). Patients with AHR ≥ 10% were more likely to demonstrate a reduction of ESV ≥ 15% (84% of patients with an AHR ≥10% vs 28% with an AHR <10%; P < 0.001). Procedure duration and fluoroscopy times were longer in the pressure wire-guided arm (104 ± 39 minutes vs 142 ± 39 minutes; P < .001 and 20 ±16 minutes vs 28 ± 15 minutes; P = .002). Conclusions AHR determined by invasively measuring LV dP/dtmax during BIV pacing predicts reverse remodeling 6 months after CRT. Patients in whom LV dP/dtmax was used to guide LV lead placement demonstrated better rates of reverse remodeling.
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Affiliation(s)
- Manav Sohal
- Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.,King's College London, London, United Kingdom
| | - Shoaib Hamid
- Queen Elizabeth Hospital, London, United Kingdom
| | | | | | - Shaumik Adhya
- Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.,Medway Maritime Hospital, Gillingham, United Kingdom
| | - John Paisey
- Royal Bournemouth Hospital, Bournemouth, United Kingdom
| | - Tim Betts
- John Radcliffe Hospital, Oxford, United Kingdom
| | - Ravi Kamdar
- Croydon University Hospital, London, United Kingdom
| | - Pier Lambiase
- The Heart Hospital, London, United Kingdom.,Barts Heart Centre, London, United Kingdom
| | | | | | | | | | | | | | | | | | - Reza Razavi
- King's College London, London, United Kingdom
| | - C Aldo Rinaldi
- Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.,King's College London, London, United Kingdom
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14
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Sidhu BS, Gould J, Elliott MK, Mehta V, Niederer S, Rinaldi CA. Leadless Left Ventricular Endocardial Pacing and Left Bundle Branch Area Pacing for Cardiac Resynchronisation Therapy. Arrhythm Electrophysiol Rev 2021; 10:45-50. [PMID: 33936743 PMCID: PMC8076968 DOI: 10.15420/aer.2020.46] [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: 12/05/2020] [Accepted: 12/31/2020] [Indexed: 12/02/2022] Open
Abstract
Cardiac resynchronisation therapy is an important intervention to reduce mortality and morbidity, but even in carefully selected patients approximately 30% fail to improve. This has led to alternative pacing approaches to improve patient outcomes. Left ventricular (LV) endocardial pacing allows pacing at site-specific locations that enable the operator to avoid myocardial scar and target areas of latest activation. Left bundle branch area pacing (LBBAP) provides a more physiological activation pattern and may allow effective cardiac resynchronisation. This article discusses LV endocardial pacing in detail, including the indications, techniques and outcomes. It discusses LBBAP, its potential benefits over His bundle pacing and procedural outcomes. Finally, it concludes with the future role of endocardial pacing and LBBAP in heart failure patients.
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Affiliation(s)
- Baldeep S Sidhu
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Guy's and St Thomas' Hospital, London, UK
| | - Justin Gould
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Guy's and St Thomas' Hospital, London, UK
| | - Mark K Elliott
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Guy's and St Thomas' Hospital, London, UK
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Guy's and St Thomas' Hospital, London, UK
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Guy's and St Thomas' Hospital, London, UK
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15
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His-bundle and left bundle pacing with optimized atrioventricular delay achieve superior electrical synchrony over endocardial and epicardial pacing in left bundle branch block patients. Heart Rhythm 2020; 17:1922-1929. [DOI: 10.1016/j.hrthm.2020.06.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/16/2020] [Accepted: 06/22/2020] [Indexed: 02/05/2023]
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16
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Heckman L, Vijayaraman P, Luermans J, Stipdonk AMW, Salden F, Maass AH, Prinzen FW, Vernooy K. Novel bradycardia pacing strategies. Heart 2020; 106:1883-1889. [DOI: 10.1136/heartjnl-2020-316849] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/08/2020] [Accepted: 08/30/2020] [Indexed: 11/04/2022] Open
Abstract
The adverse effects of ventricular dyssynchrony induced by right ventricular (RV) pacing has led to alternative pacing strategies, such as biventricular, His bundle (HBP), LV septal (LVSP) and left bundle branch pacing (LBBP). Given the overlap, LVSP and LBBP are also collectively referred to as left bundle branch area pacing (LBBAP). Although among these alternative pacing sites HBP is theoretically the ideal strategy as it maintains a physiological ventricular activation, its application requires more skills and is associated with the most complications. LBBAP, where the ventricular pacing lead is advanced through the interventricular septum to its left side, creates ventricular activation that is only slightly more dyssynchronous. Preliminary studies have shown that LBBAP is feasible, safe and encounters less limitations than HBP. Further studies are needed to differentiate between LVSP and LBBP with regard to acute functional and long-term clinical outcome.
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17
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Behar JM, Finlay MC, Rowland E, Ezzat V, Sporton S, Dhinoja M. Percutaneous left ventricular endocardial leads: adverse outcomes and a percutaneous extraction case series. Eur Heart J Case Rep 2020; 4:1-5. [PMID: 32974463 PMCID: PMC7501919 DOI: 10.1093/ehjcr/ytaa130] [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: 08/21/2019] [Revised: 10/10/2019] [Accepted: 04/24/2020] [Indexed: 11/14/2022]
Abstract
Background Conventional cardiac resynchronization therapy (CRT) involves the placement of an epicardial left ventricular (LV) lead through the coronary venous tree. However, alternative approaches of delivering CRT have been sought for patients who fail to respond to conventional methods or for those where coronary venous anatomy is unfavourable. Biventricular pacing through an endocardial LV lead has potential advantages; however, the long-term clinical and safety data are not known. Case summary This article details a case series of four patients with endocardial LV leads; three of these for previously failed conventional CRT and a fourth for an inadvertently placed defibrillator lead. Discussion We describe the clinical course and adverse events associated with left-sided leads and subsequently describe the safe and feasible method of percutaneous extraction.
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Affiliation(s)
- Jonathan M Behar
- Department of Electrophysiology, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK
| | - Malcolm C Finlay
- Department of Electrophysiology, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK
| | - Edward Rowland
- Department of Electrophysiology, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK
| | - Vivienne Ezzat
- Department of Electrophysiology, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK
| | - Simon Sporton
- Department of Electrophysiology, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK
| | - Mehul Dhinoja
- Department of Electrophysiology, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK
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18
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Technological and Clinical Challenges in Lead Placement for Cardiac Rhythm Management Devices. Ann Biomed Eng 2019; 48:26-46. [DOI: 10.1007/s10439-019-02376-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 09/25/2019] [Indexed: 01/29/2023]
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19
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Shun-Shin MJ, Miyazawa AA, Keene D, Sterliński M, Sokal A, Van Heuverswyn F, Rinaldi CA, Cornelussen R, Stegemann B, Francis DP, Whinnett Z. How to deliver personalized cardiac resynchronization therapy through the precise measurement of the acute hemodynamic response: Insights from the iSpot trial. J Cardiovasc Electrophysiol 2019; 30:1610-1619. [PMID: 31115945 DOI: 10.1111/jce.14001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 05/17/2019] [Accepted: 05/19/2019] [Indexed: 12/01/2022]
Abstract
INTRODUCTION New pacing technologies offer a greater choice of left ventricular pacing sites and greater personalization of cardiac resynchronization therapy (CRT). The effects on cardiac function of novel pacing configurations are often compared using multi-beat averages of acute hemodynamic measurements. In this analysis of the iSpot trial, we explore whether this is sufficient. MATERIALS AND METHODS The iSpot trial was an international, prospective, acute hemodynamic trial that assessed seven CRT configurations: standard CRT, MultiSpot (posterolateral vein), and MultiVein (anterior and posterior vein) pacing. Invasive and noninvasive blood pressure, and left ventricular (LV) dP/dtmax were recorded. Eight beats were recorded before and after an alternation from AAI to the tested pacing configuration and vice-versa. Eight alternations were performed for each configuration at each of the five atrioventricular delays. RESULTS Twenty-five patients underwent the full protocol of eight alternations. Only four (16%) patients had a statistically significant >3 mm Hg improvement over conventional CRT configuration (posterolateral vein, distal electrode). However, if only one alternation was analyzed (standard multi-beat averaging protocol), 15 (60%) patients falsely appeared to have a superior nonconventional configuration. Responses to pacing were significantly correlated between the different hemodynamic measures: invasive systolic blood pressure (SBP) vs noninvasive SBP r = 0.82 (P < .001); invasive SBP vs LV dP/dt r = 0.57, r2 = 0.32 (P < .001). CONCLUSIONS Current standard multibeat acquisition protocols are unfortunately unable to prevent false impressions of optimality arising in individual patients. Personalization processes need to include distinct repeated transitions to the tested pacing configuration in addition to averaging multiple beats. The need is not only during research stages but also during clinical implementation.
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Affiliation(s)
- Matthew J Shun-Shin
- International Centre for Circulatory Health, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Alejandra A Miyazawa
- International Centre for Circulatory Health, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Daniel Keene
- International Centre for Circulatory Health, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Maciej Sterliński
- The Second Department of Coronary Artery Disease, Institute of Cardiology, Warsaw, Poland
| | - Adam Sokal
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center of Heart Disease, Zabrze, Poland
| | | | | | - Richard Cornelussen
- Bakken Research Center B.V., Research and Technology, Maastricht, The Netherlands
| | - Berthold Stegemann
- Bakken Research Center B.V., Research and Technology, Maastricht, The Netherlands
| | - Darrel P Francis
- International Centre for Circulatory Health, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Zachary Whinnett
- International Centre for Circulatory Health, Imperial College London, Hammersmith Hospital, London, United Kingdom
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20
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Multisite pacing via a quadripolar lead for cardiac resynchronization therapy. J Interv Card Electrophysiol 2019; 56:117-125. [PMID: 31321658 DOI: 10.1007/s10840-019-00592-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 07/10/2019] [Indexed: 10/26/2022]
Abstract
Cardiac resynchronization therapy is challenging. Up to 40% of patients are non-responder. Multisite pacing via a quadripolar lead, also called multipoint/multipole pacing (MPP), is a debated alternative. In this review, we summarize evidence in the literature, tips and pitfalls related to MPP programming, and the different algorithms of MPP in different manufacturers.
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21
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Abstract
PURPOSE OF REVIEW Cardiac resynchronization therapy (CRT) is an effective treatment option for therapy-refractory mild to severe heart failure (HF) patients with reduced ejection fraction and left ventricular (LV) conduction delay. Multiple clinical trials have shown that CRT improves cardiac function and overall quality of life, as well as reduces HF hospitalizations, health care costs, and mortality. RECENT FINDINGS Despite its effectiveness, the "non-response" rate to CRT is around 30%, remaining a major challenge that faces electrophysiologists and researchers. It has been recently suggested that the etiology of CRT non-response is multifactorial, and it requires a multifaceted approach to address it. In this focused review, we will summarize the definitions of CRT non-response, identify key factors for CRT non-response, and offer a simplified framework to address CRT non-response with the main goal of improving CRT outcomes.
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Affiliation(s)
- Syed Yaseen Naqvi
- Heart Research Follow-Up Program, Cardiology Division, University of Rochester Medical Center, 265 Crittenden Blvd., Box 653, Rochester, NY, 14642, USA
| | - Anas Jawaid
- Heart Research Follow-Up Program, Cardiology Division, University of Rochester Medical Center, 265 Crittenden Blvd., Box 653, Rochester, NY, 14642, USA
| | - Ilan Goldenberg
- Heart Research Follow-Up Program, Cardiology Division, University of Rochester Medical Center, 265 Crittenden Blvd., Box 653, Rochester, NY, 14642, USA
| | - Valentina Kutyifa
- Heart Research Follow-Up Program, Cardiology Division, University of Rochester Medical Center, 265 Crittenden Blvd., Box 653, Rochester, NY, 14642, USA.
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22
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Abstract
Several clinical trials have established the role of cardiac resynchronization therapy in patients with heart failure, impaired left ventricular function and dyssynchrony. Challenges to traditional therapy include coronary sinus anatomy and failure to respond. Left ventricular endocardial pacing could overcome anatomic constraints, provide more flexibility, and allow for more physiologic activation. Cases and case series have demonstrated the promise of the approach. Preclinical studies support the superior hemodynamic effects of left ventricular endocardial pacing. Leadless left ventricular endocardial pacing is a recent innovation that is undergoing prospective testing. Successful delivery may be associated with clinical response and positive cardiac structural remodeling.
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Affiliation(s)
- Alan Hanley
- Cardiac Arrhythmia Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - E Kevin Heist
- Cardiac Arrhythmia Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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23
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Carpio EF, Gomez JF, Sebastian R, Lopez-Perez A, Castellanos E, Almendral J, Ferrero JM, Trenor B. Optimization of Lead Placement in the Right Ventricle During Cardiac Resynchronization Therapy. A Simulation Study. Front Physiol 2019; 10:74. [PMID: 30804805 PMCID: PMC6378298 DOI: 10.3389/fphys.2019.00074] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/22/2019] [Indexed: 12/18/2022] Open
Abstract
Patients suffering from heart failure and left bundle branch block show electrical ventricular dyssynchrony causing an abnormal blood pumping. Cardiac resynchronization therapy (CRT) is recommended for these patients. Patients with positive therapy response normally present QRS shortening and an increased left ventricle (LV) ejection fraction. However, around one third do not respond favorably. Therefore, optimal location of pacing leads, timing delays between leads and/or choosing related biomarkers is crucial to achieve the best possible degree of ventricular synchrony during CRT application. In this study, computational modeling is used to predict the optimal location and delay of pacing leads to improve CRT response. We use a 3D electrophysiological computational model of the heart and torso to get insight into the changes in the activation patterns obtained when the heart is paced from different regions and for different atrioventricular and interventricular delays. The model represents a heart with left bundle branch block and heart failure, and allows a detailed and accurate analysis of the electrical changes observed simultaneously in the myocardium and in the QRS complex computed in the precordial leads. Computational simulations were performed using a modified version of the O'Hara et al. action potential model, the most recent mathematical model developed for human ventricular electrophysiology. The optimal location for the pacing leads was determined by QRS maximal reduction. Additionally, the influence of Purkinje system on CRT response was assessed and correlation analysis between several parameters of the QRS was made. Simulation results showed that the right ventricle (RV) upper septum near the outflow tract is an alternative location to the RV apical lead. Furthermore, LV endocardial pacing provided better results as compared to epicardial stimulation. Finally, the time to reach the 90% of the QRS area was a good predictor of the instant at which 90% of the ventricular tissue was activated. Thus, the time to reach the 90% of the QRS area is suggested as an additional index to assess CRT effectiveness to improve biventricular synchrony.
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Affiliation(s)
- Edison F Carpio
- Centre for Research and Innovation in Bioengineering (Ci2B), Universitat Politècnica de València, Valencia, Spain
| | - Juan F Gomez
- Centre for Research and Innovation in Bioengineering (Ci2B), Universitat Politècnica de València, Valencia, Spain
| | - Rafael Sebastian
- Computational Multiscale Simulation Lab (CoMMLab), Department of Computer Science, Universitat de València, Valencia, Spain
| | - Alejandro Lopez-Perez
- Centre for Research and Innovation in Bioengineering (Ci2B), Universitat Politècnica de València, Valencia, Spain
| | - Eduardo Castellanos
- Electrophysiology Laboratory and Arrhythmia Unit, Grupo HM Hospitales, Hospital Monteprincipe, University CEU-San Pablo, Madrid, Spain
| | - Jesus Almendral
- Electrophysiology Laboratory and Arrhythmia Unit, Grupo HM Hospitales, Hospital Monteprincipe, University CEU-San Pablo, Madrid, Spain
| | - Jose M Ferrero
- Centre for Research and Innovation in Bioengineering (Ci2B), Universitat Politècnica de València, Valencia, Spain
| | - Beatriz Trenor
- Centre for Research and Innovation in Bioengineering (Ci2B), Universitat Politècnica de València, Valencia, Spain
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24
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Sieniewicz BJ, Gould J, Porter B, Sidhu BS, Teall T, Webb J, Carr-White G, Rinaldi CA. Understanding non-response to cardiac resynchronisation therapy: common problems and potential solutions. Heart Fail Rev 2019; 24:41-54. [PMID: 30143910 PMCID: PMC6313376 DOI: 10.1007/s10741-018-9734-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Heart failure is a complex clinical syndrome associated with a significant morbidity and mortality burden. Reductions in left ventricular (LV) function trigger adaptive mechanisms, leading to structural changes within the LV and the potential development of dyssynchronous ventricular activation. This is the substrate targeted during cardiac resynchronisation therapy (CRT); however, around 30-50% of patients do not experience benefit from this treatment. Non-response occurs as a result of pre-implant, peri-implant and post implant factors but the technical constraints of traditional, transvenous epicardial CRT mean they can be challenging to overcome. In an effort to improve response, novel alternative methods of CRT delivery have been developed and of these endocardial pacing, where the LV is stimulated from inside the LV cavity, appears the most promising.
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Affiliation(s)
- Benjamin J Sieniewicz
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, SE1 7EH, UK.
- Cardiology Department, Guys and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK.
| | - Justin Gould
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, SE1 7EH, UK
- Cardiology Department, Guys and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| | - Bradley Porter
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, SE1 7EH, UK
- Cardiology Department, Guys and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| | - Baldeep S Sidhu
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, SE1 7EH, UK
- Cardiology Department, Guys and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| | - Thomas Teall
- Cardiology Department, Guys and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| | - Jessica Webb
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, SE1 7EH, UK
- Cardiology Department, Guys and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| | - Gerarld Carr-White
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, SE1 7EH, UK
- Cardiology Department, Guys and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| | - Christopher A Rinaldi
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, SE1 7EH, UK
- Cardiology Department, Guys and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
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25
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Sassone B, Nucifora G, Mele D, Valzania C, Bisignani G, Boriani G. Role of cardiovascular imaging in cardiac resynchronization therapy: a literature review. J Cardiovasc Med (Hagerstown) 2018; 19:211-222. [PMID: 29470248 DOI: 10.2459/jcm.0000000000000635] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
: Cardiac resynchronization therapy (CRT) is an established treatment in patients with symptomatic drug-refractory heart failure and broad QRS complex on the surface ECG. Despite the presence of either mechanical dyssynchrony or viable myocardium at the site where delivering left ventricular pacing being necessary conditions for a successful CRT, their direct assessment by techniques of cardiovascular imaging, though feasible, is not recommended in clinical practice by the current guidelines. Indeed, even though there is growing body of data providing evidence of the additional value of an image-based approach as compared with routine approach in improving response to CRT, these results should be confirmed in prospective and large multicentre trials before their impact on CRT guidelines is considered.
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Affiliation(s)
- Biagio Sassone
- Department of Cardiology, SS.ma Annunziata Hospital.,Department of Cardiology, Delta Hospital, Azienda Unità Sanitaria Locale Ferrara, Ferrara, Italy
| | - Gaetano Nucifora
- Cardiology Department, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Flinders University, Adelaide, Australia
| | - Donato Mele
- Noninvasive Cardiology Unit, University Hospital of Ferrara, Ferrara
| | - Cinzia Valzania
- Institute of Cardiology, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna
| | | | - Giuseppe Boriani
- Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Policlinico of Modena, Modena, Italy
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26
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Sieniewicz BJ, Behar JM, Sohal M, Gould J, Claridge S, Porter B, Niederer S, Gamble JHP, Betts TR, Jais P, Derval N, Spragg DD, Steendijk P, van Gelder BM, Bracke FA, Rinaldi CA. Electrical latency predicts the optimal left ventricular endocardial pacing site: results from a multicentre international registry. Europace 2018; 20:1989-1996. [PMID: 29688340 DOI: 10.1093/europace/euy052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 02/27/2018] [Indexed: 11/13/2022] Open
Abstract
Aims The optimal site for biventricular endocardial (BIVENDO) pacing remains undefined. Acute haemodynamic response (AHR) is reproducible marker of left ventricular (LV) contractility, best expressed as the change in the maximum rate of LV pressure (LV-dp/dtmax), from a baseline state. We examined the relationship between factors known to impact LV contractility, whilst delivering BIVENDO pacing at a variety of LV endocardial (LVENDO) locations. Methods and results We compiled a registry of acute LVENDO pacing studies from five international centres: Johns Hopkins-USA, Bordeaux-France, Eindhoven-The Netherlands, Oxford-United Kingdom, and Guys and St Thomas' NHS Foundation Trust, London-UK. In all, 104 patients incorporating 687 endocardial and 93 epicardial pacing locations were studied. Mean age was 66 ± 11 years, mean left ventricular ejection fraction 24.6 ± 7.7% and mean QRS duration of 163 ± 30 ms. In all, 50% were ischaemic [ischaemic cardiomyopathy (ICM)]. Scarred segments were associated with worse haemodynamics (dp/dtmax; 890 mmHg/s vs. 982 mmHg/s, P < 0.01). Delivering BiVENDO pacing in areas of electrical latency was associated with greater improvements in AHR (P < 0.01). Stimulating late activating tissue (LVLED >50%) achieved greater increases in AHR than non-late activating tissue (LVLED < 50%) (8.6 ± 9.6% vs. 16.1 ± 16.2%, P = 0.002). However, the LVENDO pacing location with the latest Q-LV, was associated with the optimal AHR in just 62% of cases. Conclusions Identifying viable LVENDO tissue which displays late electrical activation is crucial to identifying the optimal BiVENDO pacing site. Stimulating late activating tissue (LVLED >50%) yields greater improvements in AHR however, the optimal location is frequently not the site of latest activation.
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Affiliation(s)
- Benjamin J Sieniewicz
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, London, UK.,Department of Cardiology, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Jonathan M Behar
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, London, UK.,Department of Cardiology, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Manav Sohal
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, London, UK.,Department of Cardiology, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Justin Gould
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, London, UK.,Department of Cardiology, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Simon Claridge
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, London, UK.,Department of Cardiology, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Bradley Porter
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, London, UK.,Department of Cardiology, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Steve Niederer
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, London, UK
| | | | - Tim R Betts
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | | | | | | | | | - Christopher A Rinaldi
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor, North Wing, London, UK.,Department of Cardiology, Guys and St Thomas' NHS Foundation Trust, London, UK
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Kočková R, Sedláček K, Wichterle D, Šikula V, Tintěra J, Jansová H, Pravečková A, Langová R, Krýže L, El-Husseini W, Segeťová M, Kautzner J. Cardiac resynchronization therapy guided by cardiac magnetic resonance imaging: A prospective, single-centre randomized study (CMR-CRT). Int J Cardiol 2018; 270:325-330. [DOI: 10.1016/j.ijcard.2018.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 05/22/2018] [Accepted: 06/04/2018] [Indexed: 10/14/2022]
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Behar JM, Ranjan K, Bhattacharyya S, Sporton S, Dhinoja M. Splinting and mechanical disruption of the mitral valve apparatus by an endocardial left ventricular lead while delivering cardiac resynchronization therapy. Clin Case Rep 2018; 6:2081-2085. [PMID: 30455895 PMCID: PMC6230603 DOI: 10.1002/ccr3.1758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 07/04/2018] [Accepted: 07/17/2018] [Indexed: 11/18/2022] Open
Abstract
Splinting and mechanical disruption of the mitral valve apparatus is an important limitation of an endocardial left ventricular (LV) pacing lead. Further, long-term data are required before this approach is more widely adopted.
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Biffi M, Defaye P, Jaïs P, Ruffa F, Leclercq C, Gras D, Yang Z, Gerritse B, Ziacchi M, Morgan JM. Benefits of left ventricular endocardial pacing comparing failed implants and prior non-responders to conventional cardiac resynchronization therapy: A subanalysis from the ALSYNC study. Int J Cardiol 2018; 259:88-93. [PMID: 29579617 DOI: 10.1016/j.ijcard.2018.01.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 12/21/2017] [Accepted: 01/08/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Cardiac resynchronisation therapy (CRT) is limited by a substantial proportion of non-responders. Left ventricular endocardial pacing (LVEP) may offer enhanced possibility to deliver CRT in patients with a failed attempt at implantation and to improve clinical status of CRT non-responders. METHODS The ALternate Site Cardiac ResYNChronisation (ALSYNC) study was a prospective, multi-centre cohort study that included 118 CRT patients with a successfully implanted endocardial left ventricular (LV) lead, including 90 failed coronary sinus (CS) implants and 28 prior non-responders who had worsened or unchanged heart failure status after at least 6 months of optimal conventional CRT therapy. RESULTS Patients were followed for 19 ± 9 months. At baseline, prior non-responders were sicker as evidenced by a larger LV end-diastolic diameter (70 ± 12 vs 65 ± 9 mm, p = .03) and a trend towards larger LV end-systolic volume index (LVESVi, 95 ± 51 vs 74 ± 39 ml/m2, p = .07), and were more frequently anti-coagulated (96% vs 72%, p = .008) despite similar history of atrial fibrillation (54% vs 51%, p = .83). At 6 months, LVEP significantly improved LV ejection fraction (2.3 ± 7.5 and 8.6 ± 10.0%), New York Heart Association Class (0.4 ± 0.9 and 0.7 ± 0.8), LVESVi (9 ± 16 and 18 ± 43 ml/m2), and six-minute walk test (56 ± 73 and 54 ± 92 m) in prior non-responders and failed CS implants, relative to baseline (all p < .05), respectively. LVESVi reduction ≥15% was seen in 47% of the prior non-responder patients and 57% of failed CS patients. CONCLUSION These data suggest that a sizable proportion of CRT non-responders can improve by LVEP, though to a lesser extent than failed CS implants. Clinical trial registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01277783.
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Affiliation(s)
- Mauro Biffi
- Policlinico S Orsola-Malpighi University Hospital, Bologna, Italy.
| | | | - Pierre Jaïs
- CHU Bordeaux - Bordeaux University, Bordeaux, France
| | | | | | - Daniel Gras
- Le Confluent Nouvelle Clinique Nantaises, Nantes, France
| | | | - Bart Gerritse
- Medtronic Bakken Research Center, Maastricht, The Netherlands
| | - Matteo Ziacchi
- Policlinico S Orsola-Malpighi University Hospital, Bologna, Italy
| | - John M Morgan
- University Hospital Southampton, Southampton, United Kingdom
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Holubec T, Beckers J, Holubcova Z, Walter V, Walther T. Cardiac resynchronization therapy with wireless left ventricular endocardial pacing: is this the direction to go? Cardiovasc Diagn Ther 2018; 8:534-537. [PMID: 30214872 DOI: 10.21037/cdt.2018.05.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Tomas Holubec
- Department of Thoracic and Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Julius Beckers
- Department of Thoracic and Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Zdenka Holubcova
- Department of Thoracic and Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Veronika Walter
- Department of Thoracic and Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Thomas Walther
- Department of Thoracic and Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
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Sieniewicz BJ, Gould J, Porter B, Sidhu BS, Behar JM, Claridge S, Niederer S, Rinaldi CA. Optimal site selection and image fusion guidance technology to facilitate cardiac resynchronization therapy. Expert Rev Med Devices 2018; 15:555-570. [PMID: 30019954 PMCID: PMC6178093 DOI: 10.1080/17434440.2018.1502084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/12/2018] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Cardiac resynchronization therapy (CRT) has emerged as one of the few effective treatments for heart failure. However, up to 50% of patients derive no benefit. Suboptimal left ventricle (LV) lead position is a potential cause of poor outcomes while targeted lead deployment has been associated with enhanced response rates. Image-fusion guidance systems represent a novel approach to CRT delivery, allowing physicians to both accurately track and target a specific location during LV lead deployment. AREAS COVERED This review will provide a comprehensive evaluation of how to define the optimal pacing site. We will evaluate the evidence for delivering targeted LV stimulation at sites displaying favorable viability or advantageous mechanical or electrical properties. Finally, we will evaluate several emerging image-fusion guidance systems which aim to facilitate optimal site selection during CRT. EXPERT COMMENTARY Targeted LV lead deployment is associated with reductions in morbidity and mortality. Assessment of tissue characterization and electrical latency are critical and can be achieved in a number of ways. Ultimately, the constraints of coronary sinus anatomy have forced the exploration of novel means of delivering CRT including endocardial pacing which hold promise for the future of CRT delivery.
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Affiliation(s)
- Benjamin J. Sieniewicz
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Justin Gould
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Bradley Porter
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Baldeep S Sidhu
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Jonathan M Behar
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Simon Claridge
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Steve Niederer
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
| | - Christopher A. Rinaldi
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
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Sieniewicz BJ, Behar JM, Gould J, Claridge S, Porter B, Sidhu BS, Niederer S, Betts TR, Webster D, James S, Turley AJ, Rinaldi CA. Guidance for Optimal Site Selection of a Leadless Left Ventricular Endocardial Electrode Improves Acute Hemodynamic Response and Chronic Remodeling. JACC Clin Electrophysiol 2018; 4:860-868. [PMID: 30025684 DOI: 10.1016/j.jacep.2018.03.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 03/08/2018] [Accepted: 03/08/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVES This study hypothesized that guided implants, in which the optimal left ventricular endocardial (LVENDO) pacing location was identified and targeted, would improve acute markers of contractility and chronic markers of cardiac resynchronization (CRT) response. BACKGROUND Biventricular endocardial (BiVENDO) pacing may offer a potential benefit over standard CRT; however, the optimal LVENDO pacing site is highly variable. Indiscriminately delivered BiVENDO pacing is associated with a reverse remodeling response rate of between 40% and 60%. METHODS Registry of centers implanting a wireless, LVENDO pacing system (WiSE-CRT System, EBR Systems, Sunnyvale, California); John Radcliffe Hospital (Oxford, United Kingdom), Guy's and St. Thomas' Hospital (London, United Kingdom), and The James Cook University Hospital (Middlesbrough, United Kingdom). Centers used a combination of preprocedural imaging and electroanatomical mapping the identify the optimal LVENDO site. RESULTS A total of 26 patients across the 3 centers underwent a guided implant. Patients were predominantly male with a mean age of 68.8 ± 8.4 years, the mean LV ejection fraction was 34.2 ± 7.8%. The mean QRS duration was 163.8 ± 26.7 ms, and 30.8% of patients had an ischemic etiology. It proved technically feasible to selectively target and deploy the pacing electrode in a chosen endocardial segment in almost all cases, with a similar complication rate to that observed during indiscriminate BiVENDO. Ninety percent of patients met the definition of echocardiographic responder. Reverse remodeling was observed in 71%. CONCLUSIONS Guided endocardial implants were associated with a higher degree of chronic LV remodeling compared with historical nonguided approaches.
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Affiliation(s)
- Benjamin J Sieniewicz
- Division of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom; Cardiology Department, Guys and St. Thomas' National Health Service (NHS) Foundation Trust, London, United Kingdom.
| | - Jonathan M Behar
- Division of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom; Cardiology Department, Guys and St. Thomas' National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Justin Gould
- Division of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom; Cardiology Department, Guys and St. Thomas' National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Simon Claridge
- Division of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom; Cardiology Department, Guys and St. Thomas' National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Bradley Porter
- Division of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom; Cardiology Department, Guys and St. Thomas' National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Baldeep S Sidhu
- Division of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom; Cardiology Department, Guys and St. Thomas' National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Steve Niederer
- Division of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom
| | - Tim R Betts
- Cardiology Department, The John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - David Webster
- Cardiology Department, The John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Simon James
- Cardiology Department, The James Cook Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom
| | - Andrew J Turley
- Cardiology Department, The James Cook Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom
| | - Christopher A Rinaldi
- Division of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom; Cardiology Department, Guys and St. Thomas' National Health Service (NHS) Foundation Trust, London, United Kingdom
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Muto C, Solimene F, Russo V, Nigro G, Rago A, Chianese R, Chiariello P, Ciardiello C, Caliendo L. Optimal left ventricular lead placement for cardiac resynchronization therapy in postmyocardial infarction patients. Future Cardiol 2018; 14:215-224. [PMID: 29767542 DOI: 10.2217/fca-2017-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To evaluate at a 12-month follow-up, the clinical and echocardiographic outcomes in postmyocardial infarction (MI) heart failure patients who underwent cardiac resynchronization therapy (CRT) device implantation. MATERIALS & METHODS A total of 100 patients received a CRT device, and the study population was divided into three groups, according to the site of MI and left ventricular (LV) lead placed downstream of the ischemic area, as evaluated by echocardiography. RESULTS At the end of the 12-month follow-up, we reported a general improvement of LV ejection fraction from 28 ± 7% to 35 ± 9% (p < 0.001) and a significant reverse remodeling: LV end-systolic volume changed from 147 ± 54 to 125 ± 63 (p = 0.001) with a 53% of echocardiographic responders. We also observed 67% of CRT responders in the group with optimal LV lead placement compared with 38% in the remaining population (p = 0.01). CONCLUSION The optimal positioning of LV lead is a feasible method to improve the percentage of CRT responders in post-MI heart failure patients.
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Affiliation(s)
- Carmine Muto
- Cardiologia, Ospedale Santa Maria della Pietà, Nola, Napoli, Italy
| | - Francesco Solimene
- Elttrostimolazione ed Elettrofisiologia, Casa Di Cura Montevergine, Mercogliano, Avellino, Italy
| | - Vincenzo Russo
- Chair of Cardiology, Cardiologia, Second University of Naples, Monaldi Hospital - Napoli, Italy
| | - Gerardo Nigro
- Chair of Cardiology, Cardiologia, Second University of Naples, Monaldi Hospital - Napoli, Italy
| | - Anna Rago
- Chair of Cardiology, Cardiologia, Second University of Naples, Monaldi Hospital - Napoli, Italy
| | | | - Paola Chiariello
- Cardiologia, Ospedale Santa Maria dell'Olmo, Cava de'Tirreni, Salerno, Italy
| | | | - Luigi Caliendo
- Cardiologia, Ospedale Santa Maria della Pietà, Nola, Napoli, Italy
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Lee AWC, Costa CM, Strocchi M, Rinaldi CA, Niederer SA. Computational Modeling for Cardiac Resynchronization Therapy. J Cardiovasc Transl Res 2018; 11:92-108. [PMID: 29327314 PMCID: PMC5908824 DOI: 10.1007/s12265-017-9779-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 12/18/2017] [Indexed: 11/21/2022]
Abstract
Cardiac resynchronization therapy (CRT) is an effective treatment for heart failure (HF) patients with an electrical substrate pathology causing ventricular dyssynchrony. However 40-50% of patients do not respond to treatment. Cardiac modeling of the electrophysiology, electromechanics, and hemodynamics of the heart has been used to study mechanisms behind HF pathology and CRT response. Recently, multi-scale dyssynchronous HF models have been used to study optimal device settings and optimal lead locations, investigate the underlying cardiac pathophysiology, as well as investigate emerging technologies proposed to treat cardiac dyssynchrony. However the breadth of patient and experimental data required to create and parameterize these models and the computational resources required currently limits the use of these models to small patient numbers. In the future, once these technical challenges are overcome, biophysically based models of the heart have the potential to become a clinical tool to aid in the diagnosis and treatment of HF.
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Affiliation(s)
- Angela W C Lee
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.
| | | | - Marina Strocchi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | | | - Steven A Niederer
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
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Lee JZ, Mulpuru SK, Shen WK. Leadless pacemaker: Performance and complications. Trends Cardiovasc Med 2018; 28:130-141. [DOI: 10.1016/j.tcm.2017.08.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 08/02/2017] [Accepted: 08/03/2017] [Indexed: 10/19/2022]
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Bordachar P, Gras D, Clementy N, Defaye P, Mondoly P, Boveda S, Anselme F, Klug D, Piot O, Sadoul N, Babuty D, Leclercq C. Clinical impact of an additional left ventricular lead in cardiac resynchronization therapy nonresponders: The V 3 trial. Heart Rhythm 2017; 15:870-876. [PMID: 29288035 DOI: 10.1016/j.hrthm.2017.12.028] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is an effective treatment of heart failure (HF), but is limited by a substantial proportion of nonresponders. We hypothesized that adding a second left ventricular (LV) lead to deliver a triple-site CRT (V3 CRT) may improve clinical status of CRT nonresponders. OBJECTIVE We assessed the feasibility and safety of adding a second LV lead to CRT nonresponders and its clinical impact. METHODS Eighty-four recipients of a CRT system and considered as nonresponders as per clinical composite score (CCS) were enrolled in this multicenter study. They were randomized to the V3 arm (implantation of an additional LV lead; n = 43) or control arm (no change; n = 41). Implant success rate, incidence of severe adverse events, CCS, and secondary clinical and echocardiographic end points were evaluated at 12 and 24 months. RESULTS Positioning of a second LV lead was successful at first (40 of 44 - 90.9%) or second (4 of 44 - 9.09%) attempt. The perioperative complication rate (infection, system explant, pneumothorax, and hematoma) was high (procedures or system-related complications for 9 patients- 20.4%). After 24 months, 35 systems (79.5%) were working properly. The multinomial logistic regression model showed that V3 treatment had no significant influence (P = .27) on the CCS, number of HF hospitalizations, time to first HF hospitalization, New York Heart Association class, and LV ejection fraction at 12 and 24 months. CONCLUSION Although addition of a second LV lead in CRT nonresponders is feasible with a high success rate, this approach is associated with a significant rate of severe adverse events and does not provide significant long-term clinical benefits (ClinicalTrials.gov Identifier No. NCT01059175).
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Affiliation(s)
| | | | | | | | | | | | | | | | - Olivier Piot
- Centre Cardiologique du Nord, Saint-Denis, France
| | - Nicolas Sadoul
- Brabois University Hospital, Vandoeuvre-les-Nancy, France
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Gallego Muñoz C, Saldarriaga CI, Cañas Arenas EM, Delgado Gómez C, González Berrío C. Evaluación de la respuesta a la terapia de resincronización cardíaca en un grupo de pacientes que asisten a un programa de falla cardíaca. REVISTA COLOMBIANA DE CARDIOLOGÍA 2017. [DOI: 10.1016/j.rccar.2017.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Auricchio A, Prinzen FW. Enhancing Response in the Cardiac Resynchronization Therapy Patient. JACC Clin Electrophysiol 2017; 3:1203-1219. [DOI: 10.1016/j.jacep.2017.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 08/02/2017] [Accepted: 08/10/2017] [Indexed: 12/17/2022]
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Providencia R, Barra S, Papageorgiou N, Ioannou A, Rogers D, Wongwarawipat T, Falconer D, Duehmke R, Colicchia M, Babu G, Segal OR, Sporton S, Dhinoja M, Ahsan S, Ezzat V, Rowland E, Lowe M, Lambiase PD, Agarwal S, Chow AW. Dual-site right ventricular pacing in patients undergoing cardiac resynchronization therapy: Results of a multicenter propensity-matched analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:1113-1120. [PMID: 28734025 DOI: 10.1111/pace.13145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 05/26/2017] [Accepted: 06/13/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Dual-site right ventricular pacing (Dual RV) has been proposed as an alternative for patients with heart failure undergoing cardiac resynchronization therapy (CRT) with a failure to deliver a coronary sinus (CS) lead. Only short-term hemodynamic and echocardiographic results of Dual RV are available. We aimed to assess the long-term results of Dual RV and its impact on survival. METHODS Multicenter retrospective assessment of all CRT implants during a 12-year period. Patients with failed CS lead implantation, treated with Dual RV, were followed and assessed for the primary endpoint of all-cause mortality and/or heart transplant. A control group was obtained from contemporary patients using propensity matching for all available baseline variables. RESULTS Ninety-three patients were implanted with Dual RV devices and compared with 93 matched controls. During a median of 1,273 days (interquartile range 557-2,218), intention-to-treat analysis showed that all-cause mortality and/or heart transplant was higher in the Dual RV group (adjusted hazard ratio [HR] = 1.66, 95% confidence interval [CI] 1.12-2.47, P = 0.012). As-treated analysis yielded similar results (HR = 1.97, 95% CI 1.31-2.96, P = 0.001). Cardiac device-related infections occurred seven times more frequently in the Dual RV site group (HR = 7.60, 95% CI 1.51-38.33, P = 0.014). Among Dual RV nonresponders, four had their apical leads switched off, five required an epicardial LV lead insertion, a transseptal LV lead was implanted in two, and in nine patients, after reviewing the CS venogram, a new CS lead insertion was successfully attempted. CONCLUSION Dual RV pacing is associated with worse clinical outcomes and higher complication rates than conventional CRT.
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Affiliation(s)
| | - Sergio Barra
- Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | | | - Adam Ioannou
- The Heart Hospital, University College of London Hospitals NHS Trust, London, UK
| | - Dominic Rogers
- The Heart Hospital, University College of London Hospitals NHS Trust, London, UK
| | | | - Debbie Falconer
- The Heart Hospital, University College of London Hospitals NHS Trust, London, UK
| | | | | | - Girish Babu
- The Heart Hospital, University College of London Hospitals NHS Trust, London, UK
| | | | - Simon Sporton
- Barts Heart Centre, Barts Health NHS Trust, London, UK
| | - Mehul Dhinoja
- Barts Heart Centre, Barts Health NHS Trust, London, UK
| | - Syed Ahsan
- Barts Heart Centre, Barts Health NHS Trust, London, UK
| | | | | | - Martin Lowe
- Barts Heart Centre, Barts Health NHS Trust, London, UK
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Behar JM, Mountney P, Toth D, Reiml S, Panayiotou M, Brost A, Fahn B, Karim R, Claridge S, Jackson T, Sieniewicz B, Patel N, O'Neill M, Razavi R, Rhode K, Rinaldi CA. Real-Time X-MRI-Guided Left Ventricular Lead Implantation for Targeted Delivery of Cardiac Resynchronization Therapy. JACC Clin Electrophysiol 2017; 3:803-814. [PMID: 29759775 DOI: 10.1016/j.jacep.2017.01.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/23/2017] [Accepted: 01/27/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVES This study sought to test the feasibility of a purpose-built, integrated software platform to process, analyze, and overlay cardiac magnetic resonance (CMR) data in real time within a combined cardiac catheter laboratory and magnetic resonance imaging scanner suite (X-MRI) to guide left ventricular (LV) lead implantation. BACKGROUND Suboptimal LV lead position is a major determinant of poor cardiac resynchronization therapy (CRT) response, and the optimal site is highly patient specific. Pacing myocardial scar is associated with poorer outcomes; conversely, targeting latest mechanical activation (LMA) may improve them. METHODS Fourteen patients (age 74 ± 5.1 years; New York Heart Association functional class: 2.7 ± 0.4; 86% ischemic with ejection fraction 27 ± 7.6%; QRSd: 157 ± 19 ms) underwent CMR followed by immediate CRT implantation using derived scar and dyssynchrony data, overlaid onto fluoroscopy in an X-MRI suite. Rapid LV segmentation enabled detailed scar quantification, identification of LMA segments, and selection of myocardial targets. At coronary venography, the CMR-derived 3-dimensional shell was fused, enabling identification of viable venous targets subtended by target segments for LV lead placement. RESULTS The platform was successful in all 14 patients, of whom 10 (71%) were paced in pre-procedurally defined target segments. Pacing in CMR-defined target segments (out of scar) showed a significant decrease in the LV capture threshold (mean difference: 2.4 [1.5 to 3.2]; p < 0.001) and shorter paced QRS duration (mean difference: 25 [15 to 34]; p < 0.001) compared with pacing in areas of CMR determined scar. In 5 (36%) patients with extensive scar in the posterolateral wall, CMR guidance enabled successful lead delivery in an alternative anatomically favorable site. Radiation dose and implant times were similar to historical controls (p = NS). CONCLUSIONS Real-time CMR-guided LV lead placement is feasible and achievable in a single clinical setting and may prove helpful to preferentially select sites for LV lead placement.
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Affiliation(s)
- Jonathan M Behar
- Department of Imaging Sciences and Biomedical Engineering, King's College London, & Guy's and St Thomas' Hospital, London, United Kingdom.
| | - Peter Mountney
- Medical Imaging Technologies, Siemens Healthineers, Princeton, New Jersey
| | - Daniel Toth
- Department of Imaging Sciences and Biomedical Engineering, King's College London, & Guy's and St Thomas' Hospital, London, United Kingdom; Siemens Healthineers, Frimley, Camberley, United Kingdom
| | | | - Maria Panayiotou
- Department of Imaging Sciences and Biomedical Engineering, King's College London, & Guy's and St Thomas' Hospital, London, United Kingdom
| | | | | | - Rashed Karim
- Department of Imaging Sciences and Biomedical Engineering, King's College London, & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Simon Claridge
- Department of Imaging Sciences and Biomedical Engineering, King's College London, & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Tom Jackson
- Department of Imaging Sciences and Biomedical Engineering, King's College London, & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Ben Sieniewicz
- Department of Imaging Sciences and Biomedical Engineering, King's College London, & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Nik Patel
- Department of Imaging Sciences and Biomedical Engineering, King's College London, & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Mark O'Neill
- Department of Imaging Sciences and Biomedical Engineering, King's College London, & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Reza Razavi
- Department of Imaging Sciences and Biomedical Engineering, King's College London, & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Kawal Rhode
- Department of Imaging Sciences and Biomedical Engineering, King's College London, & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Christopher Aldo Rinaldi
- Department of Imaging Sciences and Biomedical Engineering, King's College London, & Guy's and St Thomas' Hospital, London, United Kingdom
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Body surface mapping using an ECG belt to characterize electrical heterogeneity for different left ventricular pacing sites during cardiac resynchronization: Relationship with acute hemodynamic improvement. Heart Rhythm 2017; 14:385-391. [DOI: 10.1016/j.hrthm.2016.11.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Indexed: 11/18/2022]
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Tang H, Tang S, Zhou W. A Review of Image-guided Approaches for Cardiac Resynchronisation Therapy. Arrhythm Electrophysiol Rev 2017; 6:69-74. [PMID: 28845234 DOI: 10.15420/aer.2016.32.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cardiac resynchronisation therapy (CRT) is a standard treatment for patients with heart failure; however, the low response rate significantly reduces its cost-effectiveness. A favourable CRT response primarily depends on whether implanters can identify the optimal left ventricular (LV) lead position and accurately place the lead at the recommended site. Myocardial imaging techniques, including echocardiography, cardiac magnetic resonance imaging and nuclear imaging, have been used to assess LV myocardial viability and mechanical dyssynchrony, and deduce the optimal LV lead position. The optimal position, presented as a segment of the myocardial wall, is then overlaid with images of the coronary veins from fluoroscopy to aid navigation of the LV lead to the target venous site. Once validated by large clinical trials, these image-guided techniques for CRT lead placement may have an impact on current clinical practice.
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Affiliation(s)
- Haipeng Tang
- School of Computing, University of Southern Mississippi, Long Beach, MS, USA
| | - Shaojie Tang
- School of Automation, Xi'an University of Posts and Telecommunications, Xi'an, Shaanxi, China
| | - Weihua Zhou
- School of Computing, University of Southern Mississippi, Long Beach, MS, USA
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Thompson N, Derval N. Left Ventricular Endocardial Stimulation in Patients With a Poor Response to Cardiac Resynchronization Therapy: What Is Next? JACC Clin Electrophysiol 2016; 2:810-811. [PMID: 29759764 DOI: 10.1016/j.jacep.2016.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 06/02/2016] [Indexed: 12/31/2022]
Affiliation(s)
| | - Nicolas Derval
- Hopital Cardiologique du Haut Lévêque, CHU Bordeaux, Pessac, France.
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Behar JM, Jackson T, Hyde E, Claridge S, Gill J, Bostock J, Sohal M, Porter B, O'Neill M, Razavi R, Niederer S, Rinaldi CA. Optimized Left Ventricular Endocardial Stimulation Is Superior to Optimized Epicardial Stimulation in Ischemic Patients With Poor Response to Cardiac Resynchronization Therapy: A Combined Magnetic Resonance Imaging, Electroanatomic Contact Mapping, and Hemodynamic Study to Target Endocardial Lead Placement. JACC Clin Electrophysiol 2016; 2:799-809. [PMID: 28066827 PMCID: PMC5196018 DOI: 10.1016/j.jacep.2016.04.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES The purpose of this study was to identify the optimal pacing site for the left ventricular (LV) lead in ischemic patients with poor response to cardiac resynchronization therapy (CRT). BACKGROUND LV endocardial pacing may offer benefit over conventional CRT in ischemic patients. METHODS We performed cardiac magnetic resonance, invasive electroanatomic mapping (EAM), and measured the acute hemodynamic response (AHR) in patients with existing CRT systems. RESULTS In all, 135 epicardial and endocardial pacing sites were tested in 8 patients. Endocardial pacing was superior to epicardial pacing with respect to mean AHR (% change in dP/dtmax vs. baseline) (11.81 [-7.2 to 44.6] vs. 6.55 [-11.0 to 19.7]; p = 0.025). This was associated with a similar first ventricular depolarization (Q-LV) (75 ms [13 to 161 ms] vs. 75 ms [25 to 129 ms]; p = 0.354), shorter stimulation-QRS duration (15 ms [7 to 43 ms] vs. 19 ms [5 to 66 ms]; p = 0.010) and shorter paced QRS duration (149 ms [95 to 218 ms] vs. 171 ms [120 to 235 ms]; p < 0.001). The mean best achievable AHR was higher with endocardial pacing (25.64 ± 14.74% vs. 12.64 ± 6.76%; p = 0.044). Furthermore, AHR was significantly greater pacing the same site endocardially versus epicardially (15.2 ± 10.7% vs. 7.6 ± 6.3%; p = 0.014) with a shorter paced QRS duration (137 ± 22 ms vs. 166 ± 30 ms; p < 0.001) despite a similar Q-LV (70 ± 38 ms vs. 79 ± 34 ms; p = 0.512). Lack of capture due to areas of scar (corroborated by EAM and cardiac magnetic resonance) was associated with a poor AHR. CONCLUSIONS In ischemic patients with poor CRT response, biventricular endocardial pacing is superior to epicardial pacing. This may reflect accessibility to sites that cannot be reached via coronary sinus anatomy and/or by access to more rapidly conducting tissue. Furthermore, guidance to the optimal LV pacing site may be aided by modalities such as cardiac magnetic resonance to target delayed activating sites while avoiding scar.
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Key Words
- AHR, acute hemodynamic response
- CMR, cardiac magnetic resonance
- CRT
- CRT, cardiac resynchronization therapy
- EAM, electroanatomic mapping
- LV, left ventricle/ventricular
- LVendo, left ventricular endocardium
- LVepi, optimal epicardial response
- LVepi1, implanted LV lead
- LVepi2, temporary LV lead
- Q-LV, first ventricular depolarization
- cardiac magnetic resonance imaging
- electroanatomic map
- endocardial pacing
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Affiliation(s)
- Jonathan M Behar
- Department of Imaging Sciences and Biomedical Engineering, King's College London & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Tom Jackson
- Department of Imaging Sciences and Biomedical Engineering, King's College London & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Eoin Hyde
- Department of Imaging Sciences and Biomedical Engineering, King's College London & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Simon Claridge
- Department of Imaging Sciences and Biomedical Engineering, King's College London & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Jaswinder Gill
- Department of Imaging Sciences and Biomedical Engineering, King's College London & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Julian Bostock
- Department of Imaging Sciences and Biomedical Engineering, King's College London & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Manav Sohal
- Department of Imaging Sciences and Biomedical Engineering, King's College London & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Bradley Porter
- Department of Imaging Sciences and Biomedical Engineering, King's College London & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Mark O'Neill
- Department of Imaging Sciences and Biomedical Engineering, King's College London & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Reza Razavi
- Department of Imaging Sciences and Biomedical Engineering, King's College London & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Steve Niederer
- Department of Imaging Sciences and Biomedical Engineering, King's College London & Guy's and St Thomas' Hospital, London, United Kingdom
| | - Christopher Aldo Rinaldi
- Department of Imaging Sciences and Biomedical Engineering, King's College London & Guy's and St Thomas' Hospital, London, United Kingdom
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45
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Behar JM, Claridge S, Jackson T, Sieniewicz B, Porter B, Webb J, Rajani R, Kapetanakis S, Carr-White G, Rinaldi CA. The role of multi modality imaging in selecting patients and guiding lead placement for the delivery of cardiac resynchronization therapy. Expert Rev Cardiovasc Ther 2016; 15:93-107. [DOI: 10.1080/14779072.2016.1252674] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Jonathan M Behar
- Department of Imaging Sciences & Biomedical Engineering, King’s College London, London, UK
- Department of Cardiology, St. Thomas’ Hospital, London, UK
| | - Simon Claridge
- Department of Imaging Sciences & Biomedical Engineering, King’s College London, London, UK
- Department of Cardiology, St. Thomas’ Hospital, London, UK
| | - Tom Jackson
- Department of Imaging Sciences & Biomedical Engineering, King’s College London, London, UK
- Department of Cardiology, St. Thomas’ Hospital, London, UK
| | - Ben Sieniewicz
- Department of Imaging Sciences & Biomedical Engineering, King’s College London, London, UK
- Department of Cardiology, St. Thomas’ Hospital, London, UK
| | - Bradley Porter
- Department of Imaging Sciences & Biomedical Engineering, King’s College London, London, UK
- Department of Cardiology, St. Thomas’ Hospital, London, UK
| | - Jessica Webb
- Department of Imaging Sciences & Biomedical Engineering, King’s College London, London, UK
- Department of Cardiology, St. Thomas’ Hospital, London, UK
| | - Ronak Rajani
- Department of Cardiology, St. Thomas’ Hospital, London, UK
| | | | | | - Christopher A Rinaldi
- Department of Imaging Sciences & Biomedical Engineering, King’s College London, London, UK
- Department of Cardiology, St. Thomas’ Hospital, London, UK
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46
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X-ray and magnetic resonance imaging fusion for cardiac resynchronization therapy. Med Image Anal 2016; 31:98-107. [DOI: 10.1016/j.media.2016.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 12/22/2015] [Accepted: 03/10/2016] [Indexed: 11/23/2022]
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47
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Hyde ER, Behar JM, Crozier A, Claridge S, Jackson T, Sohal M, Gill JS, O'Neill MD, Razavi R, Niederer SA, Rinaldi CA. Improvement of Right Ventricular Hemodynamics with Left Ventricular Endocardial Pacing during Cardiac Resynchronization Therapy. Pacing Clin Electrophysiol 2016; 39:531-41. [PMID: 27001004 PMCID: PMC4913734 DOI: 10.1111/pace.12854] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 02/22/2016] [Accepted: 03/13/2016] [Indexed: 11/30/2022]
Abstract
Background Cardiac resynchronization therapy (CRT) with biventricular epicardial (BV‐CS) or endocardial left ventricular (LV) stimulation (BV‐EN) improves LV hemodynamics. The effect of CRT on right ventricular function is less clear, particularly for BV‐EN. Our objective was to compare the simultaneous acute hemodynamic response (AHR) of the right and left ventricles (RV and LV) with BV‐CS and BV‐EN in order to determine the optimal mode of CRT delivery. Methods Nine patients with previously implanted CRT devices successfully underwent a temporary pacing study. Pressure wires measured the simultaneous AHR in both ventricles during different pacing protocols. Conventional epicardial CRT was delivered in LV‐only (LV‐CS) and BV‐CS configurations and compared with BV‐EN pacing in multiple locations using a roving decapolar catheter. Results Best BV‐EN (optimal AHR of all LV endocardial pacing sites) produced a significantly greater RV AHR compared with LV‐CS and BV‐CS pacing (P < 0.05). RV AHR had a significantly increased standard deviation compared to LV AHR (P < 0.05) with a weak correlation between RV and LV AHR (Spearman rs = −0.06). Compromised biventricular optimization, whereby RV AHR was increased at the expense of a smaller decrease in LV AHR, was achieved in 56% of cases, all with BV‐EN pacing. Conclusions BV‐EN pacing produces significant increases in both LV and RV AHR, above that achievable with conventional epicardial pacing. RV AHR cannot be used as a surrogate for optimizing LV AHR; however, compromised biventricular optimization is possible. The beneficial effect of endocardial LV pacing on RV function may have important clinical benefits beyond conventional CRT.
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Affiliation(s)
- Eoin R Hyde
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Jonathan M Behar
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.,Department of Cardiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Andrew Crozier
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Simon Claridge
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.,Department of Cardiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Tom Jackson
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.,Department of Cardiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Manav Sohal
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.,Department of Cardiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Jaswinder S Gill
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.,Department of Cardiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Mark D O'Neill
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.,Department of Cardiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Reza Razavi
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Steven A Niederer
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Christopher A Rinaldi
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.,Department of Cardiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
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48
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Dawoud F, Spragg DD, Berger RD, Cheng A, Horáček BM, Halperin HR, Lardo AC. Non-invasive electromechanical activation imaging as a tool to study left ventricular dyssynchronous patients: Implication for CRT therapy. J Electrocardiol 2016; 49:375-82. [PMID: 26968312 DOI: 10.1016/j.jelectrocard.2016.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Indexed: 10/22/2022]
Abstract
AIMS Electromechanical de-coupling is hypothesized to explain non-response of dyssynchrony patient to cardiac resynchronization therapy (CRT). In this pilot study, we investigated regional electromechanical uncoupling in 10 patients referred for CRT using two non-invasive electrical and mechanical imaging techniques (CMR tissue tracking and ECGI). METHODS AND RESULTS Reconstructed regional electrical and mechanical activation captured delayed LBBB propagation direction from septal to anterior/inferior and finally to lateral walls as well as from LV apical to basal. All 5 responders demonstrated significantly delayed mechanical and electrical activation on the lateral LV wall at baseline compared to the non-responders (P<.05). On follow-up ECGI, baseline electrical activation patterns were preserved in native rhythm and global LV activation time was reduced with biventricular pacing. CONCLUSIONS The combination of novel imaging techniques of ECGI and CMR tissue tracking can be used to assess spatial concordance of LV electrical and mechanical activation to gain insight into electromechanical coupling.
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Affiliation(s)
- Fady Dawoud
- Division of Cardiology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - David D Spragg
- Division of Cardiology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ronald D Berger
- Division of Cardiology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Alan Cheng
- Division of Cardiology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - B Milan Horáček
- Department of Electrical and Computer Engineering, Dalhousie University, Halifax, NS, Canada
| | - Henry R Halperin
- Division of Cardiology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Albert C Lardo
- Division of Cardiology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
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49
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Tsai SC, Chang YC, Chiang KF, Lin WY, Huang JL, Hung GU, Kao CH, Chen J. LV Dyssynchrony Is Helpful in Predicting Ventricular Arrhythmia in Ischemic Cardiomyopathy After Cardiac Resynchronization Therapy: A Preliminary Study. Medicine (Baltimore) 2016; 95:e2840. [PMID: 26886645 PMCID: PMC4998645 DOI: 10.1097/md.0000000000002840] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
For patients with coronary artery disease, larger scar burdens are associated with higher risk of ventricular arrhythmia. Left ventricular (LV) dyssynchrony is associated with increased risk of sudden cardiac death in patients with heart failure. The purpose of this study was to assess the values of LV dyssynchrony and myocardial scar assessed by myocardial perfusion SPECT (MPS) in predicting the development of ventricular arrhythmia in ischemic cardiomyopathy. Twenty-two patients (16 males, mean age: 66 ± 13) with irreversible ischemic cardiomyopathy received cardiac resynchronization therapy (CRT) for at least 12 months were enrolled for MPS. Quantitative parameters, including LV dyssynchrony with phase standard deviation (phase SD) and bandwidth, left ventricular ejection fraction (LVEF), and scar (% of total areas), were generated by Emory Cardiac Toolbox. Ventricular tachycardia (VT) and ventricular fibrillation (VF) recorded in the CRT device during follow-up were used as the reference standard of diagnosing ventricular arrhythmia. Stepwise logistic regression analysis was performed for determining the independent predictors of VT/VF and receiver operating characteristic (ROC) curve analysis was used for generating the optimal cut-off values for predicting VT/VF. Nine (41%) of the 22 patients developed VT/VF during the follow-up periods. Patients with VT/VF had significantly lower LVEF, larger scar, larger phase SD, and larger bandwidth (all P < 0.05). Logistic regression analysis showed LVEF and bandwidth were independent predictors of VT/VF. ROC curve analysis showed the areas under the curves were 0.71 and 0.83 for LVEF and bandwidth, respectively. The optimal cut-off values were <36% and > 139° for LVEF and bandwidth, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 39%, 53%, and 100%, respectively, for LVEF; and were 78%, 92%, 88%, and 86%, respectively, for bandwidth. LV dyssynchrony as assessed by phase analysis of MPS is helpful for predicting ventricular arrhythmia in ischemic cardiomyopathy after CRT. Further implantation of defibrillator may be considered for those patients with bandwidth >139°.
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Affiliation(s)
- Shih-Chuan Tsai
- From the Department of Nuclear Medicine (S-CT, W-YL) and Cadiovascular Center (Y-CC, K-FC, J-LH), Taichung Veterans General Hospital; Department of Medical Imaging and Radiological Sciences (S-CT, G-UH), Central Taiwan University of Science and Technology; Department of Nuclear Medicine (G-UH), Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan; Department of Medical Imaging and Radiological Sciences, China Medical University, Taichung, Taiwan (G-UH, C-HK); Department of Medicine, School of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan (J-LH); and Department of Radiology and Imaging Sciences (JC), Emory University School of Medicine, Atlanta, GA
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50
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van Gelder BM, Nathoe R, Bracke FA. Haemodynamic evaluation of alternative left ventricular endocardial pacing sites in clinical non-responders to cardiac resynchronisation therapy. Neth Heart J 2015; 24:85-92. [PMID: 26645710 PMCID: PMC4692838 DOI: 10.1007/s12471-015-0773-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Introduction Non response to cardiac resynchronisation therapy (CRT) may be related to the position of the coronary sinus lead. Methods We studied the acute haemodynamic response (AHR) from alternative left ventricular (LV) endocardial pacing sites in clinical non-responders to CRT. AHR and the interval from QRS onset to LV sensing (Q-LV interval) from four different endocardial pacing sites were evaluated in 24 clinical non-responders. A rise in LVdP/dtmax ≥ 15 % from baseline was considered a positive AHR. We also compared the AHR from endocardial with the corresponding epicardial lead position. Results The implanted system showed an AHR ≥ 15 % in 5 patients. In 9 of the 19 remaining patients, AHR could be elevated to ≥ 15 % by endocardial LV pacing. The optimal endocardial pacing site was posterolateral. There was no significant difference in AHR between the epicardial and the corresponding endocardial position. The longest Q-LV interval corresponded with the best AHR in 12 out of the 14 patients with a positive AHR, with an average Q-LV/QRS width ratio of 90 %. Conclusions Acute haemodynamic testing may indicate an alternative endocardial pacing site with a positive AHR in clinical non-responders. The Q-LV interval is a strongly correlated with the optimal endocardial pacing site. Endocardial pacing opposite epicardial sites does not result in a better AHR.
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Affiliation(s)
- B M van Gelder
- Department of Cardiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
| | - R Nathoe
- Department of Cardiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - F A Bracke
- Department of Cardiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
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