2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Comparison of de novo implantation vs. upgrade cardiac resynchronisation therapy: a multicentre experience

BACKGROUND

The clinical safety and consequences of upgrade procedures compared with de novo cardiac resynchronisation therapy (CRT) implantation in heart failure remain unclear. The present study aimed to assess clinical and procedural consequences of patients undergoing CRT upgrade as compared to de novo CRT implantations.

METHODS

In this prospective cohort study, two subgroups were considered as the study population as (1) de novo group that CRT was considered on optimised medical treatment with heart failure of NYHA functional class from II to IV, left ventricular ejection fraction (LVEF) of ≤35%, and QRS width of >130 ms and (2) upgrade group including the patients with previously implantable cardioverter defibrillator (ICD) with the indications for upgrading to CRT. The two groups were compared regarding the changes in clinical outcome and echocardiography parameters.

RESULTS

The procedure was successful in 95.9% of patients who underwent CRT upgrade and 100% of those who underwent de novo CRT implantation. It showed a significant improvement in LVEF, severity of mitral regurgitation and NYHA functional classification, without any difference between the two study groups. Overall procedural related complications were reported in 10.8% and 3.8% (p = .093) and cardiac death in 5.4% and 2.5% (p = .360), respectively, with no overall difference in postoperative outcome between the two groups.

CONCLUSIONS

Upgrading to CRT is a safe and effective procedure regarding improvement of functional class, left ventricular function status and post-procedural outcome.

Useful Electrocardiographic Signs to Support the Prediction of Favorable Response to Cardiac Resynchronization Therapy

Cardiac resynchronization therapy (CRT) is a cornerstone therapeutic opportunity for selected patients with heart failure. For optimal patient selection, no other method has been proven to be more effective than the 12-lead ECG, and hence ECG characteristics are extensively researched. The evaluation of particular ECG signs before the implantation may improve selection and, consequently, clinical outcomes. The definition of a true left bundle branch block (LBBB) seems to be the best starting point with which to select patients for CRT. Although there are no universally accepted definitions of LBBB, using the classical LBBB criteria, some ECG parameters are associated with CRT response. In patients with non-true LBBB or non-LBBB, further ECG predictors of response and non-response could be analyzed, such as QRS fractionation, signs of residual left bundle branch conduction, S-waves in V6, intrinsicoid deflection, or non-invasive estimates of Q-LV which are described in newer publications. The most important and recent study results of the topic are summarized and discussed in this current review.

A Primer on Pacemakers and Defibrillators for Nurses

Although the concepts of pacing have been around for more than half a century, technological advances in cardiac implantable electronic devices (CIEDs) have changed the landscape for patients in need of pacing support or sudden death prevention. Nurses encounter patients with CIEDs in all aspects of the health care setting. Because exciting CIED therapies are on the horizon, nurses must stay up-to-date to promote optimal outcomes for CIED patients. This essential guide provides nurses with a comprehensive overview of the principles of pacing and implantable cardioverter defibrillators (ICDs), as well as innovative technologies such as leadless cardiac pacemakers and subcutaneous ICDs.

Comparisons of electrophysiological characteristics, pacing parameters and mid- to long-term effects in right ventricular septal pacing, right ventricular apical pacing and left bundle branch area pacing

Background

As a near-physiological pacing innovation, left bundle branch area pacing (LBBAP) has drawn much attention recently. This study was aimed to investigate the electrophysiological characteristics, unipolar/bipolar pacing parameters and mid- to long-term effects and safety of three different pacing methods and identify possible predictors of adverse left ventricular remodeling.

Methods

Ninety-two patients were divided into the LBBAP group, right ventricular septal pacing (RVSP) group and right ventricular apical pacing (RVAP) group. Baseline information, electrophysiological, pacing and echocardiographic parameters were collected.

Results

The three pacing methods were performed with a similar high success rate. The paced QRSd was significantly different among the LBBAP, RVSP and RVAP groups (105.93 ± 15.85 ms vs. 143.63 ± 14.71 ms vs. 155.39 ± 14.17 ms, p < 0.01). The stimulus to left ventricular activation time (Sti-LVAT) was the shortest in the LBBAP group, followed by the RVSP and RVAP groups (72.80 ± 12.07 ms vs. 86.29 ± 8.71 ms vs. 94.14 ± 10.14 ms, p < 0.001). LBBAP had a significantly lower tip impedance during the procedure and 3-month follow up as compared to RVSP and RVAP (p < 0.001). Higher bipolar captured thresholds were observed in LBBAP during the procedure (p < 0.001). Compared to the baseline values, there was a greater reduction in left ventricular end-diastolic dimension (LVEDD) in the LBBAP group (p = 0.046) and a significant enlargement in LVEDD in the RVAP group (p = 0.008). Multiple regression analysis revealed that the Sti-LVAT was a significant predictor of LVEDD at 12 months post-procedure. At the 24-h post-procedure, significant elevations were observed in the cTnI levels in LBBAP (p < 0.001) and RVSP (p < 0.05). More transient RBB injury was observed in LBBAP. But no significant difference was found in cardiac composite endpoints among three groups (p > 0.05).

Conclusions

LBBAP demonstrated a stable captured threshold, a low tip impedance and a high R-wave amplitude during the 12-month follow-up. Left ventricular remodeling was improved at 12 months post-procedure through LBBAP. The Sti-LVAT was a significant predictor of left ventricular remodeling. LBBAP demonstrated its feasibility, effectiveness, safety and some beneficial electrophysiological characteristics during this mid- to long-term follow-up, which should be confirmed by further studies.

Cardiac magnetic resonance defines mechanisms of sex-based differences in outcomes following cardiac resynchronization therapy

Background

Mechanisms of sex-based differences in outcomes following cardiac resynchronization therapy (CRT) are poorly understood.

Objective

To use cardiac magnetic resonance (CMR) to define mechanisms of sex-based differences in outcomes after CRT and describe distinct CMR-based phenotypes of CRT candidates based on sex and non-ischemic/ischemic cardiomyopathy type.

Materials and methods

In a prospective study, sex-based differences in three short-term CRT response measures [fractional change in left ventricular end-systolic volume index 6 months after CRT (LVESVI-FC), B-type natriuretic peptide (BNP) 6 months after CRT, change in peak VO2 6 months after CRT], and long-term survival were evaluated with respect to 39 baseline parameters from CMR, exercise testing, laboratory testing, electrocardiograms, comorbid conditions, and other sources. CMR was also used to quantify the degree of left-ventricular mechanical dyssynchrony by deriving the circumferential uniformity ratio estimate (CURE-SVD) parameter from displacement encoding with stimulated echoes (DENSE) strain imaging. Statistical methods included multivariable linear regression with evaluation of interaction effects associated with sex and cardiomyopathy type (ischemic and non-ischemic cardiomyopathy) and survival analysis.

Results

Among 200 patients, the 54 female patients (27%) pre-CRT had a smaller CMR-based LVEDVI (p = 0.04), more mechanical dyssynchrony based on the validated CMR CURE-SVD parameter (p = 0.04), a lower frequency of both late gadolinium enhancement (LGE) and ischemic cardiomyopathy (p < 0.0001), a greater RVEF (p = 0.02), and a greater frequency of LBBB (p = 0.01). After categorization of patients into four groups based on cardiomyopathy type (ischemic/non-ischemic cardiomyopathy) and sex, female patients with non-ischemic cardiomyopathy had the lowest CURE-SVD (p = 0.003), the lowest pre-CRT BNP levels (p = 0.01), the lowest post-CRT BNP levels (p = 0.05), and the most favorable LVESVI-FC (p = 0.001). Overall, female patients had better 3-year survival before adjustment for cardiomyopathy type (p = 0.007, HR = 0.45) and after adjustment for cardiomyopathy type (p = 0.009, HR = 0.67).

Conclusion

CMR identifies distinct phenotypes of female CRT patients with non-ischemic and ischemic cardiomyopathy relative to male patients stratified by cardiomyopathy type. The more favorable short-term response and long-term survival outcomes in female heart failure patients with CRT were associated with lower indexed CMR-based LV volumes, decreased presence of scar associated with prior myocardial infarction and ICM, and greater CMR-based dyssynchrony with the CURE-SVD.

Amateur Athlete with Sinus Arrest and Severe Bradycardia Diagnosed through a Heart Rate Monitor: A Six-Year Observation-The Necessity of Shared Decision-Making in Heart Rhythm Therapy Management

Heart rate monitors (HRMs) are used by millions of athletes worldwide to monitor exercise intensity and heart rate (HR) during training. This case report presents a 34-year-old male amateur soccer player with severe bradycardia who accidentally identified numerous pauses of over 4 s (maximum length: 7.3 s) during sleep on his own HRM with a heart rate variability (HRV) function. Simultaneous HRM and Holter ECG recordings were performed in an outpatient clinic, finding consistent 6.3 s sinus arrests (SA) with bradycardia of 33 beats/min. During the patient's hospitalization for a transient ischemic attack, the longest pauses on the Holter ECG were recorded, and he was suggested to undergo pacemaker implantation. He then reduced the volume/intensity of exercise for 4 years. Afterward, he spent 2 years without any regular training due to depression. After these 6 years, another Holter ECG test was performed in our center, not confirming the aforementioned disturbances and showing a tendency to tachycardia. The significant SA was resolved after a period of detraining. The case indicates that considering invasive therapy was unreasonable, and patient-centered care and shared decision-making play a key role in cardiac pacing therapy. In addition, some sports HRM with an HRV function can help diagnose bradyarrhythmia, both in professional and amateur athletes.

Patients' knowledge and concerns about using the implantable cardioverter defibrillator for the primary prevention of sudden cardiac death and its correlates: A cross-sectional study

Background and Aims

Sudden cardiac death (SCD) is one of the most common causes of mortality in heart failure (HF) patients with reduced ejection fraction. Patients have concerns about the disease and use the implantable cardioverter defibrillator (ICD) to reduce the effects of HF disease. The current study aims to evaluate the barriers and factors affecting the implantation of the ICD for primary prevention.

Methods

One hundred-forty-seven patients with HF were studied in public hospitals in southern Iran by using a cross-sectional design from April 2018 to June 2019. Demographic, researcher-made questionnaire, World Health Organization Quality of life-BREF (WHOQOL-BREF), general self-efficacy questionnaires, and Multidimensional Scale of Perceived Social Support (MSPSS) were measured for investigating the barriers and impact factors in patent HF.

Results

Most participants were male (56.5%), married (88.4%), illiterate (54.1%), and unemployed (72.6%). 62.6% (n = 92) of the participants did not know about HF and ICD. The total score of patients' concerns about using ICD was 47.11 ± 11.26, which showed a moderate level. The scores of knowledge about HF and ICD had a significant positive poor correlation with self-efficacy, perceived social support and QoL. Also, the score of concerns about the ICD had a significant negative poor correlation with perceived social support.

Conclusion

Understanding HF patients' issues and obstacles can help us prevent sudden death. Doctors' advice has a significant impact on patients' acceptance. Poor knowledge is the most important reason for nonparticipation. Intervention is necessary to inform patients to understand the advantages and disadvantages.

Case Report: Kearns Sayre Syndrome Complicated With Postpartum Cardiac Failure

Kearns Sayre Syndrome (KSS) is a rare mitochondrial disease characterized by a primary dysfunction of the mitochondrial respiratory chain. Cardiac involvement is a poor prognostic factor of KSS. Pregnancy and delivery in a KSS patient with cardiac involvement is uncommon, and strategies for the supervision and management of this group remain unclear. Herein, we report and discuss pregnancy and delivery complicated with acute cardiopulmonary failure in a woman with KSS.

Population-Level Impact of the Guidelines Update on Patient Selection and Outcomes After Cardiac Resynchronization Therapy

OBJECTIVES

This study sought to analyze the impact of the American College of Cardiology, American Heart Association, and Heart Rhythm Society (ACC/AHA/HRS) guidelines for cardiac resynchronization therapy with defibrillator (CRT-D) update on utilization and efficacy of CRT-D.

BACKGROUND

In September 2012, the ACC/AHA/HRS guidelines for CRT-D were modified to include left bundle branch block (LBBB) as a Class I indication.

METHODS

The IBM Watson MarketScan Database was queried between January 1, 2003, and December 31, 2018, for CRT-D implants or upgrades. The primary outcome was heart failure (HF) hospitalization following left ventricular lead implant. Secondary outcomes included all-cause mortality and device-related lead revision.

RESULTS

A total of 27,238 patients were analyzed: 18,384 pre-update and 8,854 post-update. Mean age was 69 ± 11 years, 73% men, and 98% with history of HF hospitalization. The proportion of patients with LBBB increased from 29% to 55% (P < 0.001) after the update. Patients receiving CRT-D post-update demonstrated a greater prevalence of comorbidities, including atrial fibrillation (47% vs 40%; P < 0.001), diabetes mellitus (45% vs 39%; P < 0.001), chronic kidney disease (24% vs 15%; P < 0.001), and HF hospitalization in the year before CRT-D (40% vs 37%; P < 0.001). Despite greater baseline comorbidities, HF hospitalization significantly declined post-update (HR: 0.89; P < 0.001). Multivariate predictors of reduced HF hospitalization included angiotensin receptor neprilysin inhibitor prescription (HR: 0.48; P < 0.001) and presence of LBBB (HR: 0.71; P < 0.001). All-cause mortality was not significantly different between the 2 groups, and fewer lead revisions were noted post-update (0.6% vs 1.7%; P < 0.001).

CONCLUSIONS

The revised 2012 guidelines led to an increased proportion of LBBB patients receiving CRT-D at the population-level. This change was associated with reduced HF hospitalization, despite broadening therapy to patients with more comorbid conditions.

Clinical Outcomes Of Left Bundle Branch Area Pacing Compared To His Bundle Pacing

BACKGROUND

His bundle pacing (HBP) is the most physiologic form of pacing and has been associated with reduced risk for heart failure hospitalization (HFH) and mortality compared to right ventricular pacing. Left bundle branch area pacing (LBBAP) is a safe and effective alternative option for patients needing ventricular pacing.

OBJECTIVE

The aim of this study was to compare the clinical outcomes between LBBAP and HBP among a large cohort of patients undergoing permanent pacemaker implantation.

METHODS

This observational registry included consecutive patients with AV block/AV node ablation who underwent de novo permanent pacemaker implantations with successful LBBAP or HBP between April 2018 to October 2020. The primary outcome was the composite endpoint of time to death from any cause or HFH. Secondary outcomes included the composite endpoint among patients with prespecified ventricular pacing burden and individual outcomes.

RESULTS

The study population included 359 patients who met the inclusion criteria (163 in the HBP and 196 in the LBBAP group). Paced QRSd during LBBAP was similar to HBP (125 ± 20.2 vs 126 ± 23.5 ms, p=0.643). There were no statistically significant differences in the primary composite outcome in LBBAP (17.3%) compared to HBP (24.5%) (HR 1.15, CI 0.72-1.82, p = 0.552). Secondary outcomes of death (10 vs 17%; HR 1.3, CI 0.73-2.33, p=0.38) and HFH (10 vs 12%; HR 1.02,CI 0.54-1.94, p=0.94) were not different among both groups.

CONCLUSIONS

There were no statistically significant differences in the clinical outcomes of death or HFH in LBBAP when compared to HBP. This article is protected by copyright. All rights reserved.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Complications and Mortality Following CRT-D Versus ICD Implants in Older Medicare Beneficiaries With Heart Failure

OBJECTIVES

This study sought to assess the comparative effectiveness of cardiac resynchronization therapy with defibrillator (CRT-D) over implantable cardioverter-defibrillator (ICD) alone in older Medicare patients with heart failure with reduced ejection fraction (HFrEF).

BACKGROUND

Despite growing numbers of older patients with HFrEF, the benefits of cardiac resynchronization therapy (CRT) in this group are largely unknown.

METHODS

A cohort of fee-for-service Medicare beneficiaries ≥65 years of age with HFrEF and enrolled in Medicare Part D who underwent CRT-D or ICD implantation from January 2008 to August 2015 was identified. Beneficiaries were divided by age (65-74, 75-84, and 85+ years), and outcomes were compared between the CRT-D and ICD groups after inverse probability weighting.

RESULTS

Compared with the ICD group, the CRT-D group was older and more likely to be White, be female, and have left bundle branch block. After weighting, overall complications were high across age and device groups (14%-20%). The 1-year mortality was high across all groups. In the 2 oldest age strata, the hazard of death was lower in the CRT-D group (HR: 0.90; 95% CI: 0.86-0.95 and HR: 0.81; 95% CI: 0.72-0.90, respectively; P < 0.001); the hazard of heart failure hospitalization was lower for CRT-D vs ICD in the 85+ years age group (HR: 0.82; 95% CI: 0.74-0.92; P < 0.001).

CONCLUSIONS

In older Medicare beneficiaries undergoing ICD with or without CRT, complications and 1-year mortality were high. Compared with ICD alone, CRT-D was associated with a lower hazard of mortality in patients ≥74 years of age and lower hazard of HF hospitalization in those ≥85 years of age. These findings support the use of CRT in eligible older patients undergoing ICD implantation.

Vectorcardiographic QRS area as a predictor of response to cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) is a good treatment for heart failure accompanied by ventricular conduction abnormalities. Current ECG criteria in international guidelines seem to be suboptimal to select heart failure patients for CRT. The criteria QRS duration and left bundle branch block (LBBB) QRS morphology insufficiently detect left ventricular activation delay, which is required for benefit from CRT. Additionally, there are various definitions for LBBB, in which each one has a different association with CRT benefit and is prone to subjective interpretation. Recent studies have shown that the objectively measured vectorcardiographic QRS area identifies left ventricular activation delay with higher accuracy than any of the current ECG criteria. Indeed, various studies have consistently shown that a high QRS area prior to CRT predicts both echocardiographic and clinical improvement after CRT. The beneficial relation of QRS area with CRT-outcome was largely independent from QRS morphology, QRS duration, and patient characteristics known to affect CRT-outcome including ischemic etiology and sex. On top of QRS area prior to CRT, the reduction in QRS area after CRT further improves benefit. QRS area is easily obtainable from a standard 12-lead ECG though it currently requires off-line analysis. Clinical applicability will be significantly improved when QRS area is automatically determined by ECG equipment.

Clinical outcomes of left bundle branch area pacing compared to right ventricular pacing: Results from the Geisinger-Rush Conduction System Pacing Registry

BACKGROUND

Left bundle branch area pacing (LBBAP) has been shown to be a feasible option for patients requiring ventricular pacing.

OBJECTIVE

The purpose of this study was to compare clinical outcomes between LBBAP and RVP among patients undergoing pacemaker implantation METHODS: This observational registry included patients who underwent pacemaker implantations with LBBAP or RVP for bradycardia indications between April 2018 and October 2020. The primary composite outcome included all-cause mortality, heart failure hospitalization (HFH), or upgrade to biventricular pacing. Secondary outcomes included the composite endpoint among patients with a prespecified burden of ventricular pacing and individual outcomes.

RESULTS

A total of 703 patients met inclusion criteria (321 LBBAP and 382 RVP). QRS duration during LBBAP was similar to baseline (121 ± 23 ms vs 117 ± 30 ms; P = .302) and was narrower compared to RVP (121 ± 23 ms vs 156 ± 27 ms; P <.001). The primary composite outcome was significantly lower with LBBAP (10.0%) compared to RVP (23.3%) (hazard ratio [HR] 0.46; 95%T confidence interval [CI] 0.306-0.695; P <.001). Among patients with ventricular pacing burden >20%, LBBAP was associated with significant reduction in the primary outcome compared to RVP (8.4% vs 26.1%; HR 0.32; 95% CI 0.187-0.540; P <.001). LBBAP was also associated with significant reduction in mortality (7.8% vs 15%; HR 0.59; P = .03) and HFH (3.7% vs 10.5%; HR 0.38; P = .004).

CONCLUSION

LBBAP resulted in improved clinical outcomes compared to RVP. Higher burden of ventricular pacing (>20%) was the primary driver of these outcome differences.

The importance of early evaluation after cardiac resynchronization therapy to redefine response: Pooled individual patient analysis from 5 prospective studies

BACKGROUND

Cardiac resynchronization therapy (CRT) reduces mortality and improves outcomes in appropriately selected patients with heart failure (HF); however, response may vary.

OBJECTIVE

We sought to correlate 6-month CRT response assessed by clinical composite score (CCS) and left ventricular end-systolic volume index (LVESVi) with longer-term mortality and HF hospitalizations.

METHODS

Individual patient data from 5 prospective CRT studies-MIRACLE, MIRACLE ICD, InSync III Marquis, PROSPECT, and Adaptive CRT-were pooled. Classification of CRT response status using CCS and LVESVi were made at 6 months. Kaplan-Meier analyses were used to assess time to mortality. Cox proportional hazards regression models were used to compute hazard ratios (HRs) for the 3 levels of CRT response: improved, stabilized, and worsened. Adjusted models controlled for baseline factors known to influence both CRT response and mortality. HF-related hospitalization was compared between CRT response categories using incidence rate ratios.

RESULTS

Among a total of 1603 patients, 1426 and 1165 were evaluated in the CCS and LVESVi outcome assessments, respectively. Mortality was significantly lower for patients in the improved (CCS: HR 0.22; 95% confidence interval [CI] 0.15-0.31; LVESVi: HR 0.40; 95% CI 0.27-0.60) and stabilized (CCS: HR 0.38; 95% CI 0.24-0.61; LVESVi: HR 0.41; 95% CI 0.25-0.68) groups than in the worsened group for both measures after adjusting for potential confounders.

CONCLUSION

Patients with a worsened CRT response status have a high mortality rate and HF hospitalizations. Stabilized patients have a more favorable prognosis than do worsened patients and thus should not be considered CRT nonresponders.

Association between vectorcardiographic QRS area and incident heart failure diagnosis and mortality among patients with left bundle branch block: A register-based cohort study

BACKGROUND

QRS duration and morphology including left bundle branch block (LBBB) are the most widely used electrocardiogram (ECG) markers for assessing ventricular dyssynchrony and predicting heart failure (HF). However, the vectorcardiographic QRS area may more accurately identify delayed left ventricular activation and HF development.

OBJECTIVE

We investigated the association between QRS area and incident HF risk in patients with LBBB.

METHODS

By crosslinking data from Danish nationwide registries, we identified patients with a first-time digital LBBB ECG between 2001 and 2015. The vectorcardiographic QRS area was derived from a 12‑lead ECG using the Kors transformation method and grouped into quartiles. The endpoint was a composite of HF diagnosis, filled prescriptions for loop diuretics, or death from HF. Cause-specific multivariable Cox regression was used to compute hazard ratios(HR) with 95% confidence intervals(CI).

RESULTS

We included 3316 patients with LBBB free from prior HF-related events (median age, 72 years; male, 40%). QRS area quartiles comprised Q1, 36-98 μVs; Q2, 99-119 μVs; Q3, 120-145 μVs; and Q4, 146-295 μVs. During a 5-year follow-up, 31% of patients reached the composite endpoint, with a rate of 39% in the highest quartile Q4. A QRS area in quartile Q4 was associated with increased hazard of the composite endpoint (HR:1.48, 95%CI:1.22-1.80) compared with Q1.

CONCLUSIONS

Among primary care patients with newly discovered LBBB, a large vectorcardiographic QRS area (146-295 μVs) was associated with an increased risk of incident HF diagnosis, filling prescriptions for loop diuretics, or dying from HF within 5-years.

Longitudinal Outcomes Associated With Non-Evidence-Based Implantable Cardioverter-Defibrillators Among Medicare Beneficiaries (From the National Cardiovascular Data Registry)

Primary prevention implantable cardioverter-defibrillators (ICDs) in patients with recent myocardial infarction or coronary revascularization and those with newly diagnosed or severe heart failure (HF) are considered non-evidence-based, as defined by pivotal randomized clinical trials. Although non-evidence-based ICDs have been associated previously with greater risk of in-hospital adverse events, longitudinal outcomes are not known. We used Medicare-linked data from the National Cardiovascular Data Registry's ICD Registry to identify patients discharged alive following first-time primary prevention ICD implantations performed between 2010 and 2013. We compared longitudinal outcomes, including all-cause mortality and all-cause hospital readmission among patients receiving non-evidence-based versus evidence-based ICDs, up to 4.75 years after implantation, using multivariable time-to-event analyses. Of 71,666 ICD implantations, 9,609 (13.4%) were classified as non-evidence-based. Compared to patients receiving evidence-based ICDs, non-evidence-based ICD recipients had greater mortality risk at 90 days (HR = 1.44, CI: 1.37 - 1.52, p <0.0001) and at 1 year (HR = 1.19, CI: 1.15 - 1.24, p <0.0001), but similar mortality risk at 3 years (HR = 1.03, CI: 0.98 - 1.08, p = 0.2630). Risk of all-cause hospitalization was higher in patients with non-evidence-based ICDs at 90 days (HR = 1.17, CI: 1.14 - 1.20, p <0.0001), but the difference diminished at 1 year (HR = 1.04, CI 1.00 - 1.07, p = 0.0272) and at 3 years (HR = 0.94, CI: 0.90 - 0.99, p = 0.0105). In conclusion, among patients undergoing primary prevention ICD implantations between 2010 and 2013, those with non-evidence-based ICDs were at increased risk of mortality and readmission during longitudinal follow-up. Differences in the risk of mortality and hospitalization were highest in the first year following device implantation.

Using Machine-Learning for Prediction of the Response to Cardiac Resynchronization Therapy: The SMART-AV Study

OBJECTIVES

This study aimed to apply machine learning (ML) to develop a prediction model for short-term cardiac resynchronization therapy (CRT) response to identifying CRT candidates for early multidisciplinary CRT heart failure (HF) care.

BACKGROUND

Multidisciplinary optimization of cardiac resynchronization therapy (CRT) delivery can improve long-term CRT outcomes but requires substantial staff resources.

METHODS

Participants from the SMART-AV (SmartDelay-Determined AV Optimization: Comparison of AV Optimization Methods Used in Cardiac Resynchronization Therapy [CRT]) trial (n = 741; age: 66 ± 11 years; 33% female; 100% New York Heart Association HF class III-IV; 100% ejection fraction ≤35%) were randomly split into training/testing (80%; n = 593) and validation (20%; n = 148) samples. Baseline clinical, electrocardiographic, echocardiographic, and biomarker characteristics, and left ventricular (LV) lead position (43 variables) were included in 8 ML models (random forests, convolutional neural network, lasso, adaptive lasso, plugin lasso, elastic net, ridge, and logistic regression). A composite of freedom from death and HF hospitalization and a >15% reduction in LV end-systolic volume index at 6 months after CRT was the end point.

RESULTS

The primary end point was met by 337 patients (45.5%). The adaptive lasso model was the most more accurate (area under the receiver operating characteristic curve: 0.759; 95% confidence interval [CI]: 0.678-0.840), well calibrated, and parsimonious (19 predictors; nearly half potentially modifiable). Participants in the 5th quintile compared with those in the 1st quintile of the prediction model had 14-fold higher odds of composite CRT response (odds ratio: 14.0; 95% CI: 8.0-14.4). The model predicted CRT response with 70% accuracy, 70% sensitivity, and 70% specificity, and should be further validated in prospective studies.

CONCLUSIONS

ML predicts short-term CRT response and thus may help with CRT procedure and early post-CRT care planning. (SmartDelay-Determined AV Optimization: A Comparison of AV Optimization Methods Used in Cardiac Resynchronization Therapy [CRT] [SMART-AV]; NCT00677014).

His bundle pacing capture threshold stability during long-term follow-up and correlation with lead slack

AIMS

His bundle pacing (HBP) is the most physiologic form of pacing. Long-term HBP capture threshold stability and its relation to lead characteristics at the time of implantation have not been adequately described. The aim of this study was to characterize HB capture threshold in follow-up and to identify potential lead characteristics predictive of lead capture instability.

METHODS AND RESULTS

Consecutive patients with successful HBP for bradycardia indications were identified from the Geisinger HBP registry. His bundle capture thresholds, baseline comorbidities, and radiographic lead slack characteristics were analysed. An increase in HB capture threshold ≥1 V above implant values at any time during follow-up was tracked. Forty-four of the 294 studied (15%) experienced HB capture threshold increase by ≥ 1 V. Threshold increase was seen early (41% by 8 weeks, 66% by 1 year). Eighteen (6%) patients required lead revision in follow-up. Abnormal slack shape was associated with a trend toward capture threshold increase [hazard ratio (HR) 2.07; 95% confidence interval (CI) 0.9-4.6; P = 0.08]. Non-perpendicular angle of lead insertion on radiography was associated with the capture threshold increase (HR 2.81, 95% CI 1.4-5.8; P < 0.01).

CONCLUSION

His bundle capture threshold remains stable in the majority (85%) of patients. Implant characteristics may predict the threshold rise. Further evaluation of the aetiology of threshold increase and design changes in lead and delivery systems may lead to chronically stable capture thresholds.

Clinical Significance of Global Wasted Work in Patients with Heart Failure Receiving Cardiac Resynchronization Therapy

BACKGROUND

The relationship between myocardial work assessment using pressure-strain loops by echocardiography before cardiac resynchronization therapy (CRT) and response to CRT has been recently revealed. Among myocardial work parameters, the impact of left ventricular myocardial global wasted work (GWW) on response to CRT and outcome following CRT has been seldom studied. Hence, the authors evaluated the relationship between preprocedural GWW and outcome in a large prospective cohort of patients with heart failure (HF) and reduced ejection fraction receiving CRT.

METHODS

The study included 249 patients with HF. Myocardial work indices including GWW were calculated using speckle-tracking strain two-dimensional echocardiography using pressure-strain loops. End points of the study were (1) response to CRT, defined as left ventricular reverse remodeling and/or absence of hospitalization for HF, and (2) all-cause death during follow-up.

RESULTS

Median follow-up duration was 48 months (interquartile range, 43-54 months). Median preoperative GWW was 281 mm Hg% (interquartile range, 184-388 mm Hg%). Preoperative GWW was associated with CRT response (area under the curve, 0.74; P < .0001), and a 200 mm Hg% threshold discriminated CRT nonresponders from responders with 85% specificity and 50% sensitivity, even after adjustment for known predictors of CRT response (adjusted odds ratio, 4.03; 95% CI, 1.91-8.68; P < .001). After adjustment for established predictors of outcome in patients with HF with reduced ejection fraction receiving CRT, GWW < 200 mm Hg% remained associated with a relative increased risk for all-cause death compared with GWW ≥ 200 mm Hg% (adjusted hazard ratio, 2.0; 95% CI, 1.1-3.9; P = .0245). Adding GWW to a baseline model including known predictors of outcome in CRT resulted in an improvement of this model (χ² to improve 4.85, P = .028). The relationship between GWW and CRT response and outcome was stronger in terms of size effect and statistical significance than for other myocardial work indices.

CONCLUSIONS

Low preoperative GWW (<200 mm Hg%) is associated with absence of CRT response in CRT candidates and with a relative increased risk for all-cause death. GWW appears to be a promising parameter to improve selection for CRT of patients with HF with reduced ejection fraction.

Conduction System Pacing for Cardiac Resynchronisation

Conduction system pacing (CSP) is a technique of pacing that involves implantation of permanent pacing leads along different sites of the cardiac conduction system and includes His bundle pacing and left bundle branch pacing. There is an emerging role for CSP to achieve cardiac resynchronisation in patients with heart failure with reduced ejection fraction and inter-ventricular dyssynchrony. In this article, the authors review these strategies for resynchronisation and the available data on the use of CSP in overcoming dyssynchrony.

Cardiac T-Tubule cBIN1-Microdomain, a Diagnostic Marker and Therapeutic Target of Heart Failure

Since its first identification as a cardiac transverse tubule (t-tubule) protein, followed by the cloning of the cardiac isoform responsible for t-tubule membrane microdomain formation, cardiac bridging integrator 1 (cBIN1) and its organized microdomains have emerged as a key mechanism in maintaining normal beat-to-beat heart contraction and relaxation. The abnormal remodeling of cBIN1-microdomains occurs in stressed and diseased cardiomyocytes, contributing to the pathophysiology of heart failure. Due to the homeostatic turnover of t-tubule cBIN1-microdomains via microvesicle release into the peripheral circulation, plasma cBIN1 can be assayed as a liquid biopsy of cardiomyocyte health. A new blood test cBIN1 score (CS) has been developed as a dimensionless inverse index derived from plasma cBIN1 concentration with a diagnostic and prognostic power for clinical outcomes in stable ambulatory patients with heart failure with reduced or preserved ejection fraction (HFrEF or HFpEF). Recent evidence further indicates that exogenous cBIN1 introduced by adeno-associated virus 9-based gene therapy can rescue cardiac contraction and relaxation in failing hearts. The therapeutic potential of cBIN1 gene therapy is enormous given its ability to rescue cardiac inotropy and provide lusitropic protection in the meantime. These unprecedented capabilities of cBIN1 gene therapy are shifting the current paradigm of therapy development for heart failure, particularly HFpEF.

Multipoint Pacing with Fusion-optimized Cardiac Resynchronization Therapy: Using It All to Narrow QRS Duration

Adaptive atrioventricular (AV)-shortening algorithms have achieved QRS duration (QRSd) narrowing in traditional cardiac resynchronization therapy (CRT) patients. Multipoint pacing (MPP) has also demonstrated benefit in this population. An additional site of activation via intrinsic conduction of the septum may further contribute to CRT; however, the incorporation of all strategies together has yet to be explored. We therefore developed and tested a method combining MPP-CRT and controlled septal contribution to create a multifuse pacing (MFP) technique, establishing four ventricular activation sites for CRT patients using measurements from intracardiac electrograms (EGMs) and incorporating an AV-delay shortening algorithm (SyncAV™; Abbott Laboratories, Chicago, IL, USA) to narrow the QRSd. Patients in sinus rhythm with an AV conduction time of less than 350 ms were included in this analysis and were further stratified by strictly defined left bundle branch block (sLBBB) or nonspecific intraventricular conduction delay (IVCD). EGM-based measurements to determine the QRS septal onset to right ventricular (RV) time (SRAT) and the left ventricular (LV) to RV pacing conduction time were collected and applied to a formula to facilitate MFP. QRSd was compared between before and after programming. A total of 22 patients (19 men and three women) with similar baseline characteristics were compared (all values in mean ± standard deviation). The overall baseline QRSd of 153.31 ± 24.60 ms was decreased to 115.31 ± 16.31 ms after MFP programming (p < 0.0001). The measured SRAT was 59.40 ± 28.49 ms, resulting in a negative AV offset of −20.0 ± 24.97 ms. Patients in the sLBBB group (n = 7) were aged 67.8 ± 13.3 years and had a QRSd of 168.85 ± 27.29 ms that decreased to 113 ± 16.69 ms for a reduction of 55.42 ± 19.3 ms or 32.1% (p = 0.0003). In the IVCD group (n = 15), the baseline QRSd of 146.06 ± 20.29 ms was decreased to 116 ± 16.66 ms for a reduction of 30.07 ± 16.41 ms or 20.62% (p = 0.0001). When comparing the sLBBB and IVCD groups, the sLBBB group was favored by a reduction of 25.35 ms (p = 0.00046). Ultimately, MFP achieved statistically significant reductions in QRSd in all patients tested in this analysis. The benefit was also significantly better in the sLBBB group as compared with in the IVCD group.

Left Ventricular Stimulation With Electrical Latency Predicts Mortality in Patients Undergoing Cardiac Resynchronization Therapy

OBJECTIVES

This study sought to evaluate the prognostic value of the time interval from left ventricular (LV) pacing to the earliest onset of QRS complex (S-QRS) for long-term clinical outcomes in patients who underwent cardiac resynchronization therapy (CRT).

BACKGROUND

The electrical latency during LV pacing evaluated by S-QRS is associated with local tissue property, and the S-QRS ≥37 ms has been previously proposed as an independent predictor of mechanical response to CRT.

METHODS

This study included 82 consecutive patients with heart failure with reduced LV ejection fraction (≤35%) and a wide QRS complex (≥120 ms) who underwent CRT. Patients were divided into a short S-QRS group (SS-QRS; <37 ms) and a long S-QRS group (LS-QRS; ≥37 ms). The primary endpoint was total mortality, including LV assist device implantation or heart transplantation, whereas the secondary endpoint was total mortality or HF hospitalization.

RESULTS

S-QRS was 25.9 ± 5.3 ms in SS-QRS and 51.5 ± 13.7 ms in LS-QRS (p < 0.01), and baseline QRS duration and electrical activation at the LV pacing site (i.e., Q-LV) were similar. During mean follow-up of 44.5 ± 21.1 months, 24 patients (29%) reached the primary endpoint, whereas the secondary endpoints were observed in 47 patients (57%). LS-QRS had significantly worse event-free survival for both endpoints. LS-QRS was an independent predictor of total mortality (hazard ratio: 2.6; 95% confidence interval: 1.11 to 6.12; p = 0.03) and the secondary composite events (hazard ratio: 2.4; 95% confidence interval: 1.31 to 4.33; p < 0.01).

CONCLUSIONS

The S-QRS ≥37 ms at the LV pacing site was a significant predictor of total mortality and HF hospitalization. S-QRS-guided optimal LV lead placement is critical in patients who receive CRT.

Long-Term Outcomes in Patients With a Left Ejection Fraction ≤15% Undergoing Cardiac Resynchronization Therapy

OBJECTIVES

This study aimed to determine the long-term outcomes and predictors of left ventricular (LV) ejection fraction (LVEF) improvement in patients with severe cardiomyopathies undergoing cardiac resynchronization therapy (CRT).

BACKGROUND

Whether patients with severe LV dysfunction benefit from CRT or have reached a point in disease severity past the point at which CRT is beneficial is unknown.

METHODS

We collected clinical and echocardiographic data on 420 patients with an LVEF of ≤15% and a QRS duration of ≥120 ms undergoing CRT at the Cleveland Clinic and 2 hospitals in the Johns Hopkins Health System between April 2003 and May 2014. Multivariate models were created to determine factors associated with response to CRT, defined as an absolute improvement in LVEF of >5% and survival free of LVAD and heart transplant. Procedure-related deaths were also collected.

RESULTS

A total of 298 patients had pre- and appropriately timed post-CRT echocardiograms, of whom 145 (48.7%) met the criteria for response. In multivariate analysis, LV size and left bundle branch block (LBBB) were associated with response. Among the most dilated quintile (LV end-diastolic diameter [LVEDD] of >7.8 cm), 30.4% met the criteria for response. In multivariate analysis, smaller LV end-diastolic dysfunction and presence of LBBB were associated with improved survival free of heart failure and LVAD over a mean follow-up period of 5.2 years. There were no procedure-related deaths.

CONCLUSIONS

Patients with severe LV dysfunction respond to CRT, although at a lower rate compared to traditional CRT candidates. Smaller LV size and LBBB are important predictors of positive outcomes in this population. Even among the most dilated patients, 30.4% realized a meaningful improvement in LVEF with CRT. The CRT implant procedure itself appears well tolerated.

High-rate pacing guided by short-term variability of repolarization prevents imminent ventricular arrhythmias automatically by an implantable cardioverter-defibrillator in the chronic atrioventricular block dog model

BACKGROUND

The anesthetized, complete chronic atrioventricular block (CAVB) dog model allows reproducible inducibility of torsades de pointes (TdP) arrhythmias due to ventricular remodeling and after a challenge with an I_Kr blocker. High-rate pacing (HRP) prevents ventricular arrhythmias but has long-term detrimental effects on cardiac function when applied continuously. Temporal dispersion of repolarization, quantified as short-term variability (STV), increases before ventricular arrhythmias and has been proposed as a marker to guide HRP.

OBJECTIVE

The purpose of this proof-of-principle study was to show that automatically determined STV can guide HRP to prevent imminent ventricular arrhythmias.

METHODS

Eight CAVB dogs were implanted with an implantable cardioverter-defibrillator (ICD) with software to automatically determine STV (STV_ICD) in real time. During HRP, STV was measured offline from right ventricular (RV) electrograms (EGMs) and left ventricular (LV) monophasic action potential durations (MAPDs) (STV_{RV,EGM/LV,MAPD}). The CAVB dogs were challenged twice with dofetilide (0.025 mg/kg intravenously over 5 minutes or until the first TdP). In experiment 1, the individual STV_ICD threshold before the first arrhythmic event was determined and programmed into the ICD. In experiment 2, HRP with 100 bpm was initiated automatically once the STV_ICD threshold was reached.

RESULTS

In experiment 1, 8 of 8 dogs had repetitive TdP, and STV_ICD increased from 0.96 ± 0.42 ms to 2.10 ± 1.26 ms (P <.05). In experiment 2, all dogs reached the STV threshold. HRP decreased STV_{RV,EGM/LV,MAPD} from 2.02 ± 1.12 ms to 0.78 ± 0.28 ms, which was accompanied by prevention of TdP in 7 of 8 dogs.

CONCLUSION

STV can guide HRP automatically by an ICD to prevent ventricular arrhythmias.

Trends of Acute Kidney Injury Requiring Dialysis Among Hospitalized Patients Undergoing Invasive Electrophysiology Procedures

Electrophysiology (EP) procedures carry the risk of kidney injury due to contrast/hemodynamic fluctuations. We aim to evaluate the national epidemiology of acute kidney injury requiring dialysis (AKI-D) in patients undergoing EP procedures. Using the National Inpatient Sample, we included 2,747,605 adult hospitalizations undergoing invasive diagnostic EP procedures, ablation and implantable device placement from 2006 to 2014. We examined the temporal trend of AKI-D and outcomes associated with AKI-D. The rate of AKI-D increased significantly in both diagnostic/ablation group (8-21/10,000 hospitalizations from 2006 to 2014, P = 0.02) and implanted device group (19-44/10,000 hospitalizations from 2006 to 2014, P < 0.01), but it was explained by temporal changes in demographics and comorbidities. Cardiac resynchronization therapy and pacemaker placement had higher risk of AKI-D compared to implantable cardioverter-defibrillator placement (23 vs. 31 vs. 14/10,000 hospitalizations in cardiac resynchronization therapy, pacemaker placement, and implantable cardioverter-defibrillator group, respectively). Development of AKI-D was associated with significant increase in in-hospital mortality (adjusted odds ratio, 9.6 in diagnostic/ablation group, P < 0.01; adjusted odds ratio, 5.1 in device implantation group, P < 0.01) and with longer length of stay (22.5 vs. 4.5 days in diagnostic/ablation group, 21.1 vs. 5.7 days in implanted device group) and higher cost (282,775 vs. 94,076 USD in diagnostic/ablation group, 295,660 vs. 102,007 USD in implanted device group). The incidence of AKI-D after EP procedures increased over time but largely explained by the change of demographics and comorbidities. This increasing trend, however, was associated with significant increase in resource utilization and in-hospital mortality in these patients.

How His bundle pacing prevents and reverses heart failure induced by right ventricular pacing

Ideal heart performance demands vigorous systolic contractions and rapid diastolic relaxation. These sequential events are precisely timed and interdependent and require the rapid synchronous electrical stimulation provided by the His-Purkinje system. Right ventricular (RV) pacing creates slow asynchronous electrical stimulation that disrupts the timing of the cardiac cycle and results in left ventricular (LV) mechanical asynchrony. Long-term mechanical asynchrony produces LV dysfunction, remodeling, and clinical heart failure. His bundle pacing preserves synchronous electrical and mechanical LV function, prevents or reverses RV pacemaker-induced remodeling, and reduces heart failure.

Myocardial Strain in the Assessment of Patients With Heart Failure: A Review

Importance

The cornerstones of imaging in heart failure (HF) are the measurement of systolic and diastolic function and left ventricular (LV) filling pressure.

Observations

Ejection fraction and the assessment of LV filling pressure and diastolic dysfunction using the ratio of early transmitral flow and LV relaxation (E/e') are conventional imaging markers of LV function. Despite their extensive use in HF guidelines, both have significant detractions, especially in an era when HF with preserved ejection fraction is becoming the dominant presentation. In contrast, strain imaging has provided a new window into myocardial mechanics. Myocardial strain is now well validated, robust, and can easily be performed on most modern echocardiography machines. This Review summarizes the evidence in 9 situations across the stages of HF where LV global longitudinal strain and other strain parameters may provide information on risk prediction, diagnosis, assessment of treatment response, and follow-up.

Conclusions and Relevance

The evolution of myocardial deformation imaging from research tool to clinical practice will provide clinicians with a useful additional imaging parameter to facilitate the assessment and risk evaluation of patients with HF.

Analysis of Temporal Trends and Variation in the Use of Defibrillation Testing in Contemporary Practice

IMPORTANCE

Defibrillation testing (DFT) is performed during implantable cardioverter-defibrillator (ICD) implantation to assess the capacity of the device to detect and terminate ventricular arrhythmias. However, DFT can result in complications and omission of its use has been shown to be safe.

OBJECTIVE

To describe temporal trends and variation in the use of DFT in contemporary practice in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cross-sectional study used data from the National Cardiovascular Data Registry ICD Registry. A total of 499 211 patients from 1794 different facilities undergoing first-time ICD implantation from April 2010 to December 2015 were included. Data analysis was performed from May 20, 2015, to August 15, 2019.

EXPOSURE

Defibrillation testing was assessed using the National Cardiovascular Data Registry ICD Registry.

MAIN OUTCOMES AND MEASURES

Defibrillation testing rates and median odds ratios (MORs) were assessed over time. The MOR represents the odds that a randomly selected patient receiving testing at a hospital with high testing rates would be tested compared with if he or she had received care at a hospital with low testing rates.

RESULTS

Of the 499 211 patients from 1794 different facilities included in this analysis, the mean (SD) age of the population was 65.5 (13.4) years and 356 681 patients (71.4%) were men. The use of DFT declined from 71.6% in the first calendar quarter of 2010 to 36.4% in the fourth quarter of 2015 (P < .001). Patients undergoing DFT were more likely than those without testing to have ischemic heart disease (170 569 [58.1%] vs 116 295 [56.6%]), ventricular tachycardia (91 500 [31.2%] vs 58 949 [28.7%]), and less advanced heart failure (New York Heart Association class I and II, 153 188 [52.2%] vs 91 215 [44.4%]) (P < .001 for all). The MOR for the use of defibrillation testing was 3.78 (95% CI, 3.54-4.03) in 2010, increasing to 6.05 (95% CI, 5.61-6.52) in 2015, indicating that by 2015 a randomly selected patient receiving testing at a hospital with high testing rates would have a 6-fold higher odds of being tested than if they had received care at a hospital with low testing rates.

CONCLUSIONS AND RELEVANCE

Defibrillation testing at the time of ICD placement in the United States may have declined over time; however, institutional variation in its use appears to be marked and increased. This variability in the reduced use of defibrillation testing could reflect differences in individual or institutional cultures of practice.

Impaired Recovery of Left Ventricular Function in Patients With Cardiomyopathy and Left Bundle Branch Block

BACKGROUND

Patients with left bundle branch block (LBBB) often respond to cardiac resynchronization therapy (CRT) with left ventricular ejection fraction (LVEF) improvement. Guideline-directed medical therapy (GDMT), not CRT, is first-line therapy for patients with reduced LVEF with LBBB. However, there are little data on how patients with reduced LVEF and LBBB respond to GDMT.

OBJECTIVES

This study examined patients with cardiomyopathy and sought to assess rates of LVEF improvement for patients with LBBB compared to other QRS morphologies.

METHODS

Using data from the Duke Echocardiography Laboratory Database, the study identified patients with baseline electrocardiography and LVEF ≤35% who had a follow-up LVEF 3 to 6 months later. The study excluded patients with severe valve disease, a cardiac device, left ventricular assist device, or heart transplant. QRS morphology was classified as LBBB, QRS duration <120 ms (narrow QRS duration), or a wide QRS duration ≥120 ms but not LBBB. Analysis of variance testing compared mean change in LVEF among the 3 groups with adjustment for significant comorbidities and GDMT.

RESULTS

There were 659 patients that met the criteria: 111 LBBB (17%), 59 wide QRS duration ≥120 ms but not LBBB (9%), and 489 narrow QRS duration (74%). Adjusted mean increase in LVEF over 3 to 6 months in the 3 groups was 2.03%, 5.28%, and 8.00%, respectively (p < 0.0001). Results were similar when adjusted for interim revascularization and myocardial infarction. Comparison of mean LVEF improvement between patients with LBBB on GDMT and those not on GDMT showed virtually no difference (3.50% vs. 3.44%). The combined endpoint of heart failure hospitalization or mortality was highest for patients with LBBB.

CONCLUSIONS

LBBB is associated with a smaller degree of LVEF improvement compared with other QRS morphologies, even with GDMT. Some patients with LBBB may benefit from CRT earlier than guidelines currently recommend.

Upper extremity deep venous thrombosis and stenosis after implantation of pacemakers and defibrillators; A prospective study

BACKGROUND

Obstruction of the access vein following cardiac pacemaker and defibrillator implantation is a common complication. However, the exact incidence and contributing risk factors are unknown. The aim of this study is to determine the incidence and analyze the contribution of each risk factor.

METHODS

57 consecutive patients candidate for their first transvenous pacemaker, implantable cardioverter-defibrillator (ICD), or cardiac resynchronization therapy device implantation were enrolled. After implantation, venography of the ipsilateral peripheral arm was performed. Patients underwent their second venography after the follow-up period of 3 to 6 months.

RESULTS

42 patients (13 females, mean age 59.71 ± 12.33) completed the study. The followup venography showed significant venous obstruction (more than 50%) in 9 (21%) patients, but in none of the individuals, venography revealed total occlusion of the veins. Patients with obstruction had more leads in their veins (2.56 ± 0.53 vs 1.58 ± 0.71, P = 0.001). Venous obstruction was significantly more prevalent in patients with implanted cardiac resynchronization therapy device compared with an ICD or pacemaker (p = 0. 01). Age, gender, diabetes mellitus, hypertension, ischemic heart disease and antiplatelet consumption did not reveal any other contribution to the risk of thrombosis. In multivariate analysis, total lead number was a positive predictor for venous occlusion (P = 0.015, OR:19.2, and CI: 1.7-207.1).

CONCLUSION

Venous obstruction is relatively frequent after pacemaker or ICD implantation. This study also shows that pacemaker and ICD leads have a similar risk for lead-related venous obstruction. However, patients with multiple leads are associated with an increased risk.

Immediate clinical outcomes of left bundle branch area pacing vs conventional right ventricular pacing

BACKGROUND

Left bundle branch area pacing (LBBaP) is a new physiological pacing strategy that produces comparable clinical effects to His bundle pacing (HBP).

OBJECTIVE

The purpose of this study was to investigate the immediate clinical outcomes of LBBaP vs RVP.

METHODS AND RESULTS

From April 2018 to September 2018, we included 44 patients under continuous pacemaker implantation. Patients were randomly divided into the LBBaP group and conventional RVP group. Compared to the RVP group, the LBBaP group displayed significantly increased operative (90.10 ± 19.68 minutes vs 61.57 ± 6.62 minutes, P < .001) and X-ray exposure times (15.55 ± 5.62 minutes vs 4.67 ± 2.06 minutes, P < .001). The lead threshold of the LBBaP group was increased (0.68 ± 0.20 mV vs 0.51 ± 0.0 mV, P = .001), while the R-wave amplitude and ventricular impedance did not significantly differ between the two groups. The conventional RVP procedure significantly widened the QRS complex (93.62 ± 8.28 ms vs 135.19 ± 12.21 ms, P = .001), whereas the LBBaP had no effect on QRS complex (130.13 ± 43.30 ms vs 112.63 ± 12.14 ms, P = .904). Furthermore, the LBBaP procedure significantly narrowed the QRS complex in patients with left bundle branch block (LBBB) (168.43 ± 38.870 ms vs 119.86 ± 6.69 ms, P = .019).

CONCLUSION

LBBaP is a new physiological, safe and effective pacing procedure with a high overall success rate. Compared to conventional RVP, LBBaP can correct LBBB, thereby improving cardiac electrical dyssynchrony.

Left bundle branch block-induced cardiomyopathy: a diagnostic proposal for a poorly explored pathological entity

Despite being increasingly recognized as a specific disease, at the present time left bundle branch block (LBBB)-induced cardiomyopathy is neither formally included among unclassified cardiomyopathies nor among the acquired/non-genetic forms of dilated cardiomyopathy (DCM). Currently, a post-hoc diagnosis of LBBB-induced cardiomyopathy is possible when evaluating patients' response to cardiac resynchronization therapy (CRT). However, an early detection of a LBBB-induced cardiomyopathy could have significant clinical and therapeutic implications. Patients with the aforementioned form of dyssynchronopathy may benefit from early CRT and overall prognosis might be better as compared to patients with a primary muscle cell disorder (i.e. "true" DCM). The real underlying mechanisms, the possible genetic background as well as the early identification of this specific form of DCM remain largely unknown. In this review the complex relationship between LBBB and left ventricular non-ischaemic dysfunction is described. Furthermore, a multiparametric approach based on clinical, electrocardiographic and imaging red flags, is provided in order to allow an early detection of the LBBB-induced cardiomyopathy.

Clinical value of different QRS-T angle expressions

Aims

Increased spatial angle between QRS complex and T wave loop orientations has repeatedly been shown to predict cardiac risk. However, there is no consensus on the methods for the calculation of the angle. This study compared the reproducibility and predictive power of three most common ways of QRS-T angle assessment.

Methods and results

Electrocardiograms of 352 healthy subjects, 941 survivors of acute myocardial infarction (MI), and 605 patients recorded prior to the implantation of automatic defibrillator [implantable cardioverter defibrillator (ICD)] were used to obtain QRS-T angle measurements by the maximum R to T (MRT), area R to T (ART), and total cosine R to T (TCRT) methods. The results were compared in terms of physiologic reproducibility and power to predict mortality in the cardiac patients during 5-year follow-up. Maximum R to T results were significantly less reproducible compared to the other two methods. Among both survivors of acute MI and ICD recipients, TCRT method was statistically significantly more powerful in predicting mortality during follow-up. Among the acute MI survivors, increased spatial QRS-T angle (TCRT assessment) was particularly powerful in predicting sudden cardiac death with the area under the receiver operator characteristic of 78% (90% confidence interval 63-90%). Among the ICD recipients, TCRT also predicted mortality significantly among patients with prolonged QRS complex duration when the spatial orientation of the QRS complex is poorly defined.

Conclusion

The TCRT method for the assessment of spatial QRS-T angle appears to offer important advantages in comparison to other methods of measurement. This approach should be included in future clinical studies of the QRS-T angle. The TCRT method might also be a reasonable candidate for the standardization of the QRS-T angle assessment.

Clinical Outcomes of Selective Versus Nonselective His Bundle Pacing

OBJECTIVES

The aim of the study was to evaluate the clinical outcomes of nonselective (NS) His bundle pacing (HBP) compared with selective (S) HBP.

BACKGROUND

HBP is the most physiologic form of ventricular pacing. NS-HBP results in right ventricular septal pre-excitation due to fusion with myocardial capture in addition to His bundle capture resulting in widened QRS duration compared with S-HBP wherein there is exclusive His bundle capture and conduction.

METHODS

The Geisinger and Rush University HBP registries comprise 640 patients who underwent successful HBP. Our study population included 350 consecutive patients treated with HBP for bradyarrhythmic indications who demonstrated ≥20% ventricular pacing burden 3 months post-implantation. Patients were categorized into S-HBP or NS-HBP based on QRS morphology (NS-HBP n = 232; S-HBP n = 118) at the programmed output at the 3-month follow-up. The primary analysis outcome was a combined endpoint of all-cause mortality or heart failure hospitalization.

RESULTS

The NS-HBP group had a higher number of men (64% vs. 50%; p = 0.01), higher incidence of infranodal atrioventricular block (40% vs. 9%; p < 0.01), ischemic cardiomyopathy (24% vs. 14%; p = 0.03), and permanent atrial fibrillation (18% vs. 8%; p = 0.01). The primary endpoint occurred in 81 of 232 patients (35%) in the NS-HBP group compared with 23 of 118 patients (19%) in the S-HBP group (hazard ratio: 1.38; 95% confidence interval: 0.87 to 2.20; p = 0.17). Subgroup analyses of patients at greatest risk (higher pacing burden or lower left ventricular ejection fraction) revealed no incremental risk with NS-HBP.

CONCLUSIONS

NS-HBP was associated with similar outcomes of death or heart failure hospitalization when compared with S-HBP. Multicenter risk-matched clinical studies are needed to confirm these findings.

Multi-morbidity burden, psychological distress, and quality of life in implantable cardioverter defibrillator recipients: Results from a nationwide study

BACKGROUND

The prevalence of multi-morbidity in implantable cardioverter defibrillator (ICD) recipients is approximately 25%. Multi-morbidity is associated with poor health and psychological outcomes in this population and may affect ICD recipients' quality-of-life (QOL). The purpose of this study was to determine the prevalence of psychological distress (anxiety, depressive symptoms, and Type-D personality) in ICD recipients with varying levels of comorbidities, and to examine the association between multi-morbidity burden and QOL in this population.

METHODS

All adults listed in the Swedish ICD and Pacemaker Registry in 2012 with an ICD implanted for at least one year were invited to participate in this study. Binary logistic regression was used to predict QOL using the EQ-5D mean index dichotomized based on median QOL scores. Multi-morbidity burden scores were based on quartile groupings.

RESULTS

A total of 2658 ICD recipients participated in the study (with a mean age of 65, 20.6% female, mean implant duration of 4.7 years, with 35.4% implanted for primary prevention of sudden cardiac arrest). Greater multi-morbidity burden, female sex, not working outside the home, history of ICD shock, negative ICD experience, higher levels of ICD-related concerns, and the presence of anxiety, depression, or Type D personality were associated with worse QOL in ICD recipients. Predictors differed by multi-morbidity burden level.

CONCLUSIONS

Multi-morbidity burden and psychological distress is an essential factor related to QOL. This issue should be discussed with potential ICD recipients prior to implant. Further exploration of increased recognition and treatment of psychological distress in ICD recipients is warranted.

Evolution of extravascular implantable defibrillator technologies

The implantable cardioverter-defibrillator (ICD) has been successfully treating patients with lethal ventricular arrhythmias for decades. The main acute and chronic complications of this therapy modality are related to the use of a transvenous lead. An entirely extravascular ICD concept was developed over the last 20 years, with emergence of the subcutaneous ICD (S-ICD). This device was approved for clinical use seven years ago, and accumulating real-life experience confirms its safety and efficacy. The main limitations related to this system include the lack of pacing capabilities for bradycardia, tachycardia or resynchronization therapy, a large size, and relatively high energy requirements for effective defibrillation. This review article summarizes current knowledge and potential future developments of the extravascular ICD technologies.