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Corbisiero R, Cao M, Muller D, Lee K, Martin D. Performance of the Quadripolar CRT-D system: 5-Year Results from the Quadripolar Pacing Post Approval Study. Heart Rhythm 2024:S1547-5271(24)02877-7. [PMID: 38971416 DOI: 10.1016/j.hrthm.2024.07.006] [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: 04/18/2024] [Revised: 06/11/2024] [Accepted: 07/01/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is associated with challenges such as elevated capture thresholds, diaphragmatic stimulation, and lead instability. OBJECTIVE Assess the chronic safety and efficacy of the quadripolar CRT-D device system with the Quartet 1458Q Left Ventricular (LV) lead in a CRT-indicated population followed for 5 years and evaluate all-cause mortality and impact of baseline characteristics on survival through 5 years. METHODS Patients indicated for a CRT-D system were followed every 6 months post-implant for 5 years and assessed device performance and adverse events at each visit. The three primary endpoints were freedom from quadripolar CRT-D system-related complications through 5 years, freedom from Quartet 1458Q LV lead-related complications through 5 years, and the mean programmed pacing capture threshold at 5 years. RESULTS The study enrolled 1,970 subjects at 71 sites. The quadripolar CRT-D system was successfully implanted in 97.2% of subjects. Freedom from quadripolar CRT-D device system-related complications through 5 years was 89.7% and freedom from Quartet 1458Q LV lead-related complications through 5 years was 95.7%. 3.49 % of subjects had LV lead-related complications and an overall LV lead complication rate was 0.0122 events per subject-year. A mean LV pacing capture threshold was 1.52 ± 1.01 V at 5 years. The 5-year survival rate was 67.4%. CONCLUSION The quadripolar CRT-D system with the Quartet 1458Q LV lead exhibited low rates of complications and stable electrical performance through 5 years of follow-up and suggested a higher 5-year survival rate compared to traditional CRT systems.
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Affiliation(s)
| | - Michael Cao
- University of Southern California, Los Angeles, CA, USA
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Chyou JY, Qin H, Butler J, Voors AA, Lam CSP. Sex-related similarities and differences in responses to heart failure therapies. Nat Rev Cardiol 2024; 21:498-516. [PMID: 38459252 DOI: 10.1038/s41569-024-00996-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2024] [Indexed: 03/10/2024]
Abstract
Although sex-related differences in the epidemiology, risk factors, clinical characteristics and outcomes of heart failure are well known, investigations in the past decade have shed light on an often overlooked aspect of heart failure: the influence of sex on treatment response. Sex-related differences in anatomy, physiology, pharmacokinetics, pharmacodynamics and psychosocial factors might influence the response to pharmacological agents, device therapy and cardiac rehabilitation in patients with heart failure. In this Review, we discuss the similarities between men and women in their response to heart failure therapies, as well as the sex-related differences in treatment benefits, dose-response relationships, and tolerability and safety of guideline-directed medical therapy, device therapy and cardiac rehabilitation. We provide insights into the unique challenges faced by men and women with heart failure, highlight potential avenues for tailored therapeutic approaches and call for sex-specific evaluation of treatment efficacy and safety in future research.
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Affiliation(s)
- Janice Y Chyou
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hailun Qin
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-NUS Medical School, Singapore, Singapore.
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Wijesuriya N, Mehta V, De Vere F, Howell S, Niederer SA, Burri H, Sperzel J, Calo L, Thibault B, Lin W, Lee K, Grammatico A, Varma N, Gwechenberger M, Leclercq C, Rinaldi CA. Heart Size Difference Drives Sex-Specific Response to Cardiac Resynchronization Therapy: A Post Hoc Analysis of the MORE-MPP CRT Trial. J Am Heart Assoc 2024; 13:e035279. [PMID: 38879456 PMCID: PMC11255746 DOI: 10.1161/jaha.123.035279] [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: 02/29/2024] [Accepted: 05/10/2024] [Indexed: 06/19/2024]
Abstract
BACKGROUND Studies have reported that female sex predicts superior cardiac resynchronization therapy (CRT) response. One theory is that this association is related to smaller female heart size, thus increased relative dyssynchrony at a given QRS duration (QRSd). Our objective was to investigate the mechanisms of sex-specific CRT response relating to heart size, relative dyssynchrony, cardiomyopathy type, QRS morphology, and other patient characteristics. METHODS AND RESULTS This is a post hoc analysis of the MORE-CRT MPP (More Response on Cardiac Resynchronization Therapy with Multipoint Pacing) trial (n=3739, 28% women), with a subgroup analysis of patients with nonischemic cardiomyopathy and left bundle-branch block (n=1308, 41% women) to control for confounding characteristics. A multivariable analysis examined predictors of response to 6 months of conventional CRT, including sex and relative dyssynchrony, measured by QRSd/left ventricular end-diastolic volume (LVEDV). Women had a higher CRT response rate than men (70.1% versus 56.8%, P<0.0001). In subgroup analysis, regression analysis of the nonischemic cardiomyopathy left bundle-branch block subgroup identified QRSd/LVEDV, but not sex, as a modifier of CRT response (P<0.0039). QRSd/LVEDV was significantly higher in women (0.919) versus men (0.708, P<0.001). CRT response was 78% for female patients with QRSd/LVEDV greater than the median value, compared with 68% with QRSd/LVEDV less than the median value (P=0.012). The association between CRT response and QRSd/LVEDV was strongest at QRSd <150 ms. CONCLUSIONS In the nonischemic cardiomyopathy left bundle-branch block population, increased relative dyssynchrony in women, who have smaller heart sizes than their male counterparts, is a driver of sex-specific CRT response, particularly at QRSd <150 ms. Women may benefit from CRT at a QRSd <130 ms, opening the debate on whether sex-specific QRSd cutoffs or QRS/LVEDV measurement should be incorporated into clinical guidelines.
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Affiliation(s)
- Nadeev Wijesuriya
- King’s College LondonLondonUK
- Guy’s and St Thomas’s NHS Foundation TrustLondonUK
| | - Vishal Mehta
- King’s College LondonLondonUK
- Guy’s and St Thomas’s NHS Foundation TrustLondonUK
| | - Felicity De Vere
- King’s College LondonLondonUK
- Guy’s and St Thomas’s NHS Foundation TrustLondonUK
| | - Sandra Howell
- King’s College LondonLondonUK
- Guy’s and St Thomas’s NHS Foundation TrustLondonUK
| | - Steven A. Niederer
- King’s College LondonLondonUK
- National Heart and Lung InstituteImperial College LondonLondonUK
| | - Haran Burri
- University Hospital of GenevaGenevaSwitzerland
| | | | | | | | | | | | | | | | | | | | - Christopher A. Rinaldi
- King’s College LondonLondonUK
- Guy’s and St Thomas’s NHS Foundation TrustLondonUK
- Cleveland ClinicLondonUK
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4
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Yamamoto N, Noda T, Nakano M, Ito T, Sato H, Hayashi H, Chiba T, Hasebe Y, Ueda N, Kamakura T, Ishibashi K, Miyata S, Kusano K, Yasuda S. Clinical utility of QRS duration normalized to left ventricular volume for predicting cardiac resynchronization therapy efficacy in patients with "mid-range" QRS duration. Heart Rhythm 2024; 21:855-862. [PMID: 38367890 DOI: 10.1016/j.hrthm.2024.02.019] [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: 10/05/2023] [Revised: 01/30/2024] [Accepted: 02/09/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is effective for patients with heart failure with QRS duration (QRSd) ≥150 ms. However, its beneficial effect seems to be limited for those with "mid-range" QRSd (120-149 ms). Recent studies have demonstrated that modifying QRSd to left ventricular end-diastolic volume (LVEDV)-modified QRSd-improves the prediction of clinical outcomes of CRT. OBJECTIVE The purpose of this study was to investigate the clinical impact of the modified QRSd on the efficacy of CRT in patients with "mid-range" QRSd. METHODS We conducted a retrospective, multicenter, observational study, with heart failure hospitalization (HFH) after CRT as the primary endpoint. Modified QRSd is defined as QRSd divided by LVEDV, determined through the Teichholtz method of echocardiography. RESULTS Among the 506 consecutive patients considered, 119 (mean age 61 ± 15 years; 80% male, QRSd 135 ± 9 ms) with a "mid-range" QRSd who underwent de novo CRT device implantation were included for analysis. During median follow-up of 878 days [interquartile range 381-1663 days], HFH occurred in 45 patients (37%). Fine-Gray analysis revealed modified QRSd was an independent predictor of HFH (hazard ratio [HR] 0.97; 95% confidence interval [CI] 0.96-0.99; P <.01). Receiver operating characteristic curve analysis revealed a cutoff value of 0.65 ms/mL for the modified QRSd in predicting HFH. Patients above the threshold exhibited a significantly lower incidence of HFH than patients below the threshold (HR 0.46; 95% CI 0.25-0.86; P = .01). CONCLUSION Modified QRSd can effectively predict the efficacy of CRT in patients with a "mid-range" QRSd.
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Affiliation(s)
- Nobuhiko Yamamoto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Noda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan; Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Makoto Nakano
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomohiro Ito
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroyuki Sato
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hideka Hayashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takahiko Chiba
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yuhi Hasebe
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Nobuhiko Ueda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tsukasa Kamakura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Miyata
- Teikyo University Graduate School of Public Health, Tokyo, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan; Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.
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5
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Friedman DJ, Olivas-Martinez A, Dalgaard F, Fudim M, Abraham WT, Cleland JGF, Curtis AB, Gold MR, Kutyifa V, Linde C, Tang AS, Ali-Ahmed F, Inoue LYT, Sanders GD, Al-Khatib SM. Relationship between sex, body size, and cardiac resynchronization therapy benefit: A patient-level meta-analysis of randomized controlled trials. Heart Rhythm 2024; 21:845-854. [PMID: 38360252 DOI: 10.1016/j.hrthm.2024.01.058] [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: 10/07/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Women might benefit more than men from cardiac resynchronization therapy (CRT) and do so at shorter QRS durations. OBJECTIVE This meta-analysis was performed to determine whether sex-based differences in CRT effects are better accounted for by height, body surface area (BSA), or left ventricular end-diastolic dimension (LVEDD). METHODS We analyzed patient-level data from CRT trials (MIRACLE, MIRACLE ICD, MIRACLE ICD II, REVERSE, RAFT, COMPANION, and MADIT-CRT) using bayesian hierarchical Weibull regression models. Relationships between QRS duration and CRT effects were examined overall and in sex-stratified cohorts; additional analyses indexed QRS duration by height, BSA, or LVEDD. End points were heart failure hospitalization (HFH) or death and all-cause mortality. RESULTS Compared with men (n = 5628), women (n = 1439) were shorter (1.62 [interquartile range, 1.57-1.65] m vs 1.75 [1.70-1.80] m; P < .001), with smaller BSAs (1.76 [1.62-1.90] m2 vs 2.02 [1.89-2.16] m2; P < .001). In adjusted sex-stratified analyses, the reduction in HFH or death was greater for women (hazard ratio, 0.54; credible interval, 0.42-0.70) than for men (hazard ratio, 0.77; credible interval, 0.66-0.89; Pinteraction = .009); results were similar for all-cause mortality even after adjustment for height, BSA, and LVEDD. Sex-specific differences were observed only in nonischemic cardiomyopathy. The effect of CRT on HFH or death was observed at a shorter QRS duration for women (126 ms) than for men (145 ms). Indexing QRS duration by height, BSA, or LVEDD attenuated sex-specific QRS duration thresholds for the effects of CRT on HFH or death but not on mortality. CONCLUSION Although body size partially explains sex-specific QRS duration thresholds for CRT benefit, it is not associated with the magnitude of CRT benefit. Indexing QRS duration for body size might improve selection of patients for CRT, particularly with a "borderline" QRS duration.
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Affiliation(s)
- Daniel J Friedman
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
| | | | - Frederik Dalgaard
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Department of Medicine, Nykøbing Falster Sygehus, Nykøbing, Denmark
| | - Marat Fudim
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Division of Cardiology, Wroclaw University, Wroclaw, Poland
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio
| | - John G F Cleland
- National Heart and Lung Institute, Royal Brompton & Harefield Hospitals, Imperial College, London, United Kingdom; British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | - Anne B Curtis
- Department of Medicine, University at Buffalo, Buffalo, New York
| | - Michael R Gold
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Valentina Kutyifa
- Division of Cardiology, Department of Medicine, University of Rochester Medical Center Rochester, New York
| | - Cecilia Linde
- Karolinska Institutet and Department of Cardiology, Karolinska University, Stockholm, Sweden
| | - Anthony S Tang
- Department of Medicine, Western University, London, Ontario, Canada
| | - Fatima Ali-Ahmed
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Lurdes Y T Inoue
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Gillian D Sanders
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina; Evidence Synthesis Group, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Sana M Al-Khatib
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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6
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Varma N. Dropping the floor on QRS duration boundaries for CRT patient selection in 2024-effects of sex, race, height, and heart size. Heart Rhythm 2024; 21:863-864. [PMID: 38479463 DOI: 10.1016/j.hrthm.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 04/07/2024]
Affiliation(s)
- Niraj Varma
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
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7
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Ito R, Kondo Y, Nakano M, Kajiyama T, Nakano M, Kitagawa M, Sugawara M, Chiba T, Kobayashi Y. Interaction of left ventricular size with the outcome of cardiac resynchronization therapy in Japanese patients. Clin Cardiol 2024; 47:e24267. [PMID: 38619004 PMCID: PMC11017297 DOI: 10.1002/clc.24267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/08/2024] [Accepted: 03/28/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND We analyzed the influence of the QRS duration (QRSd) to LV end-diastolic volume (LVEDV) ratio on cardiac resynchronization therapy (CRT) outcomes in heart failure patients classified as III/IV per the New York Heart Association (NYHA) and with small body size. HYPOTHESIS We proposed the hypothesis that the QRSd/LV size ratio is a better index of the CRT substrate. METHODS We enrolled 114 patients with advanced heart failure (NYHA class III/IV, and LV ejection fraction >35%) who received a CRT device, including those with left bundle branch block (LBBB) and QRSd ≥120 milliseconds (n = 60), non-LBBB and QRSd ≥150 milliseconds (n = 30) and non-LBBB and QRSd of 120-149 milliseconds (n = 24). RESULTS Over a mean follow-up period of 65 ± 58 months, the incidence of the primary endpoint, a composite of all-cause death and hospitalization for heart failure, showed no significant intergroup difference (43.3% vs. 50.0% vs. 37.5%, respectively, p = .72). Similarly, among 104 patients with QRSd/LVEDV ≥ 0.67 (n = 54) and QRSd/LVEDV < 0.67 (n = 52), no significant differences were observed in the incidence of the primary endpoint (35.1% vs. 51.9%, p = .49). Nevertheless, patients with QRSd/LVEDV ≥ 0.67 showed better survival than those with QRSd/LVEDV < 0.67 (14.8% vs. 34.6%, p = .0024). CONCLUSION Advanced HF patients with a higher QRSd/LVEDV ratio showed better survival in this small-body-size population. Thus, the risk is concentrated among those with a larger QRSd, and patients with a relatively smaller left ventricular size appeared to benefit from CRT.
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Affiliation(s)
- Ryo Ito
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Yusuke Kondo
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Masahiro Nakano
- Department of Advanced Cardiorhythm TherapeuticsChiba University Graduate School of MedicineChibaJapan
| | - Takatsugu Kajiyama
- Department of Advanced Cardiorhythm TherapeuticsChiba University Graduate School of MedicineChibaJapan
| | - Miyo Nakano
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Mari Kitagawa
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Masafumi Sugawara
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Toshinori Chiba
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Yoshio Kobayashi
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
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8
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Manne M, Niebauer M, Tchou P, Varma N. LBBB and heart failure-Relationships among QRS amplitude, duration, height, LV mass, and sex. J Cardiovasc Electrophysiol 2024; 35:583-591. [PMID: 37811553 DOI: 10.1111/jce.16097] [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: 08/24/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Height, left ventricular (LV) size, and sex were proposed as additional criteria for patient selection for cardiac resynchronization therapy (CRT) but their connections with the QRS complex in left bundle branch block (LBBB) are little investigated. We evaluated these. METHODS Among patients with "true" LBBB, QRS duration (QRSd) and amplitude, and LV hypertrophy indices, were correlated with patient's height and LV mass, and compared between sexes. RESULTS In this study cohort (n = 220; 60 ± 12 years; left ventricular ejection fraction [LVEF] 21 ± 7%; mostly New York Heart Association II-III, QRSd 165 ± 19 ms; 57% female; 70% responders [LVEF increased ≥5%]), LV mass was increased in all patients. QRS amplitude did not correlate with LV mass or height in any individual lead or with Sokolow-Lyon or Cornell-Lyon indices. QRSd did not correlate with height. In contrast, QRSd correlated strongly with LV mass (r = .51). CRT response rate was greater in women versus men (84% vs. 58%, p < .001) despite shorter QRSd [7% shorter (p < .0001)]. QRSd normalized for height resulted in a 2.7% and for LV mass 24% greater index in women. CONCLUSION True LBBB criteria do not exclude HF patients with increased LV mass. QRS amplitudes do not correlate with height or LV mass. Height does not affect QRSd. However, QRSd correlates with LV size. QRSd normalized for LV mass results in 24% greater value in women in the direction of sex-specific responses. LV mass may be a significant nonelectrical modifier of QRSd for CRT.
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Affiliation(s)
- Mahesh Manne
- Section of Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mark Niebauer
- Section of Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Patrick Tchou
- Section of Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Niraj Varma
- Section of Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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9
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Bacharova L, Chevalier P, Gorenek B, Jons C, Li Y, Locati ET, Maanja M, Pérez‐Riera AR, Platonov PG, Ribeiro ALP, Schocken D, Soliman EZ, Svehlikova J, Tereshchenko LG, Ugander M, Varma N, Elena Z, Ikeda T. ISE/ISHNE expert consensus statement on the ECG diagnosis of left ventricular hypertrophy: The change of the paradigm. Ann Noninvasive Electrocardiol 2024; 29:e13097. [PMID: 37997698 PMCID: PMC10770819 DOI: 10.1111/anec.13097] [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: 08/10/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/25/2023] Open
Abstract
The ECG diagnosis of LVH is predominantly based on the QRS voltage criteria. The classical paradigm postulates that the increased left ventricular mass generates a stronger electrical field, increasing the leftward and posterior QRS forces, reflected in the augmented QRS amplitude. However, the low sensitivity of voltage criteria has been repeatedly documented. We discuss possible reasons for this shortcoming and proposal of a new paradigm. The theoretical background for voltage measured at the body surface is defined by the solid angle theorem, which relates the measured voltage to spatial and non-spatial determinants. The spatial determinants are represented by the extent of the activation front and the distance of the recording electrodes. The non-spatial determinants comprise electrical characteristics of the myocardium, which are comparatively neglected in the interpretation of the QRS patterns. Various clinical conditions are associated with LVH. These conditions produce considerable diversity of electrical properties alterations thereby modifying the resultant QRS patterns. The spectrum of QRS patterns observed in LVH patients is quite broad, including also left axis deviation, left anterior fascicular block, incomplete and complete left bundle branch blocks, Q waves, and fragmented QRS. Importantly, the QRS complex can be within normal limits. The new paradigm stresses the electrophysiological background in interpreting QRS changes, i.e., the effect of the non-spatial determinants. This postulates that the role of ECG is not to estimate LV size in LVH, but to understand and decode the underlying electrical processes, which are crucial in relation to cardiovascular risk assessment.
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Affiliation(s)
| | - Philippe Chevalier
- Neuromyogene InstituteClaude Bernard UniversityVilleurbanneFrance
- Service de RythmologieHospices Civils de LyonLyonFrance
| | - Bulent Gorenek
- Eskisehir Osmangazi University Cardiology DepartmentEskisehirTurkey
| | - Christian Jons
- Department of CardiologyRigshospitalet, Copenhagen University HospitalCopenhagenDenmark
| | - Yi‐Gang Li
- Department of Cardiology, Xinhua HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Emanuela T. Locati
- Department of Arrhythmology and ElectrophysiologyIRCCS Policlinico San DonatoMilanoItaly
| | - Maren Maanja
- Department of Clinical PhysiologyKarolinska University Hospital, and Karolinska InstitutetStockholmSweden
| | | | - Pyotr G. Platonov
- Department of Cardiology, Clinical SciencesLund UniversityLundSweden
| | - Antonio Luiz Pinho Ribeiro
- Internal Medicine, Faculdade de Medicina da Universidade Federal de Minas GeraisBelo HorizonteBrazil
- Telehealth Center, Hospital das Clínicas da Universidade Federal de Minas GeraisBelo HorizonteBrazil
| | - Douglas Schocken
- Division of Cardiology, Department of MedicineDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Elsayed Z. Soliman
- Section on Cardiovascular Medicine, Department of Medicine, Epidemiological Cardiology Research CenterWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Jana Svehlikova
- Institute of Measurement Sciences, Slovak Academy of SciencesBratislavaSlovak Republic
| | - Larisa G. Tereshchenko
- Department of Quantitative Health SciencesLerner Research Institute, Cleveland ClinicClevelandOhioUSA
| | - Martin Ugander
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Department of Clinical PhysiologyKarolinska InstituteStockholmSweden
| | - Niraj Varma
- Cardiac Pacing & ElectrophysiologyHeart and Vascular Institute, Cleveland ClinicClevelandOhioUSA
| | - Zaklyazminskaya Elena
- Medical Genetics LaboratoryPetrovsky National Research Centre of SurgeryMoscowRussia
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10
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Dural M, Ghossein MA, Gerrits W, Daniels F, Meine M, Maass AH, Rienstra M, Prinzen FW, Vernooy K, van Stipdonk AMW. Association of vectorcardiographic T-wave area with clinical and echocardiographic outcomes in cardiac resynchronization therapy. Europace 2023; 26:euad370. [PMID: 38146837 PMCID: PMC10766142 DOI: 10.1093/europace/euad370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/19/2023] [Indexed: 12/27/2023] Open
Abstract
AIMS Data on repolarization parameters in cardiac resynchronization therapy (CRT) are scarce. We investigated the association of baseline T-wave area, with both clinical and echocardiographic outcomes of CRT in a large, multi-centre cohort of CRT recipients. Also, we evaluated the association between the baseline T-wave area and QRS area. METHODS AND RESULTS In this retrospective study, 1355 consecutive CRT recipients were evaluated. Pre-implantation T-wave and QRS area were calculated from vectorcardiograms. Echocardiographic response was defined as a reduction of ≥15% in left ventricular end-systolic volume between 3 and 12 months after implantation. The clinical outcome was a combination of all-cause mortality, heart transplantation, and left ventricular assist device implantation. Left ventricular end-systolic volume reduction was largest in patients with QRS area ≥ 109 μVs and T-wave area ≥ 66 μVs compared with QRS area ≥ 109 μVs and T-wave area < 66 μVs (P = 0.004), QRS area < 109 μVs and T-wave area ≥ 66 μVs (P < 0.001) and QRS area < 109 μVs and T-wave area < 66 μVs (P < 0.001). Event-free survival rate was higher in the subgroup of patients with QRS area ≥ 109 μVs and T-wave area ≥ 66 μVs (n = 616, P < 0.001) and QRS area ≥ 109 μVs and T-wave area < 66 μVs (n = 100, P < 0.001) than the other subgroups. In the multivariate analysis, T-wave area remained associated with echocardiographic response (P = 0.008), but not with the clinical outcome (P = 0.143), when QRS area was included in the model. CONCLUSION Baseline T-wave area has a significant association with both clinical and echocardiographic outcomes after CRT. The association of T-wave area with echocardiographic response is independent from QRS area; the association with clinical outcome, however, is not.
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Affiliation(s)
- Muhammet Dural
- Department of Cardiology, Eskişehir Osmangazi University Faculty of Medicine, Odunpazarı, Eskişehir 26040, Turkey
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht 6202, The Netherlands
| | - Mohammed A Ghossein
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Willem Gerrits
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Fenna Daniels
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mathias Meine
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Alexander H Maass
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht 6202, The Netherlands
| | - Antonius M W van Stipdonk
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht 6202, The Netherlands
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11
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Bacharova L, Chevalier P, Gorenek B, Jons C, Li YG, Locati ET, Maanja M, Pérez-Riera AR, Platonov PG, Ribeiro ALP, Schocken D, Soliman EZ, Svehlikova J, Tereshchenko LG, Ugander M, Varma N, Zaklyazminskaya E, Ikeda T. ISE/ISHNE Expert Consensus Statement on ECG Diagnosis of Left Ventricular Hypertrophy: The Change of the Paradigm. The joint paper of the International Society of Electrocardiology and the International Society for Holter Monitoring and Noninvasive Electrocardiology. J Electrocardiol 2023; 81:85-93. [PMID: 37647776 DOI: 10.1016/j.jelectrocard.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 09/01/2023]
Abstract
The ECG diagnosis of LVH is predominantly based on the QRS voltage criteria, i.e. the increased QRS complex amplitude in defined leads. The classical ECG diagnostic paradigm postulates that the increased left ventricular mass generates a stronger electrical field, increasing the leftward and posterior QRS forces. These increased forces are reflected in the augmented QRS amplitude in the corresponding leads. However, the clinical observations document increased QRS amplitude only in the minority of patients with LVH. The low sensitivity of voltage criteria has been repeatedly documented. We discuss possible reasons for this shortcoming and proposal of a new paradigm.
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Affiliation(s)
- Ljuba Bacharova
- International Laser Center CVTI, Ilkovicova 3, 841 04 Bratislava, Slovak Republic.
| | - Philippe Chevalier
- Neuromyogene Institute, Claude Bernard University, Lyon 1, Villeurbanne, France; Service de Rythmologie, Hospices Civils de Lyon, Lyon, France.
| | - Bulent Gorenek
- Eskisehir Osmangazi University, Cardiology Department, Eskisehir, Turkiye.
| | - Christian Jons
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Yi-Gang Li
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, 200092 Shanghai, PR China.
| | - Emanuela T Locati
- Department of Arrhythmology and Electrophysiology, IRCCS Policlinico San Donato, Piazza E. Malan 2, 20097 San Donato Milanese, Milano, Italy.
| | - Maren Maanja
- Department of Clinical Physiology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden.
| | | | - Pyotr G Platonov
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden.
| | - Antonio Luiz P Ribeiro
- Internal Medicine, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; Telehealth Center, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Douglas Schocken
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA.
| | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center, Section on Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Jana Svehlikova
- Institute of Measurement Sciences, Slovak Academy of Sciences, Bratislava, Slovak Republic.
| | - Larisa G Tereshchenko
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave JJN3-01, Cleveland, OH 44195, USA.
| | - Martin Ugander
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Clinical Physiology, Karolinska Institute, Stockholm, Stockholm, Sweden
| | - Niraj Varma
- Cardiac Pacing & Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave J2-2, Cleveland, OH 44195, USA.
| | - Elena Zaklyazminskaya
- Medical Genetics Laboratory, Petrovsky National Research Centre of Surgery, Moscow 119991, Russia
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12
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Chung MK, Patton KK, Lau CP, Dal Forno ARJ, Al-Khatib SM, Arora V, Birgersdotter-Green UM, Cha YM, Chung EH, Cronin EM, Curtis AB, Cygankiewicz I, Dandamudi G, Dubin AM, Ensch DP, Glotzer TV, Gold MR, Goldberger ZD, Gopinathannair R, Gorodeski EZ, Gutierrez A, Guzman JC, Huang W, Imrey PB, Indik JH, Karim S, Karpawich PP, Khaykin Y, Kiehl EL, Kron J, Kutyifa V, Link MS, Marine JE, Mullens W, Park SJ, Parkash R, Patete MF, Pathak RK, Perona CA, Rickard J, Schoenfeld MH, Seow SC, Shen WK, Shoda M, Singh JP, Slotwiner DJ, Sridhar ARM, Srivatsa UN, Stecker EC, Tanawuttiwat T, Tang WHW, Tapias CA, Tracy CM, Upadhyay GA, Varma N, Vernooy K, Vijayaraman P, Worsnick SA, Zareba W, Zeitler EP, Lopez-Cabanillas N, Ellenbogen KA, Hua W, Ikeda T, Mackall JA, Mason PK, McLeod CJ, Mela T, Moore JP, Racenet LK. 2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure. J Arrhythm 2023; 39:681-756. [PMID: 37799799 PMCID: PMC10549836 DOI: 10.1002/joa3.12872] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Eugene H Chung
- University of Michigan Medical School Ann Arbor Michigan USA
| | | | | | | | | | - Anne M Dubin
- Stanford University, Pediatric Cardiology Palo Alto California USA
| | - Douglas P Ensch
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Taya V Glotzer
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
| | - Michael R Gold
- Medical University of South Carolina Charleston South Carolina USA
| | - Zachary D Goldberger
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
| | | | - Eiran Z Gorodeski
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
| | | | | | - Weijian Huang
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
| | - Peter B Imrey
- Cleveland Clinic Cleveland Ohio USA
- Case Western Reserve University Cleveland Ohio USA
| | - Julia H Indik
- University of Arizona, Sarver Heart Center Tucson Arizona USA
| | - Saima Karim
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
| | - Peter P Karpawich
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
| | - Yaariv Khaykin
- Southlake Regional Health Center Newmarket Ontario Canada
| | | | - Jordana Kron
- Virginia Commonwealth University Richmond Virginia USA
| | | | - Mark S Link
- University of Texas Southwestern Medical Center Dallas Texas USA
| | - Joseph E Marine
- Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Wilfried Mullens
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
| | - Seung-Jung Park
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
| | | | | | - Rajeev Kumar Pathak
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
| | | | | | | | | | | | - Morio Shoda
- Tokyo Women's Medical University Tokyo Japan
| | - Jagmeet P Singh
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
| | - David J Slotwiner
- Weill Cornell Medicine Population Health Sciences New York New York USA
| | | | - Uma N Srivatsa
- University of California Davis Sacramento California USA
| | | | | | | | | | - Cynthia M Tracy
- George Washington University Washington District of Columbia USA
| | | | | | - Kevin Vernooy
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
| | | | | | - Wojciech Zareba
- University of Rochester Medical Center Rochester New York USA
| | | | - Nestor Lopez-Cabanillas
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Kenneth A Ellenbogen
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Wei Hua
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Takanori Ikeda
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Judith A Mackall
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Pamela K Mason
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Christopher J McLeod
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Theofanie Mela
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Jeremy P Moore
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Laurel Kay Racenet
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
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13
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Rorsman C, Farouq M, Marinko S, Mörtsell D, Chaudhry U, Wang L, Borgquist R. Sex-based differences in cardiac resynchronization therapy upgrade and outcome for patients with pacemaker and new-onset heart failure. Pacing Clin Electrophysiol 2023; 46:1153-1161. [PMID: 37638818 DOI: 10.1111/pace.14796] [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: 05/25/2023] [Revised: 06/29/2023] [Accepted: 07/17/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Patients with chronic right ventricular (RV) pacing are at an increased risk of heart failure. Previous studies have indicated that cardiac resynchronization therapy (CRT) is underused in this setting, and that there may be sex-based differences in both CRT use and clinical outcome. OBJECTIVE To evaluate sex-based differences in CRT use and clinical outcome for patients with new-onset heart failure post RV pacing. METHODS Data from the Swedish pacemaker registry was matched with data from the national death and disease registries. Patients with de novo pacemaker implant due to AV block during the period 2005-2020 were included. New-onset heart-failure within two years post-implant was evaluated, primary outcome was all-cause mortality. RESULTS In all, 30183 patients (37% female) were included. Women were on average 3 years older, but had less comorbidities than men. Median follow-up time was 4.5 [2.0-8.0] years. Women had better age- and comorbidity-adjusted survival (HR 0.78 [0.73-0.84], p < .001). For the 3560 patients (12.4% men and 10.7% women, p < .001) who were diagnosed with new-onset heart failure, 5-year mortality was similar for men and women (50% vs. 48%, p = .29). However, women were less likely to receive CRT-upgrade (3.8% vs. 9.1%, p < .001), and those who did were almost ten years younger than the men. CONCLUSION Women with pacemaker due to AV block are older but have less comorbidities than men. They are less likely to develop new-onset heart failure, but also less likely to receive a CRT upgrade if they do develop heart failure. Increased awareness of the positive effects of CRT upgrade and potential sex- and age-based discrimination is warranted.
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Affiliation(s)
- Cecilia Rorsman
- Cardiology, Department of Clinical, Sciences, Lund University, Lund, Sweden
- Internal Medicine Department, Varberg Hospital, Varberg, Sweden
| | - Maiwand Farouq
- Cardiology, Department of Clinical, Sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Sofia Marinko
- Cardiology, Department of Clinical, Sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - David Mörtsell
- Cardiology, Department of Clinical, Sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Uzma Chaudhry
- Cardiology, Department of Clinical, Sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Lingwei Wang
- Cardiology, Department of Clinical, Sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Rasmus Borgquist
- Cardiology, Department of Clinical, Sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
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14
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Chung MK, Patton KK, Lau CP, Dal Forno ARJ, Al-Khatib SM, Arora V, Birgersdotter-Green UM, Cha YM, Chung EH, Cronin EM, Curtis AB, Cygankiewicz I, Dandamudi G, Dubin AM, Ensch DP, Glotzer TV, Gold MR, Goldberger ZD, Gopinathannair R, Gorodeski EZ, Gutierrez A, Guzman JC, Huang W, Imrey PB, Indik JH, Karim S, Karpawich PP, Khaykin Y, Kiehl EL, Kron J, Kutyifa V, Link MS, Marine JE, Mullens W, Park SJ, Parkash R, Patete MF, Pathak RK, Perona CA, Rickard J, Schoenfeld MH, Seow SC, Shen WK, Shoda M, Singh JP, Slotwiner DJ, Sridhar ARM, Srivatsa UN, Stecker EC, Tanawuttiwat T, Tang WHW, Tapias CA, Tracy CM, Upadhyay GA, Varma N, Vernooy K, Vijayaraman P, Worsnick SA, Zareba W, Zeitler EP. 2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure. Heart Rhythm 2023; 20:e17-e91. [PMID: 37283271 PMCID: PMC11062890 DOI: 10.1016/j.hrthm.2023.03.1538] [Citation(s) in RCA: 85] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 06/08/2023]
Abstract
Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Eugene H Chung
- University of Michigan Medical School, Ann Arbor, Michigan
| | | | | | | | | | - Anne M Dubin
- Stanford University, Pediatric Cardiology, Palo Alto, California
| | | | - Taya V Glotzer
- Hackensack Meridian School of Medicine, Hackensack, New Jersey
| | - Michael R Gold
- Medical University of South Carolina, Charleston, South Carolina
| | - Zachary D Goldberger
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | - Eiran Z Gorodeski
- University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | | | - Weijian Huang
- First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Peter B Imrey
- Cleveland Clinic, Cleveland, Ohio; Case Western Reserve University, Cleveland, Ohio
| | - Julia H Indik
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | - Saima Karim
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Peter P Karpawich
- The Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan
| | - Yaariv Khaykin
- Southlake Regional Health Center, Newmarket, Ontario, Canada
| | | | - Jordana Kron
- Virginia Commonwealth University, Richmond, Virginia
| | | | - Mark S Link
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joseph E Marine
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wilfried Mullens
- Ziekenhuis Oost-Limburg Genk, Belgium and Hasselt University, Hasselt, Belgium
| | - Seung-Jung Park
- Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Ratika Parkash
- QEII Health Sciences Center, Halifax, Nova Scotia, Canada
| | | | - Rajeev Kumar Pathak
- Australian National University, Canberra Hospital, Garran, Australian Capital Territory, Australia
| | | | | | | | | | | | - Morio Shoda
- Tokyo Women's Medical University, Tokyo, Japan
| | - Jagmeet P Singh
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David J Slotwiner
- Weill Cornell Medicine Population Health Sciences, New York, New York
| | | | | | | | | | | | | | - Cynthia M Tracy
- George Washington University, Washington, District of Columbia
| | | | | | - Kevin Vernooy
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
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15
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Friedman DJ, Al-Khatib SM, Dalgaard F, Fudim M, Abraham WT, Cleland JGF, Curtis AB, Gold MR, Kutyifa V, Linde C, Tang AS, Ali-Ahmed F, Olivas-Martinez A, Inoue LY, Sanders GD. Cardiac Resynchronization Therapy Improves Outcomes in Patients With Intraventricular Conduction Delay But Not Right Bundle Branch Block: A Patient-Level Meta-Analysis of Randomized Controlled Trials. Circulation 2023; 147:812-823. [PMID: 36700426 PMCID: PMC10243743 DOI: 10.1161/circulationaha.122.062124] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 01/03/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Benefit from cardiac resynchronization therapy (CRT) varies by QRS characteristics; individual randomized trials are underpowered to assess benefit for relatively small subgroups. METHODS The authors analyzed patient-level data from pivotal CRT trials (MIRACLE [Multicenter InSync Randomized Clinical Evaluation], MIRACLE-ICD [Multicenter InSync ICD Randomized Clinical Evaluation], MIRACLE-ICD II [Multicenter InSync ICD Randomized Clinical Evaluation II], REVERSE [Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction], RAFT [Resynchronization-Defibrillation for Ambulatory Heart Failure], BLOCK-HF [Biventricular Versus Right Ventricular Pacing in Heart Failure Patients with Atrioventricular Block], COMPANION [Comparison of Medical Therapy, Pacing and Defibrillation in Heart Failure], and MADIT-CRT [Multicenter Automatic Defibrillator Implantation Trial - Cardiac Resynchronization Therapy]) using Bayesian Hierarchical Weibull survival regression models to assess CRT benefit by QRS morphology (left bundle branch block [LBBB], n=4549; right bundle branch block [RBBB], n=691; and intraventricular conduction delay [IVCD], n=1024) and duration (with 150-ms partition). The continuous relationship between QRS duration and CRT benefit was also examined within subgroups defined by QRS morphology. The primary end point was time to heart failure hospitalization (HFH) or death; a secondary end point was time to all-cause death. RESULTS Of 6264 patients included, 25% were women, the median age was 66 [interquartile range, 58 to 73] years, and 61% received CRT (with or without an implantable cardioverter defibrillator). CRT was associated with an overall lower risk of HFH or death (hazard ratio [HR], 0.73 [credible interval (CrI), 0.65 to 0.84]), and in subgroups of patients with QRS ≥150 ms and either LBBB (HR, 0.56 [CrI, 0.48 to 0.66]) or IVCD (HR, 0.59 [CrI, 0.39 to 0.89]), but not RBBB (HR 0.97 [CrI, 0.68 to 1.34]; Pinteraction <0.001). No significant association for CRT with HFH or death was observed when QRS was <150 ms (regardless of QRS morphology) or in the presence of RBBB. Similar relationships were observed for all-cause death. CONCLUSIONS CRT is associated with reduced HFH or death in patients with QRS ≥150 ms and LBBB or IVCD, but not for those with RBBB. Aggregating RBBB and IVCD into a single "non-LBBB" category when selecting patients for CRT should be reconsidered. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifiers: NCT00271154, NCT00251251, NCT00267098, and NCT00180271.
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Affiliation(s)
- Daniel J. Friedman
- Division of Cardiology, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Sana M. Al-Khatib
- Division of Cardiology, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Frederik Dalgaard
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
- Department of Medicine, Nykøbing Falster Sygehus, Nykøbing, Denmark
| | - Marat Fudim
- Division of Cardiology, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - William T. Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH
| | - John G. F. Cleland
- National Heart and Lung Institute, Royal Brompton & Harefield Hospitals, Imperial College, London, UK and British Heart Foundation Centre of Research Excellence. School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow. UK
| | | | | | - Valentina Kutyifa
- Division of Cardiology, Department of Medicine, University of Rochester Medical Center Rochester, NY
| | - Cecilia Linde
- Karolinska Institutet and Department of Cardiology, Karolinska University, Stockholm, Sweden
| | | | - Fatima Ali-Ahmed
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | - Gillian D. Sanders
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC
- Evidence Synthesis Group, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
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16
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Odland HH, Holm T, Cornelussen R, Kongsgård E. Determinants of the time-to-peak left ventricular dP/dt (Td) and QRS duration with different fusion strategies in cardiac resynchronization therapy. Front Cardiovasc Med 2022; 9:979581. [PMID: 36186985 PMCID: PMC9520326 DOI: 10.3389/fcvm.2022.979581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/23/2022] [Indexed: 12/03/2022] Open
Abstract
Background Cardiac resynchronization therapy (CRT) is helpful in selected patients; however, responder rates rarely exceed 70%. Optimization of CRT may therefore benefit a large number of patients. Time-to-peak dP/dt (Td) is a novel marker of myocardial synergy that reflects the degree of myocardial dyssynchrony with the potential to guide and optimize treatment with CRT. Optimal electrical activation is a prerequisite for CRT to be effective. Electrical activation can be altered by changing the electrical wave-front fusion resulting from pacing to optimize resynchronization. We designed this study to understand the acute effects of different electrical wave-front fusion strategies and LV pre-/postexcitation on Td and QRS duration (QRSd). A better understanding of measuring and optimizing resynchronization can help improve the benefits of CRT. Methods Td and QRSd were measured in 19 patients undergoing a CRT implantation. Two biventricular pacing groups were compared: pacing the left ventricle (LV) with fusion with intrinsic right ventricular activation (FUSION group) and pacing the LV and right ventricle (RV) at short atrioventricular delay (STANDARD group) to avoid fusion with intrinsic RV activation. A quadripolar LV lead enabled pacing from widely separated electrodes; distal (DIST), proximal (PROX) and both electrodes combined (multipoint pacing, MPP). The LV was stimulated relative in time to RV activation (either RV pace-onset or QRS-onset), with the LV stimulated prior to (PRE), simultaneous with (SIM) or after (POST) RV activation. In addition, we analyzed the interactions of the two groups (FUSION/STANDARD) with three different electrode configurations (DIST, PROX, MPP), each paced with three different degrees of LV pre-/postexcitation (PRE, SIM, POST) in a statistical model. Results We found that FUSION provided shorter Td and QRSd than STANDARD, MPP provided shorter Td and QRSd than DIST and PROX, and SIM provided both the shortest QRSd and Td compared to PRE and POST. The interaction analysis revealed that pacing MPP with fusion with intrinsic RV activation simultaneous with the onset of the QRS complex (MPP*FUSION*SIM) shortened QRSd and Td the most compared to all other modes and configurations. The difference in QRSd and Td from their respective references were significantly correlated (β = 1, R = 0.9, p < 0.01). Conclusion Pacing modes and electrode configurations designed to optimize electrical wave-front fusion (intrinsic RV activation, LV multipoint pacing and simultaneous RV and LV activation) shorten QRSd and Td the most. As demonstrated in this study, electrical and mechanical measures of resynchronization are highly correlated. Therefore, Td can potentially serve as a marker for CRT optimization.
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Affiliation(s)
- Hans Henrik Odland
- Department of Cardiology and Pediatric Cardiology, Section for Arrhythmias, Oslo University Hospital, Oslo, Norway
- *Correspondence: Hans Henrik Odland
| | - Torbjørn Holm
- Department of Cardiology, Section for Arrhythmias, Oslo University Hospital, Oslo, Norway
| | | | - Erik Kongsgård
- Department of Cardiology, Section for Arrhythmias, Oslo University Hospital, Oslo, Norway
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17
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Suzuki Y, Takami M, Fukuzawa K, Kiuchi K, Shimane A, Sakai J, Nakamura T, Yatomi A, Sonoda Y, Takahara H, Nakasone K, Yamamoto K, Tani K, Iwai H, Nakanishi Y, Hirata K. Impact of corticosteroid use on the clinical response and prognosis in patients with cardiac sarcoidosis who underwent an upgrade to cardiac resynchronization therapy. J Arrhythm 2022; 38:400-407. [PMID: 35785370 PMCID: PMC9237305 DOI: 10.1002/joa3.12697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/14/2022] [Accepted: 03/05/2022] [Indexed: 11/12/2022] Open
Abstract
Background Corticosteroids are widely used in patients with cardiac sarcoidosis (CS). In addition, upgrading to cardiac resynchronization therapy (CRT) is sometimes needed. This study aimed to investigate the impact of corticosteroid use on the clinical outcomes following CRT upgrades. Methods A total of 48 consecutive patients with non‐ischemic cardiomyopathies who underwent CRT upgrades were retrospectively reviewed and divided into three groups: group 1 included CS patients taking corticosteroids before the CRT upgrade (n = 7), group 2, CS patients not taking corticosteroids before the CRT upgrade (n = 10), and group 3, non‐CS patients (n = 31). The echocardiographic response, heart failure hospitalizations, and cardiovascular deaths were evaluated. Results The baseline characteristics during CRT upgrades exhibited no significant differences in the echocardiographic data between the three groups. After the CRT upgrade, responses regarding the ejection fraction (EF) and end‐systolic volume (ESV) were significantly lower in CS patients than non‐CS patients (ΔEF: group 1, 6.7% vs. group 2, 7.7% vs. group 3, 13.6%; p = .039, ΔESV: 3.0 ml vs. ‐12.7 ml vs. ‐37.2 ml; p = .008). The rate of an echocardiographic response was lowest in group 1 (29%). There were, however, no significant differences in the cumulative freedom from a composite outcome among the three groups (p = .19). No cardiovascular deaths occurred in group 1. Conclusion The echocardiographic response to an upgrade to CRT and the long‐term prognosis in patients with CS should be carefully evaluated because of the complex etiologies and impact of immunosuppressive therapy.
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Affiliation(s)
- Yuya Suzuki
- Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - Mitsuru Takami
- Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - Koji Fukuzawa
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - Kunihiko Kiuchi
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - Akira Shimane
- Division of Cardiovascular Medicine Hyogo Brain and Heart Center Himeji Hyogo Japan
| | - Jun Sakai
- Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - Toshihiro Nakamura
- Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - Atsusuke Yatomi
- Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - Yusuke Sonoda
- Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - Hiroyuki Takahara
- Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - Kazutaka Nakasone
- Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - Kyoko Yamamoto
- Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - Ken‐ichi Tani
- Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - Hidehiro Iwai
- Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - Yusuke Nakanishi
- Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - Ken‐ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
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18
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Prinzen FW, Auricchio A, Mullens W, Linde C, Huizar JF. OUP accepted manuscript. Eur Heart J 2022; 43:1917-1927. [PMID: 35265992 PMCID: PMC9123241 DOI: 10.1093/eurheartj/ehac088] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/02/2021] [Accepted: 02/22/2022] [Indexed: 11/14/2022] Open
Abstract
Electrical disturbances, such as atrial fibrillation (AF), dyssynchrony, tachycardia, and premature ventricular contractions (PVCs), are present in most patients with heart failure (HF). While these disturbances may be the consequence of HF, increasing evidence suggests that they may also cause or aggravate HF. Animal studies show that longer-lasting left bundle branch block, tachycardia, AF, and PVCs lead to functional derangements at the organ, cellular, and molecular level. Conversely, electrical treatment may reverse or mitigate HF. Clinical studies have shown the superiority of atrial and pulmonary vein ablation for rhythm control and AV nodal ablation for rate control in AF patients when compared with medical treatment. Ablation of PVCs can also improve left ventricular function. Cardiac resynchronization therapy (CRT) is an established adjunct therapy currently undergoing several interesting innovations. The current guideline recommendations reflect the safety and efficacy of these ablation therapies and CRT, but currently, these therapies are heavily underutilized. This review focuses on the electrical treatment of HF with reduced ejection fraction (HFrEF). We believe that the team of specialists treating an HF patient should incorporate an electrophysiologist in order to achieve a more widespread use of electrical therapies in the management of HFrEF and should also include individual conditions of the patient, such as body size and gender in therapy fine-tuning.
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Affiliation(s)
| | - Angelo Auricchio
- Division of Cardiology, Istituto Cardiocentro Ticino, Lugano, Switzerland
| | - Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, University Hasselt, Hasselt, Belgium
| | - Cecilia Linde
- Department of Medicine, Karolinska Institutet, Solna, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Jose F Huizar
- Cardiology Division, Virginia Commonwealth University/Pauley Heart Center, Richmond, VA, USA
- Cardiology Division, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
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19
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Odland HH, Villegas-Martinez M, Ross S, Holm T, Cornelussen R, Remme EW, Kongsgard E. Shortening of time-to-peak left ventricular pressure rise (Td) in cardiac resynchronization therapy. ESC Heart Fail 2021; 8:5222-5236. [PMID: 34514746 PMCID: PMC8712829 DOI: 10.1002/ehf2.13601] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/29/2021] [Accepted: 08/19/2021] [Indexed: 11/05/2022] Open
Abstract
Aims We tested the hypothesis that shortening of time‐to‐peak left ventricular pressure rise (Td) reflect resynchronization in an animal model and that Td measured in patients will be helpful to identify long‐term volumetric responders [end‐systolic volume (ESV) decrease >15%] in cardiac resynchronization therapy (CRT). Methods Td was analysed in an animal study (n = 12) of left bundle‐branch block (LBBB) with extensive instrumentation to detect left ventricular myocardial deformation, electrical activation, and pressures during pacing. The sum of electrical delays from the onset of pacing to four intracardiac electrodes formed a synchronicity index (SI). Pacing was performed at baseline, with LBBB, right and left ventricular pacing and finally with biventricular pacing (BIVP). We then studied Td at baseline and with BIVP in a clinical observational study in 45 patients during the implantation of CRT and followed up for up to 88 months. Results We found a strong relationship between Td and SI in the animals (R = 0.84, P < 0.01). Td and SI increased from narrow QRS at baseline (Td = 95 ± 2 ms, SI = 141 ± 8 ms) to LBBB (Td = 125 ± 2 ms, SI = 247 ± 9 ms, P < 0.01), and shortened with biventricular pacing (BIVP) (Td = 113 ± 2 ms and SI = 192 ± 7 ms, P < 0.01). Prolongation of Td was associated with more wasted deformation during the preejection period (R = 0.77, P < 0.01). Six patients increased ESV by 2.5 ± 18%, while 37 responders (85%) had a mean ESV decrease of 40 ± 15% after more than 6 months of follow‐up. Responders presented with a higher Td at baseline than non‐responders (163 ± 26 ms vs. 121 ± 19 ms, P < 0.01). Td decreased to 156 ± 16 ms (P = 0.02) with CRT in responders, while in non‐responders, Td increased to 148 ± 21 ms (P < 0.01). A decrease in Td with BIVP to values similar or below what was found at baseline accurately identified responders to therapy (AUC 0.98, P < 0.01). Td at baseline and change in Td from baseline was linear related to the decrease in ESV at follow‐up. All‐cause mortality was high among six non‐responders (n = 4), while no patients died in the responder group during follow‐up. Conclusions Prolongation of Td is associated with cardiac dyssynchrony and more wasted deformation during the preejection period. Shortening of a prolonged Td with CRT in patients accurately identifies volumetric responders to CRT with incremental value on top of current guidelines and practices. Thus, Td carries the potential to become a biomarker to predict long‐term volumetric response in CRT candidates.
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Affiliation(s)
- Hans Henrik Odland
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, 0027, Norway.,Department of Pediatric Cardiology, Oslo University Hospital, Oslo, 0027, Norway
| | | | - Stian Ross
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, 0027, Norway
| | - Torbjørn Holm
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, 0027, Norway
| | | | - Espen W Remme
- Intervention Center, Oslo University Hospital, Rikshospitalet, Oslo, 0027, Norway.,Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, 0027, Norway
| | - Erik Kongsgard
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, 0027, Norway
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20
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Park SJ, Kwon DH, Rickard JW, Varma N. Right ventricular dilatation and systolic dysfunction and relationship to QRS duration in patients with left bundle branch block and cardiomyopathy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1890-1896. [PMID: 34499749 DOI: 10.1111/pace.14357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 08/02/2021] [Accepted: 09/05/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Marked QRS widening in patients with left bundle branch block (LBBB) may reduce efficacy of cardiac resynchronization therapy (CRT). We hypothesized that extreme QRS prolongation may accompany right ventricular (RV) dilatation/systolic dysfunction (RVD/RVsD) as well as left ventricular dilatation/systolic dysfunction (LVD/LVsD). METHODS We assessed rates of both ventricular dilatation and systolic dysfunction according to widening of QRS duration (QRSd) in 100 consecutive cardiomyopathy patients with true LBBB (QRSd ≥ 130 ms in female or ≥140 ms in male, QS or rS in leads V1/V2, and mid-QRS notching/slurring in ≥2 contiguous leads of I, aVL, and V1/V2/V5/V6). Ventricular dimensions and function were measured by cardiac magnetic resonance imaging. RESULTS There was a trend toward an increase in the prevalence of LVD (13%, 20%, and 90%), LVsD (67%, 77%, and 90%), RVD (23%, 27%, and 50%), RVsD (27%, 27%, and 40%), RVD plus RVsD (13%, 17%, and 40%), or RVD/RVsD (37%, 37%, and 50%) according to the degree of QRS prolongation (<150 ms, n = 30; 150-180 ms, n = 60; and ≥180 ms, n = 10). Similarly, patients in the highest quartile of QRSd (QRSd ≥ 168 ms, n = 26) showed greater rates of RVD (23% vs. 44%, p = .069), RVsD (22% vs. 48%, p = .032), RVD plus RVsD (10% vs. 30%, p = .040), or RVD/RVsD (33% vs. 57%, p = .050) compared to those in the remaining quartiles (n = 74). QRSd ≥ 180 ms was identified as an independent predictor for the presence of RVD plus RVsD. CONCLUSION The rates of RVD and/or RVsD increased with QRS widening, particularly when QRSd exceeded 180 ms. This may diminish anticipated CRT response rates in cardiomyopathy patients with LBBB.
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Affiliation(s)
- Seung-Jung Park
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Deborah H Kwon
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John W Rickard
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Niraj Varma
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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21
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Mullens W, Auricchio A, Martens P, Witte K, Cowie MR, Delgado V, Dickstein K, Linde C, Vernooy K, Leyva F, Bauersachs J, Israel CW, Lund LH, Donal E, Boriani G, Jaarsma T, Berruezo A, Traykov V, Yousef Z, Kalarus Z, Nielsen JC, Steffel J, Vardas P, Coats A, Seferovic P, Edvardsen T, Heidbuchel H, Ruschitzka F, Leclercq C. Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care. Europace 2021; 23:1324-1342. [PMID: 34037728 DOI: 10.1093/europace/euaa411] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/28/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heart failure hospitalization rates and all-cause mortality. Nevertheless, up to two-thirds of eligible patients are not referred for CRT. Furthermore, post-implantation follow-up is often fragmented and suboptimal, hampering the potential maximal treatment effect. This joint position statement from three European Society of Cardiology Associations, Heart Failure Association (HFA), European Heart Rhythm Association (EHRA) and European Association of Cardiovascular Imaging (EACVI), focuses on optimized implementation of CRT. We offer theoretical and practical strategies to achieve more comprehensive CRT referral and post-procedural care by focusing on four actionable domains: (i) overcoming CRT under-utilization, (ii) better understanding of pre-implant characteristics, (iii) abandoning the term 'non-response' and replacing this by the concept of disease modification, and (iv) implementing a dedicated post-implant CRT care pathway.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, Belgium
- University Hasselt, Hasselt, Belgium
| | - Angelo Auricchio
- Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Pieter Martens
- Ziekenhuis Oost Limburg, Genk, Belgium
- University Hasselt, Hasselt, Belgium
| | - Klaus Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Martin R Cowie
- Imperial College London (Royal Brompton Hospital), London, UK
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Cecilia Linde
- Heart and Vascular Theme, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Carsten W Israel
- Department of Medicine - Cardiology, Diabetology and Nephrology, Bethel-Clinic, Bielefeld, Germany
| | - Lars H Lund
- Department of Medicine Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Erwan Donal
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Tiny Jaarsma
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
| | | | - Vassil Traykov
- Department of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Zaheer Yousef
- Department of Cardiology, University Hospital of Wales & Cardiff University, Cardiff, UK
| | - Zbigniew Kalarus
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | | | - Jan Steffel
- UniversitätsSpital Zürich, Zürich, Switzerland
| | - Panos Vardas
- Heart Sector, Hygeia Hospitals Group, Athens, Greece
| | | | - Petar Seferovic
- Faculty of Medicine, Serbian Academy of Science and Arts, Belgrade University, Belgrade, Serbia
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, and University of Oslo, Oslo, Norway
| | - Hein Heidbuchel
- Antwerp University and Antwerp University Hospital, Antwerp, Belgium
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital, University Heart Center, Zurich, Switzerland
| | - Christophe Leclercq
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
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22
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Mullens W, Auricchio A, Martens P, Witte K, Cowie MR, Delgado V, Dickstein K, Linde C, Vernooy K, Leyva F, Bauersachs J, Israel CW, Lund LH, Donal E, Boriani G, Jaarsma T, Berruezo A, Traykov V, Yousef Z, Kalarus Z, Cosedis Nielsen J, Steffel J, Vardas P, Coats A, Seferovic P, Edvardsen T, Heidbuchel H, Ruschitzka F, Leclercq C. Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care: A joint position statement from the Heart Failure Association (HFA), European Heart Rhythm Association (EHRA), and European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology. Eur J Heart Fail 2021; 22:2349-2369. [PMID: 33136300 DOI: 10.1002/ejhf.2046] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/28/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heart failure hospitalization rates and all-cause mortality. Nevertheless, up to two-thirds of eligible patients are not referred for CRT. Furthermore, post-implantation follow-up is often fragmented and suboptimal, hampering the potential maximal treatment effect. This joint position statement from three European Society of Cardiology Associations, Heart Failure Association (HFA), European Heart Rhythm Association (EHRA) and European Association of Cardiovascular Imaging (EACVI), focuses on optimized implementation of CRT. We offer theoretical and practical strategies to achieve more comprehensive CRT referral and post-procedural care by focusing on four actionable domains: (i) overcoming CRT under-utilization, (ii) better understanding of pre-implant characteristics, (iii) abandoning the term 'non-response' and replacing this by the concept of disease modification, and (iv) implementing a dedicated post-implant CRT care pathway.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University Hasselt, Hasselt, Belgium
| | - Angelo Auricchio
- Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Pieter Martens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University Hasselt, Hasselt, Belgium
| | - Klaus Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Martin R Cowie
- Imperial College London (Royal Brompton Hospital), London, UK
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Cecilia Linde
- Heart and Vascular Theme, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Carsten W Israel
- Department of Medicine - Cardiology, Diabetology and Nephrology, Bethel-Clinic, Bielefeld, Germany
| | - Lars H Lund
- Department of Medicine Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Erwan Donal
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Tiny Jaarsma
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
| | | | - Vassil Traykov
- Department of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Zaheer Yousef
- Department of Cardiology, University Hospital of Wales & Cardiff University, Cardiff, UK
| | - Zbigniew Kalarus
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | | | - Jan Steffel
- UniversitätsSpital Zürich, Zürich, Switzerland
| | - Panos Vardas
- Heart Sector, Hygeia Hospitals Group, Athens, Greece
| | | | - Petar Seferovic
- Faculty of Medicine, Serbian Academy of Science and Arts, Belgrade University, Belgrade, Serbia
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, and University of Oslo, Oslo, Norway
| | - Hein Heidbuchel
- Antwerp University and Antwerp University Hospital, Antwerp, Belgium
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital, University Heart Center, Zurich, Switzerland
| | - Christophe Leclercq
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
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23
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Changes in cardiac conduction time following cardiac resynchronization therapy: rationale and design of the RECOVER study. J Interv Card Electrophysiol 2021; 63:303-309. [PMID: 33774800 DOI: 10.1007/s10840-021-00979-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 03/10/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND It has been known that ventricular conduction delays play a key role in the cardiac resynchronization therapy (CRT) response of patients with advanced heart failure (HF). However, no study to our knowledge has yet evaluated the serial changes in conduction times measured between different electrodes of CRT devices. METHODS AND RESULTS The Reduction or Extension of Conduction Time with Ventricular Electromechanical Remodeling (RECOVER) study (NCT04397224) was designed to investigate serial changes in interelectrode conduction times and to elucidate their prognostic value. We plan to enroll 100 patients implanted with CRT systems with endocardial quadripolar left ventricular leads. Patients will be scheduled for follow-up every 3 months over a period of 2 years, where they will undergo measurement of interelectrode conduction times to evaluate their serial changes. The primary outcome of the RECOVER study is the correlation between the degree of conduction time changes and the CRT response as defined by echocardiography. The time course and prognostic value of the serial changes in conduction times will be investigated as well. CONCLUSION The RECOVER study is investigating whether serial changes in interelectrode conduction times can be useful parameters in predicting the CRT response or detecting worsening HF at an early stage.
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24
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Chyou JY, Tay WT, Anand IS, Teng THK, Yap JJL, MacDonald MR, Chopra V, Loh SY, Shimizu W, Abidin IZ, Richards AM, Butler J, Lam CSP. Electroanatomic Ratios and Mortality in Patients With Heart Failure: Insights from the ASIAN-HF Registry. J Am Heart Assoc 2021; 10:e017932. [PMID: 33719492 PMCID: PMC8174226 DOI: 10.1161/jaha.120.017932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background QRS duration (QRSd) is a marker of electrical remodeling in heart failure. Anthropometrics and left ventricular size may influence QRSd and, in turn, may influence the association between QRSd and heart failure outcomes. Methods and Results Using the prospective, multicenter, multinational ASIAN‐HF (Asian Sudden Cardiac Death in Heart Failure) registry, this study evaluated whether electroanatomic ratios (QRSd indexed for height or left ventricular end‐diastole volume) are associated with 1‐year mortality in individuals with heart failure with reduced ejection fraction. The study included 4899 individuals (aged 60±19 years, 78% male, mean left ventricular ejection fraction: 27.3±7.1%). In the overall cohort, QRSd was not associated with all‐cause mortality (hazard ratio [HR], 1.003; 95% CI, 0.999–1.006, P=0.142) or sudden cardiac death (HR, 1.006; 95% CI, 1.000–1.013, P=0.059). QRS/height was associated with all‐cause mortality (HR, 1.165; 95% CI, 1.046–1.296, P=0.005 with interaction by sex pinteraction=0.020) and sudden cardiac death (HR, 1.270; 95% CI, 1.021–1.580, P=0.032). QRS/left ventricular end‐diastole volume was associated with all‐cause mortality (HR, 1.22; 95% CI, 1.05–1.43, P=0.011) and sudden cardiac death (HR, 1.461; 95% CI, 1.090–1.957, P=0.011) in patients with nonischemic cardiomyopathy but not in patients with ischemic cardiomyopathy (all‐cause mortality: HR, 0.94; 95% CI, 0.79–1.11, P=0.467; sudden cardiac death: HR, 0.734; 95% CI, 0.477–1.132, P=0.162). Conclusions Electroanatomic ratios of QRSd indexed for body size or left ventricular size are associated with mortality in individuals with heart failure with reduced ejection fraction. In particular, increased QRS/height may be a marker of high risk in individuals with heart failure with reduced ejection fraction, and QRS/left ventricular end‐diastole volume may further risk stratify individuals with nonischemic heart failure with reduced ejection fraction. Registration URL: https://Clinicaltrials.gov. Unique identifier: NCT01633398.
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Affiliation(s)
- Janice Y Chyou
- Division of Cardiology Icahn School of Medicine at Mount Sinai and the Mount Sinai Health System New York NY
| | - Wan Ting Tay
- National Heart Centre Singapore Singapore Singapore
| | - Inder S Anand
- Department of Medicine University of Minnesota Medical School and VA Medical Center Minneapolis MN
| | | | | | | | - Vijay Chopra
- Heart Institute Medanta-The Medicity Gurugram India
| | - Seet Yoong Loh
- Department of Cardiology Tan Tock Seng Hospital Singapore Singapore
| | - Wataru Shimizu
- Department of Cardiovascular MedicineNippon Medical School Tokyo Japan
| | | | | | - Arthur Mark Richards
- Cardiovascular Research InstituteNational University of Singapore Singapore Singapore
| | - Javed Butler
- Department of Medicine University of Mississippi Medical Center Jackson MI
| | - Carolyn S P Lam
- National Heart Centre SingaporeDuke-NUS Medical School Singapore Singapore
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25
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Tokodi M, Behon A, Merkel ED, Kovács A, Tősér Z, Sárkány A, Csákvári M, Lakatos BK, Schwertner WR, Kosztin A, Merkely B. Sex-Specific Patterns of Mortality Predictors Among Patients Undergoing Cardiac Resynchronization Therapy: A Machine Learning Approach. Front Cardiovasc Med 2021; 8:611055. [PMID: 33718444 PMCID: PMC7947699 DOI: 10.3389/fcvm.2021.611055] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/27/2021] [Indexed: 12/31/2022] Open
Abstract
Background: The relative importance of variables explaining sex-related differences in outcomes is scarcely explored in patients undergoing cardiac resynchronization therapy (CRT). We sought to implement and evaluate machine learning (ML) algorithms for the prediction of 1- and 3-year all-cause mortality in CRT patients. We also aimed to assess the sex-specific differences in predictors of mortality utilizing ML. Methods: Using a retrospective registry of 2,191 CRT patients, ML models were implemented in 6 partially overlapping patient subsets (all patients, females, or males with 1- or 3-year follow-up). Each cohort was randomly split into training (80%) and test sets (20%). After hyperparameter tuning in the training sets, the best performing algorithm was evaluated in the test sets. Model discrimination was quantified using the area under the receiver-operating characteristic curves (AUC). The most important predictors were identified using the permutation feature importances method. Results: Conditional inference random forest exhibited the best performance with AUCs of 0.728 (0.645-0.802) and 0.732 (0.681-0.784) for the prediction of 1- and 3-year mortality, respectively. Etiology of heart failure, NYHA class, left ventricular ejection fraction, and QRS morphology had higher predictive power, whereas hemoglobin was less important in females compared to males. The importance of atrial fibrillation and age increased, while the importance of serum creatinine decreased from 1- to 3-year follow-up in both sexes. Conclusions: Using ML techniques in combination with easily obtainable clinical features, our models effectively predicted 1- and 3-year all-cause mortality in CRT patients. Sex-specific patterns of predictors were identified, showing a dynamic variation over time.
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Affiliation(s)
- Márton Tokodi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Anett Behon
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zoltán Tősér
- Argus Cognitive, Inc., Lebanon, NH, United States
| | | | | | | | | | | | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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26
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Varma N, Baker J, Tomassoni G, Love CJ, Martin D, Sheppard R, Niazi I, Cranke G, Lee K, Corbisiero R. Left Ventricular Enlargement, Cardiac Resynchronization Therapy Efficacy, and Impact of MultiPoint Pacing. Circ Arrhythm Electrophysiol 2020; 13:e008680. [DOI: 10.1161/circep.120.008680] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background:
Left ventricular (LV) epicardial pacing results in slowly propagating paced wavefronts. We postulated that this effect might limit cardiac resynchronization therapy efficacy in patients with LV enlargement using conventional biventricular pacing with single-site LV pacing, but be mitigated by LV stimulation from 2 widely spaced sites using MultiPoint pacing with wide anatomic separation (MPP-AS: ≥30 mm). We tested this hypothesis in the multicenter randomized MPP investigational device exemption trial.
Methods:
Following implant, quadripolar biventricular single-site pacing was activated in all patients (n=506). From 3 to 9 months postimplant, among patients with available baseline LV end-diastolic volume (LVEDV) measures, 188 received biventricular single-site pacing and 43 received MPP-AS. Patients were dichotomized by median baseline LVEDV indexed to height (LVEDVI
Median
). Outcomes were measured by the clinical composite score (primary efficacy end point), quality of life, LV structural remodeling (↑EF >5% and ↓ESV 10%) and heart failure event/cardiovascular death.
Results:
LVEDVI
Median
was 1.1 mL/cm. Baseline characteristics differed in patients with LVEDVI
>Median
versus LVEDVI
≤Median
. Among patients with LVEDVI
>Median
, biventricular single-site pacing was less efficacious compared to patients with LVEDVI
≤Median
(clinical composite score, 65% versus 79%). In contrast, MPP-AS programming generated greater clinical composite score response (92% versus 65%,
P
=0.023) and improved quality of life (−31.0±29.7 versus −15.7±22.1,
P
=0.038) versus biventricular single-site pacing in patients with LVEDVI
>Median
. Reverse remodeling trended better with MPP-AS programming. In patients with LVEDVI
>Median
, heart failure event rate increased following the 3-month randomization point with biventricular single-site pacing (0.0150±0.1725 in LVEDVI
>Median versus
−0.0190±0.0808 in LVEDVI
≤Median
,
P
=0.012), but no heart failure event occurred in patients with MPP-AS programming between 3 and 9 months in LVEDVI
>Median
. All measured outcomes did not differ in patients receiving MPP-AS and biventricular single-site pacing with LVEDVI
≤Median
.
Conclusions:
Conventional biventricular single-site pacing, even with a quadripolar lead, has reduced efficacy in patients with LV enlargement. However, the greatest response rate in patients with larger hearts was observed when programmed to MPP-AS pacing.
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Affiliation(s)
- Niraj Varma
- Cleveland Clinic Foundation, Cleveland, OH (N.V.)
| | - James Baker
- Saint Thomas Research Institute, Nashville, TN (J.B.)
| | | | | | | | | | - Imran Niazi
- Aurora Cardiovascular Services, Milwaukee, WI (I.N.)
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27
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Moti H. Should different ECG QRS duration criteria be used for men and women with heart failure for cardiac resynchronization therapy? Minerva Cardiol Angiol 2020; 69:64-69. [PMID: 32996306 DOI: 10.23736/s2724-5683.20.05329-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In the present paper we review data of the efficacy of CRT based on baseline QRS duration and morphology in patients with heart failure due to left ventricle systolic dysfunction. We specifically review data that analyzed men and women separately. The main findings suggest benefit of CRT in patients with baseline LBBB, but not in patients without LBBB. Benefit is directly related to QRS duration at baseline with increasing rates and magnitude of echocardiographic response (in terms of improvement in ejection fraction and decrease in LV size) and clinical response with increasing baseline QRS. The effect was most pronounced when QRSd was above 150 ms. Among women treated with CRT, similar to men, the benefit is also confined mainly to patients with baseline LBBB. In contrast to men benefit is evident starting with QRSd >130 ms. These findings may suggest that different QRS duration criteria should be used for men and women considered for CRT.
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Affiliation(s)
- Haim Moti
- Department of Cardiology, Cardiac Electrophysiology and Pacing, Soroka University Hospital, Ben-Gurion University of the Negev, Beer-Sheva, Israel -
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28
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Wilkoff BL, Birnie D, Gold MR, Hersi AS, Jacobs S, Gerritse B, Kusano K, Leclercq C, Mullens W, Filippatos G. Differences in clinical characteristics and reported quality of life of men and women undergoing cardiac resynchronization therapy. ESC Heart Fail 2020; 7:2972-2982. [PMID: 32790108 PMCID: PMC7524066 DOI: 10.1002/ehf2.12914] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 06/13/2020] [Accepted: 07/13/2020] [Indexed: 01/15/2023] Open
Abstract
Aims Response to cardiac resynchronization therapy (CRT) is known to be associated with a number of clinical characteristics, including QRS duration and morphology, gender, height, and the aetiology of heart failure (HF). We assessed the relation of gender and baseline characteristics with QRS duration and Kansas City Cardiomyopathy Questionnaire. Methods and results AdaptResponse is a global randomized trial. The trial enrolled CRT‐indicated patients with New York Heart Association classes II–IV HF, left bundle branch block (QRS ≥ 140 ms in men, ≥130 ms in women), and baseline PR interval ≤200 ms. In total, 3620 patients were randomized, including 1569 women (43.3%) approaching the actual proportion of women in the HF population. Women were older and more often New York Heart Association class III or IV than men (55.6% vs. 48.7%), had less frequent ischaemic cardiomyopathy (21.2% vs. 39.5%), and had a 5.1 ms shorter QRS duration than men. Women were more often depressed (18.5% vs. 9.7%), had a significantly lower Kansas City Cardiomyopathy Questionnaire score, and had differences in medication prescriptions. Conclusions AdaptResponse is the largest randomized CRT trial and enrolled more women than any other landmark CRT trial. Women differed from men with regard to baseline characteristics and quality of life. Whether these differences translate into clinical outcome differences will be examined further in the AdaptResponse trial.
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Affiliation(s)
| | - David Birnie
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michael R Gold
- Department of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Ahmad S Hersi
- Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sandra Jacobs
- Medtronic Bakken Research Center, Maastricht, The Netherlands
| | - Bart Gerritse
- Medtronic Bakken Research Center, Maastricht, The Netherlands
| | - Kengo Kusano
- National Cerebral and Cardiovascular Center, Osaka, Japan
| | | | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium and Hasselt University, Hasselt, Belgium
| | - Gerasimos Filippatos
- School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,School of Medicine, University of Cyprus, Nicosia, Cyprus
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29
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Friedman DJ, Emerek K, Sørensen PL, Zeitler EP, Goldstein SA, Al-Khatib SM, Søgaard P, Graff C, Atwater BD. Sex differences in left ventricular electrical dyssynchrony and outcomes with cardiac resynchronization therapy. Heart Rhythm O2 2020; 1:243-249. [PMID: 34113878 PMCID: PMC8183970 DOI: 10.1016/j.hroo.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Women seem to derive more benefit from cardiac resynchronization therapy (CRT) than men, even after accounting for the higher burden of risk factors for nonresponse often observed in men. Objective To assess for sex-specific differences in left ventricular (LV) electrical dyssynchrony as a contributing electrophysiological explanation for the greater degree of CRT benefit among women. Methods We compared the extent of baseline LV electrical dyssynchrony, as measured by the QRS area (QRSA), among men and women with left bundle branch block (LBBB) undergoing CRT at Duke University (n = 492, 35% women) overall and in relation to baseline QRS characteristics using independent sample t tests and Pearson correlation coefficients. Cox regression analyses were used to relate sex, QRSA, and QRS characteristics to the risk of cardiac transplantation, LV assist device implant, or death. Results Although the mean QRS duration (QRSd) did not differ by sex, QRSA was greater for women vs men (113.8 μVs vs 98.2 μVs, P < .001), owing to differences in the QRSd <150 ms subgroup (92.3 ± 28.7 μVs vs 67.6 ± 26.2 μVs, P < .001). Among those with nonstrict LBBB, mean QRSd was similar but QRSA was significantly greater among women than men (96.0 ± 25.0 μVs vs 63.6 ± 26.2 μVs, P < .001). QRSA was similar among men and women with strict LBBB (P = .533). Female sex was associated with better long-term outcomes in an unadjusted model (hazard ratio 0.623, confidence interval 0.454–0.857, P = .004) but sex no longer predicted outcomes after accounting for differences in QRSA. Conclusions Our study suggests that sex-specific differences in LV dyssynchrony contribute to greater CRT benefit among women. Standard QRSd and morphology assessments seem to underestimate the extent of LV electrical dyssynchrony among women with LBBB.
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Affiliation(s)
- Daniel J Friedman
- Section of Cardiac Electrophysiology, Yale School of Medicine, New Haven, Connecticut
| | - Kasper Emerek
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Peter L Sørensen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Emily P Zeitler
- Division of Cardiology, The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Sarah A Goldstein
- Section of Cardiac Electrophysiology, Duke University School of Medicine, Durham, North Carolina
| | - Sana M Al-Khatib
- Section of Cardiac Electrophysiology, Duke University School of Medicine, Durham, North Carolina
| | - Peter Søgaard
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Brett D Atwater
- Section of Cardiac Electrophysiology, Duke University School of Medicine, Durham, North Carolina
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30
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Ramirez FD. Sex Differences in Cardiac Resynchronization Therapy Device Implantations and Complications: Tough Questions, Tougher Answers. Can J Cardiol 2020; 37:14-16. [PMID: 32619450 DOI: 10.1016/j.cjca.2020.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 03/17/2020] [Accepted: 03/17/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- F Daniel Ramirez
- Hôpital Cardiologique du Haut Lévêque, CHU Bordeaux, and LIRYC (L'Institut de Rythmologie et Modélisation Cardiaque), Bordeaux-Pessac, France.
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31
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Mohamed MO, Contractor T, Zachariah D, van Spall HGC, Parwani P, Minissian MB, Rashid M, Martin GP, Barker D, Patwala A, Mamas MA. Sex Disparities in the Choice of Cardiac Resynchronization Therapy Device: An Analysis of Trends, Predictors, and Outcomes. Can J Cardiol 2020; 37:86-93. [PMID: 32376344 DOI: 10.1016/j.cjca.2020.02.073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 01/13/2020] [Accepted: 02/09/2020] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND There is limited evidence on the influence of sex on the decision to implant a cardiac resynchronization therapy device with pacemaker (CRT-P) or defibrillator (CRT-D) and the existence of sex-dependent differences in complications that may affect this decision. METHODS All patients undergoing de novo CRT implantation (2004-2014) in the United States National Inpatient Sample were included and stratified by device type (CRT-P and CRT-D). Multivariable logistic regression models were conducted to assess the association of female sex with receipt of CRT-D and periprocedural complications. RESULTS Out of 400,823 weighted CRT procedural records, the overall percentages of women undergoing CRT-P and CRT-D implantations were 41.5% and 27.8%, respectively, and these percentages increased compared with men over the study period. Women were less likely to receive CRT-D (odds ratio 0.66, 95% confidence interval 0.64-0.67), and this trend remained stable throughout the study period (P = 0.06). Furthermore, compared with men, women were associated with increased odds of procedure-related complications (bleeding, thoracic, and cardiac) in the CRT-D group but not in the CRT-P group. Factors such as atrial fibrillation, malignancies, renal failure, advanced age (> 60 years), and admission to nonurban/small hospitals favoured the receipt of CRT-P over CRT-D, whereas history of ischemic heart disease, cardiac arrest ,or ventricular arrhythmias favoured the receipt of CRT-D over CRT-P. CONCLUSIONS Women were associated with persistently reduced odds of receipt of CRT-D compared with men over an 11-year period. This study identifies important factors that predict the choice of CRT device offered to patients in the United States.
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Affiliation(s)
- Mohamed Osama Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Keele, United Kingdom; Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | | | - Donah Zachariah
- Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Harriette G C van Spall
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Margo B Minissian
- Barbara Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Keele, United Kingdom
| | - Glen P Martin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Diane Barker
- Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Ashish Patwala
- Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Keele, United Kingdom; Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom; Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom.
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32
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Abstract
This in-depth review of sex differences in advanced heart failure therapy summarizes the existing literature on implantable cardioverter defibrillators, biventricular pacemakers, mechanical circulatory support, and transplantation with a focus on utilization, efficacy/clinical effectiveness, adverse events, and controversies. One will learn about the controversies regarding efficacy/clinical effectiveness of implantable cardioverter defibrillators and understand why these devices should be implanted in women even if there are sex differences in appropriate shocks. Individuals will learn about the sex differences with biventricular pacemakers with respect to ventricular remodeling and reduction in heart failure hospitalizations/mortality, as well as, possible mechanisms. We will demonstrate sex differences in heart transplantation and waitlist survival. Despite similar survival for women and men with left ventricular assist devices, there are sex differences in adverse events. These devices do successfully bridge women and men to transplant, yet women are less likely than men to have a left ventricular assist at time of listing and time of transplantation. Finally, one will learn about the concerns regarding poor outcome for men who receive female donor hearts and discover this may not be due to sex, but rather size. More research is needed to better understand sex differences and further improve advanced heart failure therapy for both women and men.
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Affiliation(s)
- Eileen M Hsich
- Heart and Vascular Institute at the Cleveland Clinic, OH. Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine, OH
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33
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Lee AWC, O'Regan DP, Gould J, Sidhu B, Sieniewicz B, Plank G, Warriner DR, Lamata P, Rinaldi CA, Niederer SA. Sex-Dependent QRS Guidelines for Cardiac Resynchronization Therapy Using Computer Model Predictions. Biophys J 2019; 117:2375-2381. [PMID: 31547974 PMCID: PMC6990372 DOI: 10.1016/j.bpj.2019.08.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/16/2019] [Accepted: 08/12/2019] [Indexed: 01/30/2023] Open
Abstract
Cardiac resynchronization therapy (CRT) is an important treatment for heart failure. Low female enrollment in clinical trials means that current CRT guidelines may be biased toward males. However, females have higher response rates at lower QRS duration (QRSd) thresholds. Sex differences in the left ventricle (LV) size could provide an explanation for the improved female response at lower QRSd. We aimed to test if sex differences in CRT response at lower QRSd thresholds are explained by differences in LV size and hence predict sex-specific guidelines for CRT. We investigated the effect that LV size sex difference has on QRSd between male and females in 1093 healthy individuals and 50 CRT patients using electrophysiological computer models of the heart. Simulations on the healthy mean shape models show that LV size sex difference can account for 50–100% of the sex difference in baseline QRSd in healthy individuals. In the CRT patient cohort, model simulations predicted female-specific guidelines for CRT, which were 9–13 ms lower than current guidelines. Sex differences in the LV size are able to account for a significant proportion of the sex difference in QRSd and provide a mechanistic explanation for the sex difference in CRT response. Simulations accounting for the smaller LV size in female CRT patients predict 9–13 ms lower QRSd thresholds for female CRT guidelines.
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Affiliation(s)
- Angela W C Lee
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Declan P O'Regan
- MRC London Institute of Medical Sciences, Imperial College London, London, UK
| | - Justin Gould
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Baldeep Sidhu
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Benjamin Sieniewicz
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Gernot Plank
- Department of Biophysics, Medical University of Graz, Graz, Austria
| | - David R Warriner
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Pablo Lamata
- 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
| | - Steven A Niederer
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.
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34
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Tam E, Piña IL. Sex Differences in Heart Failure—Female Representation in Heart Failure Studies. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0613-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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35
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Wang NC, Mezu-Chukwu U, Adelstein EC, Althouse AD, Sharbaugh MS, Jain SK, Shalaby AA, Voigt AH, Saba S. Sex-specific clinical outcomes after cardiac resynchronization therapy in left bundle branch block-associated idiopathic nonischemic cardiomyopathy: A NEOLITH II substudy. Ann Noninvasive Electrocardiol 2019; 24:e12641. [PMID: 30919524 DOI: 10.1111/anec.12641] [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: 12/12/2018] [Revised: 12/30/2018] [Accepted: 01/23/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Sex differences in clinical outcomes for left bundle branch block (LBBB)-associated idiopathic nonischemic cardiomyopathy (NICM) after cardiac resynchronization therapy (CRT) are not well described. METHODS A retrospective cohort study at an academic medical center included subjects with LBBB-associated idiopathic NICM who received CRT. Cox regression analyses estimated the hazard ratios (HRs) between sex and clinical outcomes. RESULTS In 123 total subjects (mean age 62 years, mean initial left ventricular ejection fraction 22.8%, 76% New York Heart Association class III, and 98% CRT-defibrillators), 55 (45%) were men and 68 (55%) were women. The median follow-up time after CRT was 72.4 months. Similar risk for adverse clinical events (heart failure hospitalization, appropriate implantable cardioverter-defibrillator shock, appropriate antitachycardia pacing therapy, ventricular assist device implantation, heart transplantation, and death) was observed between men and women (HR, 1.20; 95% confidence interval [CI] 0.57-2.51; p = 0.63). This persisted in multivariable analyses. Men and women had similar risk for all-cause mortality in univariable analysis, but men had higher risk in the final multivariable model that adjusted for age at diagnosis, QRS duration, and left ventricular end-diastolic dimension index (HR, 4.55; 95% CI, 1.26-16.39; p = 0.02). The estimated 5-year mortality was 9.5% for men and 6.9% for women. CONCLUSIONS In LBBB-associated idiopathic NICM, men have higher risk for all-cause mortality after CRT when compared to women.
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Affiliation(s)
- Norman C Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ure Mezu-Chukwu
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Andrew D Althouse
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael S Sharbaugh
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sandeep K Jain
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Alaa A Shalaby
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew H Voigt
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Samir Saba
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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36
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Zweerink A, Friedman DJ, Klem I, van de Ven PM, Vink C, Biesbroek PS, Hansen SM, Emerek K, Kim RJ, van Rossum AC, Atwater BD, Nijveldt R, Allaart CP. Size Matters. Circ Arrhythm Electrophysiol 2018; 11:e006767. [DOI: 10.1161/circep.118.006767] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alwin Zweerink
- Department of Cardiology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, the Netherlands (ACS) (A.Z., C.V., S.B., A.C.v.R., R.N., C.P.A.)
| | - Daniel J. Friedman
- Division of Cardiology, Duke University Hospital, Durham, NC (D.J.F., I.K., S.M.H., K.E., R.J.K., B.D.A.)
| | - Igor Klem
- Division of Cardiology, Duke University Hospital, Durham, NC (D.J.F., I.K., S.M.H., K.E., R.J.K., B.D.A.)
| | - Peter M. van de Ven
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, the Netherlands (P.M.v.d.V.)
| | - Caitlin Vink
- Department of Cardiology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, the Netherlands (ACS) (A.Z., C.V., S.B., A.C.v.R., R.N., C.P.A.)
| | - P. Stefan Biesbroek
- Department of Cardiology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, the Netherlands (ACS) (A.Z., C.V., S.B., A.C.v.R., R.N., C.P.A.)
| | - Steen M. Hansen
- Division of Cardiology, Duke University Hospital, Durham, NC (D.J.F., I.K., S.M.H., K.E., R.J.K., B.D.A.)
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Denmark (S.M.H.)
| | - Kasper Emerek
- Division of Cardiology, Duke University Hospital, Durham, NC (D.J.F., I.K., S.M.H., K.E., R.J.K., B.D.A.)
- Department of Clinical Medicine, Aalborg University Hospital, Denmark (K.E.)
| | - Raymond J. Kim
- Division of Cardiology, Duke University Hospital, Durham, NC (D.J.F., I.K., S.M.H., K.E., R.J.K., B.D.A.)
| | - Albert C. van Rossum
- Department of Cardiology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, the Netherlands (ACS) (A.Z., C.V., S.B., A.C.v.R., R.N., C.P.A.)
| | - Brett D. Atwater
- Division of Cardiology, Duke University Hospital, Durham, NC (D.J.F., I.K., S.M.H., K.E., R.J.K., B.D.A.)
| | - Robin Nijveldt
- Department of Cardiology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, the Netherlands (ACS) (A.Z., C.V., S.B., A.C.v.R., R.N., C.P.A.)
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands (R.N.)
| | - Cornelis P. Allaart
- Department of Cardiology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, the Netherlands (ACS) (A.Z., C.V., S.B., A.C.v.R., R.N., C.P.A.)
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Crousillat DR, Ibrahim NE. Sex Differences in the Management of Advanced Heart Failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:88. [PMID: 30242521 DOI: 10.1007/s11936-018-0687-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Heart failure (HF) is prevalent among women and remains a leading cause of morbidity and mortality in the United States. Currently, 3 million women live with HF and the prevalence is projected to continue to increase. The purpose of this review is to highlight sex differences in the use and response to evidence-based pharmacological, device, and advanced HF therapies, as well as explore emerging areas of research in sex differences in the treatment of HF. RECENT FINDINGS Under-representation of women in clinical HF trials has limited our understanding of sex-related differences in the treatment and outcomes of HF. Important sex differences exist in the use of evidence-based HF therapies and clinical response among women with HF. In general, women tend to obtain the same clinical benefit from evidence-based HF drug and device therapies, but the utilization rates of guideline-directed medical therapies remain poor compared to men. Future research efforts should focus on increasing the enrollment of women in HF trials to help gain helpful insight into sex-specific differences in treatment effects and subsequent clinical outcomes.
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Affiliation(s)
| | - Nasrien E Ibrahim
- Massachusetts General Hospital, 55 Fruit Street GRB-800, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, USA.
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Safety and Effectiveness of Medical Device Therapy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1065:107-121. [DOI: 10.1007/978-3-319-77932-4_7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Varma N, Sogaard P, Bax JJ, Abraham WT, Borer JS, Dickstein K, Singh JP, Gras D, Holzmeister J, Brugada J, Ruschitzka F. Interaction of Left Ventricular Size and Sex on Outcome of Cardiac Resynchronization Therapy Among Patients With a Narrow QRS Duration in the EchoCRT Trial. J Am Heart Assoc 2018; 7:JAHA.118.009592. [PMID: 29807890 PMCID: PMC6015380 DOI: 10.1161/jaha.118.009592] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Longer QRS duration (QRSd) improves, but increased left ventricular (LV) end-diastolic volume (LVEDV) reduces, efficacy of cardiac resynchronization therapy (CRT). QRSd/LVEDV ratios differ between sexes. We hypothesized that in the EchoCRT (Echocardiography Guided Cardiac Resynchronization Therapy) trial enrolling patients with heart failure with QRSd <130 ms, those with larger LVEDV would deteriorate but those with the highest QRSd/LVEDV would improve with CRT. METHODS AND RESULTS Primary outcome in patients (n=787, 72% men, 93% New York Heart Association class III, QRSd <130 ms, LV ejection fraction ≤35%, LV dilation and dyssynchrony) randomized to CRT-ON or CRT-OFF and followed up for 19 months was compared according to LVEDV (height indexed) or QRSd/LVEDV ratio, in multivariable analysis. Structural remodeling was assessed echocardiographically 6 months after implantation. Patients with baseline LVEDV higher than or equal to median worsened with CRT (death/heart failure hospitalization: CRT-ON versus CRT-OFF, 35.2% versus 24.5% [hazard ratio, 1.64; 95% confidence interval, 1.11-2.42; P=0.012]), but those with LVEDV lower than median remained unaffected. Patients with the highest QRSd/LVEDV ratio improved with CRT (death/heart failure hospitalization in top quartile: 20.9% in CRT-ON [n=91] versus 28.3% in CRT-OFF [n=106] [hazard ratio, 0.64; 95% confidence interval, 0.34-1.24; P=0.188], versus the remaining quartiles: 31.7% in CRT-ON [n=300] versus 24.8% in CRT-OFF [n=290] [hazard ratio, 1.47; 95% confidence interval, 1.07-2.02; P=0.016], test for interaction P=0.046). QRSd and dyssynchrony were similar between groups. The 3-way test for interaction indicated no sex-specific effects. However, numerically, men with LVEDV higher than or equal to median accounted for worse outcomes of CRT-ON. Women, with the highest QRSd/LVEDV ratio exhibited significant reverse remodeling. CONCLUSION CRT has opposite effects among patients with heart failure with QRSd <130 ms according to LV size: worsening outcomes in patients with larger LV, but inducing beneficial effects in those with smaller LV. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00683696.
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Affiliation(s)
- Niraj Varma
- Cleveland Clinic, Heart and Vascular Institute, Cleveland, OH
| | | | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - William T Abraham
- Division of Cardiovascular Medicine, Ohio State University Medical Center, Davis Heart and Lung Research Institute, Columbus, OH
| | - Jeffrey S Borer
- Division of Cardiovascular Medicine and Howard Gilman and Ron and Jean Schiavone Institutes, State University of New York Downstate College of Medicine, Brooklyn, NY
| | - Kenneth Dickstein
- University of Bergen Stavanger University Hospital, Stavanger, Norway
| | - Jagmeet P Singh
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Corrigan Minehan Heart Center, Boston, MA
| | - Daniel Gras
- Nouvelles Cliniques Nantaises, Nantes, France
| | | | - Josep Brugada
- Cardiology Department, Thorax Institute, Hospital Clinic, University of Barcelona, Spain
| | - Frank Ruschitzka
- Clinic for Cardiology, University Hospital Zurich, Zurich, Switzerland
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Varma N, O'Donnell D, Bassiouny M, Ritter P, Pappone C, Mangual J, Cantillon D, Badie N, Thibault B, Wisnoskey B. Programming Cardiac Resynchronization Therapy for Electrical Synchrony: Reaching Beyond Left Bundle Branch Block and Left Ventricular Activation Delay. J Am Heart Assoc 2018; 7:e007489. [PMID: 29432133 PMCID: PMC5850248 DOI: 10.1161/jaha.117.007489] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 11/30/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND QRS narrowing following cardiac resynchronization therapy with biventricular (BiV) or left ventricular (LV) pacing is likely affected by patient-specific conduction characteristics (PR, qLV, LV-paced propagation interval), making a universal programming strategy likely ineffective. We tested these factors using a novel, device-based algorithm (SyncAV) that automatically adjusts paced atrioventricular delay (default or programmable offset) according to intrinsic atrioventricular conduction. METHODS AND RESULTS Seventy-five patients undergoing cardiac resynchronization therapy (age 66±11 years; 65% male; 32% with ischemic cardiomyopathy; LV ejection fraction 28±8%; QRS duration 162±16 ms) with intact atrioventricular conduction (PR interval 194±34, range 128-300 ms), left bundle branch block, and optimized LV lead position were studied at implant. QRS duration (QRSd) reduction was compared for the following pacing configurations: nominal simultaneous BiV (Mode I: paced/sensed atrioventricular delay=140/110 ms), BiV+SyncAV with 50 ms offset (Mode II), BiV+SyncAV with offset that minimized QRSd (Mode III), or LV-only pacing+SyncAV with 50 ms offset (Mode IV). The intrinsic QRSd (162±16 ms) was reduced to 142±17 ms (-11.8%) by Mode I, 136±14 ms (-15.6%) by Mode IV, and 132±13 ms (-17.8%) by Mode II. Mode III yielded the shortest overall QRSd (123±12 ms, -23.9% [P<0.001 versus all modes]) and was the only configuration without QRSd prolongation in any patient. QRS narrowing occurred regardless of QRSd, PR, or LV-paced intervals, or underlying ischemic disease. CONCLUSIONS Post-implant electrical optimization in already well-selected patients with left bundle branch block and optimized LV lead position is facilitated by patient-tailored BiV pacing adjusted to intrinsic atrioventricular timing using an automatic device-based algorithm.
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Affiliation(s)
| | | | | | | | - Carlo Pappone
- Department of Electrophysiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | | | | | | | - Bernard Thibault
- Electrophysiology Service, Montreal Heart Institute, Montreal, Canada
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Varma N, Mittal S, Prillinger JB, Snell J, Dalal N, Piccini JP. Survival in Women Versus Men Following Implantation of Pacemakers, Defibrillators, and Cardiac Resynchronization Therapy Devices in a Large, Nationwide Cohort. J Am Heart Assoc 2017; 6:JAHA.116.005031. [PMID: 28490521 PMCID: PMC5524072 DOI: 10.1161/jaha.116.005031] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Whether outcomes differ between sexes following treatment with pacemakers (PM), implantable cardioverter defibrillators, and cardiac resynchronization therapy (CRT) devices is unclear. Methods and Results Consecutive US patients with newly implanted PM, implantable cardioverter defibrillators, and CRT devices from a large remote monitoring database between 2008 and 2011 were included in this observational cohort study. Sex‐specific all‐cause survival postimplant was compared within each device type using a multivariable Cox proportional hazards model, stratified on age and adjusted for remote monitoring utilization and ZIP‐based socioeconomic variables. A total of 269 471 patients were assessed over a median 2.9 [interquartile range, 2.2, 3.6] years. Unadjusted mortality rates (MR; deaths/100 000 patient‐years) were similar between women versus men receiving PMs (n=115 076, 55% male; MR 4193 versus MR 4256, respectively; adjusted hazard ratio, 0.87; 95% CI, 0.84–0.90; P<0.001) and implantable cardioverter defibrillators (n=85 014, 74% male; MR 4417 versus MR 4479, respectively; adjusted hazard ratio, 0.98; 95% CI, 0.93–1.02; P=0.244). In contrast, survival was superior in women receiving CRT defibrillators (n=61 475, 72% male; MR 5270 versus male MR 7175; adjusted hazard ratio, 0.73; 95% CI, 0.70–0.76; P<0.001) and also CRT pacemakers (n=7906, 57% male; MR 5383 versus male MR 7625, adjusted hazard ratio, 0.69; 95% CI, 0.61–0.78; P<0.001). This relative difference increased with time. These results were unaffected by age or remote monitoring utilization. Conclusions Women accounted for less than 30% of high‐voltage implants and fewer than half of low‐voltage implants in a large, nation‐wide cohort. Survival for women and men receiving implantable cardioverter defibrillators and PMs was similar, but dramatically greater for women receiving both defibrillator‐ and PM‐based CRT.
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