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Kerr N, Miller RJH, Chew DS. Can nuclear cardiology optimize cardiac resynchronization therapy lead placement: Paving the way to precision medicine? J Nucl Cardiol 2024; 36:101873. [PMID: 38704017 DOI: 10.1016/j.nuclcard.2024.101873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/06/2024]
Affiliation(s)
- Nicholas Kerr
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Robert J H Miller
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Derek S Chew
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, AB, Canada.
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2
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Nguyên UC, Prinzen FW, Vernooy K. Left ventricular lead placement in cardiac resynchronization therapy: Current data and potential explanations for the lack of benefit. Heart Rhythm 2024; 21:197-205. [PMID: 37806647 DOI: 10.1016/j.hrthm.2023.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/22/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Abstract
The present article reviews the literature on image-guided cardiac resynchronization therapy (CRT) studies. Improved outcome to CRT has been associated with the placement of a left ventricular (LV) lead in the latest activated segment free from scar. The majority of randomized controlled trials investigating guided LV lead implantation did not show superiority over conventional implantation approaches. Several factors may contribute to this paradoxical observation, including inclusion criteria favoring patients with left bundle branch block who already respond well to conventional anatomical LV lead implantation, differences in activation wavefronts during simultaneous right ventricular and LV pacing, incorrect definition of target regions, and limitations in coronary venous anatomy that prevent access to target regions that are detected by imaging. It is imperative that exclusion of patients lacking access to target regions from these studies would lead to larger benefit of image-guided CRT.
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Affiliation(s)
- Uyên Châu Nguyên
- Department of Physiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands; Department of Cardiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.
| | - Frits W Prinzen
- Department of Physiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
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Grbović A, Pavlović S, Žugić V. Predictors of Higher Frequency of Atrial Fibrillation in Patients with Cardiac Resynchronization Therapy. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2178. [PMID: 38138281 PMCID: PMC10745040 DOI: 10.3390/medicina59122178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/15/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: Cardiac resynchronization therapy (CRT) is one of the effective therapeutic options in the treatment of systolic heart failure (HF) with persistent symptoms. This prospective study was designed to determine whether CRT with biventricular pacing would reduce the risk of development of atrial fibrillation (AF) and to identify predictors for AF occurrence. Materials and Methods: The study population consisted of 126 patients, with a mean age of 63.8 ± 9.1 years, who were eligible for CRT with biventricular pacing. Inclusion criteria were left ventricular ejection fraction (LVEF) ≤ 35%, QRS duration ≥ 130 msec, and persistent HF symptoms of New York Heart Association (NYHA) II or III, despite optimal drug therapy. Patients were followed for a period of 24 months and were evaluated through clinical, electrocardiographic, and echocardiographic examination at baseline (prior to CRT implantation), as well as at 6 and 24 months post-implantation. At the end of follow-up, patients were divided into clinical responders and non-responders based on the following criteria: decrease in NYHA class ≥ I, increase in LVEF ≥ 10%, and reduction in QRS duration ≥ 20 msec. Results: At follow-up, CRT was associated with a significant increase in LVEF (20.6 ± 6.9% pre-implantation, 32.9 ± 9.3% 24 months after implantation; p < 0.001), reduction in left ventricular end-diastolic and end-systolic diameters, and decrease in QRS duration (167.6 ± 14.3 msec pre-implantation, 131.7 ± 11.7 msec 24 months after implantation; p < 0.001), while left atrial (LA) diameter was slightly increased (p = 0.070). The frequency of AF occurrence increased after two years of follow-up (52.4% to 56.9%, p < 0.001). Significant predictors of AF occurrence in our study population were response to CRT-AF more frequent in non-responders (B = 8.134; p < 0.001), LA diameter-AF more frequent with larger LA diameter (B = 0.813; p < 0.001), and coronary sinus (CS) lead position-AF more frequent with posterolateral in comparison with lateral CS lead position (B = 5.159; p = 0.005). Conclusions: The results of our study provide new data on AF predictors in patients with HF subjected to CRT. There remains a permanent need for new predictors, which might help in patient selection and improvement in response rate.
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Affiliation(s)
- Aleksandra Grbović
- Dedinje Cardiovascular Institute, Heroja Milana Tepića 1, 11000 Belgrade, Serbia; (S.P.); (V.Ž.)
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Friedman DJ, Qin L, Freeman JV, Singh JP, Curtis JP, Piccini JP, Al-Khatib SM, Jackson KP. Left ventricular lead implantation failure in an unselected nationwide cohort. Heart Rhythm 2023; 20:1420-1428. [PMID: 37406870 DOI: 10.1016/j.hrthm.2023.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 06/26/2023] [Accepted: 06/29/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Left ventricular (LV) lead implantation is often the most challenging aspect of cardiac resynchronization therapy (CRT) procedures; early studies reported implant failure rates in ∼10% of cases. OBJECTIVE The purpose of this study was to define rates, reasons for, and factors independently associated with LV lead implant failure. METHODS We studied patients with left bundle branch block and ejection fraction ≤ 35% who underwent planned de novo transvenous CRT implantation (2010-2016) and were reported to the National Cardiovascular Data Registry ICD Registry. Independent predictors of LV lead implant failure were determined using logistic regression; age, sex, and variables with a univariable P value of <.15 were considered for inclusion in the model. RESULTS Of the 111,802 patients who underwent a planned CRT procedure, 3.6% of patients (n = 3979) had LV lead implant failure. Reasons for implant failure included venous access (7.5%), coronary sinus access (64.3%), tributary vein access (13.5%), coronary sinus dissection (7.6%), unacceptable threshold (4.4%), and diaphragmatic stimulation (1.7%). Significant independent predictors of LV lead implant failure included younger age (odds ratio [OR] 1.01; 95% confidence interval [CI] 0.1.01-1.02), female sex (OR 1.38; 95% CI 1.29-1.47), black race (vs white, OR 1.44; 95% CI 1.32-1.57), Hispanic ethnicity (OR 1.23; 95% CI 1.08-1.40), QRS duration (OR 1.055 per 10 ms; 95% CI 1.038-1.072 per 10 ms), obstructive sleep apnea (OR 1.14; 95% CI 1.04-1.24), and implantation by a physician without specialized training (vs electrophysiology trained, OR 1.53; 95% CI 1.34-1.76). CONCLUSION LV lead implant failure is uncommon in the current era and is most commonly due to coronary sinus access failure. Predictors of LV lead implant failure included younger age, female sex, black race, Hispanic ethnicity, increased QRS duration, sleep apnea, and absence of electrophysiology training.
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Affiliation(s)
- Daniel J Friedman
- Electrophysiology Section, Duke University Hospital, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
| | - Li Qin
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
| | - James V Freeman
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
| | - Jagmeet P Singh
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeptha P Curtis
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
| | - Jonathan P Piccini
- Electrophysiology Section, Duke University Hospital, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Sana M Al-Khatib
- Electrophysiology Section, Duke University Hospital, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Kevin P Jackson
- Electrophysiology Section, Duke University Hospital, Durham, North Carolina
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Gerrits W, Danad I, Velthuis B, Mushtaq S, Cramer MJ, van der Harst P, van Slochteren FJ, Meine M, Suchá D, Guglielmo M. Cardiac CT in CRT as a Singular Imaging Modality for Diagnosis and Patient-Tailored Management. J Clin Med 2023; 12:6212. [PMID: 37834855 PMCID: PMC10573271 DOI: 10.3390/jcm12196212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/16/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
Between 30-40% of patients with cardiac resynchronization therapy (CRT) do not show an improvement in left ventricular (LV) function. It is generally known that patient selection, LV lead implantation location, and device timing optimization are the three main factors that determine CRT response. Research has shown that image-guided CRT placement, which takes into account both anatomical and functional cardiac properties, positively affects the CRT response rate. In current clinical practice, a multimodality imaging approach comprised of echocardiography, cardiac magnetic resonance imaging, or nuclear medicine imaging is used to capture these features. However, with cardiac computed tomography (CT), one has an all-in-one acquisition method for both patient selection and the division of a patient-tailored, image-guided CRT placement strategy. This review discusses the applicability of CT in CRT patient identification, selection, and guided placement, offering insights into potential advancements in optimizing CRT outcomes.
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Affiliation(s)
- Willem Gerrits
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Ibrahim Danad
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Birgitta Velthuis
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Saima Mushtaq
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Via Parea 4, 20138 Milan, Italy
| | - Maarten J. Cramer
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Pim van der Harst
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Frebus J. van Slochteren
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- CART-Tech BV, Padualaan 8, 3584 CH Utrecht, The Netherlands
| | - Mathias Meine
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Dominika Suchá
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Marco Guglielmo
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Department of Cardiology, Haga Teaching Hospital, Els Borst-Eilersplein 275, 2545 AA The Hague, The Netherlands
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Melgaard J, van Dam PM, Sommer A, Fruelund P, Nielsen JC, Riahi S, Graff C. Non-invasive estimation of QLV from the standard 12-lead ECG in patients with left bundle branch block. Front Physiol 2022; 13:939240. [PMID: 36213226 PMCID: PMC9532835 DOI: 10.3389/fphys.2022.939240] [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: 05/08/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Cardiac resynchronization therapy (CRT) is a treatment for patients with heart failure and electrical dyssynchrony, i.e., left bundle branch block (LBBB) ECG pattern. CRT resynchronizes ventricular contraction with a right ventricle (RV) and a left ventricle (LV) pacemaker lead. Positioning the LV lead in the latest electrically activated region (measured from Q wave onset in the ECG to LV sensing by the left pacemaker electrode [QLV]) is associated with favorable outcome. However, optimal LV lead placement is limited by coronary venous anatomy and the inability to measure QLV non-invasively before implantation. We propose a novel non-invasive method for estimating QLV in sinus-rhythm from the standard 12-lead ECG.Methods: We obtained 12-lead ECG, LV electrograms and LV lead position in a standard LV 17-segment model from procedural recordings from 135 standard CRT recipients. QLV duration was measured post-operatively. Using a generic heart geometry and corresponding forward model for ECG computation, the electrical activation pattern of the heart was fitted to best match the 12-lead ECG in an iterative optimization procedure. This procedure initialized six activation sites associated with the His-Purkinje system. The initial timing of each site was based on the directions of the vectorcardiogram (VCG). Timing and position of the sites were then changed iteratively to improve the match between simulated and measured ECG. Noninvasive estimation of QLV was done by calculating the time difference between Q-onset on the computed ECG and the activation time corresponding to centroidal epicardial activation time of the segment where the LV electrode is positioned. The estimated QLV was compared to the measured QLV. Further, the distance between the actual LV position and the estimated LV position was computed from the generic ventricular model.Results: On average there was no difference between QLV measured from procedural recordings and non-invasive estimation of QLV (ΔQLV=−3.0±22.5 ms, p=0.12). Median distance between actual LV pacing site and the estimated pacing site was 18.6 mm (IQR 17.3 mm).Conclusion: Using the standard 12-lead ECG and a generic heart model it is possible to accurately estimate QLV. This method may potentially be used to support patient selection, optimize implant procedures, and to simulate optimal stimulation parameters prior to pacemaker implantation.
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Affiliation(s)
- Jacob Melgaard
- CardioTech Research Group, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- *Correspondence: Jacob Melgaard,
| | - Peter M. van Dam
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
- Peacs BV, Nieuwerbrug Aan Den Rijn, Netherlands
| | - Anders Sommer
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Patricia Fruelund
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Sam Riahi
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Claus Graff
- CardioTech Research Group, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
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Green PG, Herring N, Betts TR. What Have We Learned in the Last 20 Years About CRT Non-Responders? Card Electrophysiol Clin 2022; 14:283-296. [PMID: 35715086 DOI: 10.1016/j.ccep.2021.12.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Although cardiac resynchronization therapy (CRT) has become well established in the treatment of heart failure, the management of patients who do not respond after CRT remains a key challenge. This review will summarize what we have learned about non-responders over the last 20 years and discuss methods for optimizing response, including the introduction of novel therapies.
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Affiliation(s)
- Peregrine G Green
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK; Oxford Centre for Clinical Magnetic Resonance Research (OCMR), University of Oxford, Level 0 John Radcliffe Hospital, Oxford, OX3 9DU, UK; Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Neil Herring
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK; Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Timothy R Betts
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK; Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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8
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Johansen JB, Nielsen JC, Kristensen J, Sandgaard NC. Troubleshooting the difficult left ventricular lead placement in cardiac resynchronization therapy: current status and future perspectives. Expert Rev Med Devices 2022; 19:341-352. [PMID: 35536115 DOI: 10.1080/17434440.2022.2075728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Cardiac resynchronization therapy (CRT) is an important option in modern cardiac implantable electronic device (CIED) treatment. Techniques for left ventricular (LV) lead placement in the coronary sinus and its tributaries are neither well described nor studied systematically, despite attention regarding where to place the LV lead. AREAS COVERED This review presents specialized tools and techniques to overcome some of the most common problems encountered in LV lead placement in CRT. These tools and techniques are termed Interventional-CRT (I-CRT), as they share technology with other interventional procedures. The main principle in I-CRT, compared to the traditional Over-The-Wire technique, is to add better support for delivery of the LV lead through dedicated inner catheters that also allows more flexibility with use of more guidewires and better imaging with direct venography in the target vein. EXPERT OPINION Even though CRT is an established therapeutic option, there are still many challenges in the implementation of the therapy. The cornerstone should be an ease of delivering the CRT and specifically implantation of the LV lead. Therefore, knowledge of the principles in I-CRT, as I-CRT could make implantation simpler in general and easier to reach the optimal LV pacing site.
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Affiliation(s)
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Kristensen
- Department of Cardiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Schiedat F, Bogossian H, Schöne D, Aweimer A, Patsalis PC, Hanefeld C, Mügge A, Kloppe A. Long-Term Performance Comparison of Bipolar Active vs. Quadripolar Passive Fixation Leads in Cardiac Resynchronisation Therapy. Front Cardiovasc Med 2021; 8:734666. [PMID: 34881300 PMCID: PMC8645570 DOI: 10.3389/fcvm.2021.734666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 10/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Bipolar active fixation (BipolarAFL) and quadripolar passive fixation left-ventricular leads (QuadPFL) have been designed to reduce the risk of phrenic nerve stimulation (PNS), enable targeted left-ventricular pacing, and overcome problems of difficult coronary venous anatomy and lead dislodgment. This study sought to report the long-term safety and performance of a BipolarAFL, Medtronic Attain Stability 20066, compared to QuadPFL. Methods: We performed a single-operator retrospective analysis of 81 patients receiving cardiac resynchronization therapy (CRT) (36 BipolarAFL, 45 QuadPFL). Immediate implant data and electrical and clinical data during follow-up (FU) were analyzed. Results: BipolarAFL has been chosen in patients with significantly larger estimated vein diameter (at the lead tip: 7.2 ± 4.1 Fr vs. 4.1 ± 2.3 Fr, p < 0.001) without significant time difference until the final lead position was achieved (BipolarAFL: 20.9 ± 10.5 min, vs. QuadPFL: 18.9 ± 8.9 min, p = 0.35). At 12 month FU no difference in response rate to CRT was recorded between BipolarAFL and QuadPFL according to left ventricular end-systolic volume (61.1 vs. 60.0%, p = 0.82) and New York Heart Association (66.7 vs. 62.2%, p = 0.32). At median FU of 48 months (IQR: 44-54), no lead dislodgment occurred in both groups but a significantly higher proportion of PNS was recorded in QuadPFL (13 vs. 0%, p < 0.05). Electrical parameters were stable during FU in both groups without significant differences. Conclusion: BipolarAFL can be implanted with ease in challenging coronary venous anatomy, shows excellent electrical performance and no difference in clinical outcome compared to QuadPFL.
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Affiliation(s)
- Fabian Schiedat
- Department of Cardiology and Angiology at University Hospital Bergmannsheil Bochum of the Ruhr-University Bochum, Bochum, Germany.,Department of Cardiology and Angiology at Marienhospital Gelsenkirchen, Gelsenkirchen, Germany
| | | | - Dominik Schöne
- Department of Cardiology and Angiology at Marienhospital Gelsenkirchen, Gelsenkirchen, Germany
| | - Assem Aweimer
- Department of Cardiology and Angiology at University Hospital Bergmannsheil Bochum of the Ruhr-University Bochum, Bochum, Germany
| | - Polykarpos C Patsalis
- Department of Cardiology and Angiology at University Hospital Bergmannsheil Bochum of the Ruhr-University Bochum, Bochum, Germany
| | - Christoph Hanefeld
- Department of Internal Medicine at Elisabeth Krankenhaus Bochum of the Ruhr University Bochum, Bochum, Germany
| | - Andreas Mügge
- Department of Cardiology and Angiology at University Hospital Bergmannsheil Bochum of the Ruhr-University Bochum, Bochum, Germany
| | - Axel Kloppe
- Department of Cardiology and Angiology at Marienhospital Gelsenkirchen, Gelsenkirchen, Germany
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Glikson M, Beinart R, Golovchiner G, Sheshet AB, Swissa M, Bolous M, Rosso R, Medina A, Haim M, Friedman P, Khalamaizer V, Benzvi S, Ito S, Goldenberg I, Klempfner R, Vaturi O, Oh JK. Radial strain imaging-guided lead placement for improving response to cardiac resynchronization therapy in patients with ischaemic cardiomyopathy: the raise cardiac resynchronization therapy trial. Europace 2021; 24:835-844. [PMID: 34734227 DOI: 10.1093/europace/euab253] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS To evaluate the benefit of speckle tracking radial strain imaging (STRSI)-guided left ventricular (LV) lead (LVL) positioning in cardiac resynchronization therapy (CRT) in patients (pts) with ischaemic cardiomyopathy with CRT indication. METHODS AND RESULTS We conducted a prospective randomized controlled trial. Patients were enrolled in nine centres with 2:1 randomization into two groups (guided vs. control). Patients underwent STRSI to identify the optimal LV position from six LV segments at midventricular level. Implantation via STRSI was attempted for recommended segment in the guided group only. Follow-up included echocardiography (6 months) and clinical evaluation (6 and 12 months). The primary endpoint was comparison % reduction in LV end-systolic volume at 6 months with baseline. Secondary endpoints included hospitalizations for heart failure and death, and improvement in additional echocardiographic measurements and quality of life score. A total of 172 patients (115 guided vs. 57 control) were enrolled. In the guided group, 60% of the implanted LV leads were adjudicated to be successfully located at the recommended segment, whereas in the control group 44% reached the best STRSI determined segment. There was no difference between the groups in any of the primary or secondary endpoints at 6 and 12 months. CONCLUSION Our findings suggest that echo-guided implantation of an LV lead using STRSI does not improve the clinical or echocardiographic response compared with conventional implantation.
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Affiliation(s)
- Michael Glikson
- Integrated Heart Centre, Shaare Zedek Medical Centre, Hebrew University, Jerusalem, Israel.,Arrhythmia center, Sheba Medical Centre, Tel Aviv University, Tel Hashomer, Israel
| | - Roy Beinart
- Arrhythmia center, Sheba Medical Centre, Tel Aviv University, Tel Hashomer, Israel
| | - Gregory Golovchiner
- Department of cardiology, Rabin MC, Tel Aviv University, Petah Tikva, Israel
| | - Alon Bar Sheshet
- Department of cardiology, Rabin MC, Tel Aviv University, Petah Tikva, Israel
| | - Moshe Swissa
- Department of cardiology, Kaplan MC, Hebrew University, Rehovot, Israel
| | - Munther Bolous
- Department of cardiology, Rambam MC, Technion Institute, Haifa, Israel
| | - Raphael Rosso
- Department of cardiology, Tel Aviv Souraski MC, Tel Aviv University, Tel Aviv, Israel
| | - Aharon Medina
- Integrated Heart Centre, Shaare Zedek Medical Centre, Hebrew University, Jerusalem, Israel
| | - Moti Haim
- Department of cardiology, Soroka MC, Ben Gurion University, Beer Sheba, Israel
| | - Paul Friedman
- Department of cardiovascular medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Shlomit Benzvi
- Israeli Centre for Cardiovascular Research, Tel Hashomer, Israel
| | - Saki Ito
- Department of cardiovascular medicine, Mayo Clinic, Rochester, MN, USA
| | - Ilan Goldenberg
- Israeli Centre for Cardiovascular Research, Tel Hashomer, Israel.,University of Rochester, Rochester, NY, USA
| | - Robert Klempfner
- Israeli Centre for Cardiovascular Research, Tel Hashomer, Israel
| | - Ori Vaturi
- Arrhythmia center, Sheba Medical Centre, Tel Aviv University, Tel Hashomer, Israel
| | - Jae K Oh
- Department of cardiovascular medicine, Mayo Clinic, Rochester, MN, USA
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11
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Butter C, Georgi C, Stockburger M. Optimal CRT Implantation-Where and How To Place the Left-Ventricular Lead? Curr Heart Fail Rep 2021; 18:329-344. [PMID: 34495452 PMCID: PMC8484220 DOI: 10.1007/s11897-021-00528-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 12/28/2022]
Abstract
Purpose of Review Cardiac resynchronization therapy (CRT) represents a well-established and effective non-pharmaceutical heart failure (HF) treatment in selected patients. Still, a significant number of patients remain CRT non-responders. An optimal placement of the left ventricular (LV) lead appears crucial for the intended hemodynamic and hence clinical improvement. A well-localized target area and tools that help to achieve successful lead implantation seem to be of utmost importance to reach an optimal CRT effect. Recent Findings Recent studies suggest previous multimodal imaging (CT/cMRI/ECG torso) to guide intraprocedural LV lead placement. Relevant benefit compared to empirical lead optimization is still a matter of debate. Technical improvements in leads and algorithms (e.g., multipoint pacing (MPP), adaptive algorithms) promise higher procedural success. Recently emerging alternatives for ventricular synchronization such as conduction system pacing (CSP), LV endocardial pacing, or leadless pacing challenge classical biventricular pacing. Summary This article reviews current strategies for a successful planning, implementation, and validation of the optimal CRT implantation. Pre-implant imaging modalities offer promising assistance for complex cases; empirical lead positioning and intraoperative testing remain the cornerstone in most cases and ensure a successful CRT effect.
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Affiliation(s)
- Christian Butter
- Department of Cardiology, Heart Center Brandenburg, University Hospital Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany
| | - Christian Georgi
- Department of Cardiology, Heart Center Brandenburg, University Hospital Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany
| | - Martin Stockburger
- Department of Internal Medicine/Cardiology, Havelland Kliniken GmbH, Nauen, Germany
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Raj A, Singh AP, Nath RK, Pandit N, Aggarwal P, Thakur AK, Bharadwaj R, Kumar V. Six months clinical outcome comparison between quadripolar and bipolar left ventricular leads in cardiac resynchronization therapy: A prospective, non-randomized, single-centre observational study. Indian Pacing Electrophysiol J 2021; 21:162-168. [PMID: 33636279 PMCID: PMC8116790 DOI: 10.1016/j.ipej.2021.02.009] [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] [Received: 08/27/2020] [Revised: 12/31/2020] [Accepted: 02/17/2021] [Indexed: 11/15/2022] Open
Abstract
Background and objectives Quadripolar left ventricular (LV) leads in cardiac resynchronization therapy (CRT) offer multi-vector pacing with different pacing configurations and hence enabling LV pacing at most suitable site with better lead stability. We aim to compare the outcomes between quadripolar and bipolar LV lead in patients receiving CRT. Methods In this prospective, non-randomized, single-center observational study, we enrolled 93 patients receiving CRT with bipolar (BiP) (n = 31) and quadripolar (Quad) (n = 62) LV lead between August 2016 to August 2019. Patients were followed for six months, and outcomes were compared with respect to CRT response (defined as ≥5% absolute increase in left ventricle ejection fraction), electrocardiographic, echocardiographic parameters, NYHA functional class improvement, and incidence of LV lead-related complication. Results At the end of six months follow up, CRT with quadripolar lead was associated with better response rate as compared to bipolar pacing (85.48% vs 64.51%; p = 0.03), lesser heart failure (HF) hospitalization events (1.5 vs 2; p = 0.04) and better improvement in HF symptoms (patients with ≥1 NYHA improvement 87.09% vs 67.74%; p = 0.04). There were fewer deaths per 100 patient-year (6.45 vs 9.37; p = 0.04) and more narrowing of QRS duration (Δ12.56 ± 3.11 ms vs Δ7.29 ± 1.87 ms; p = 0.04) with quadripolar lead use. Lead related complications were significantly more with the use of bipolar lead (74.19% vs 41.94%; p = 0.02). Conclusions Our prospective, non-randomized, single-center observational study reveals that patients receiving CRT with quadripolar leads have a better response to therapy, lesser heart failure hospitalizations, lower all-cause mortality, and fewer lead-related complications, proving its superiority over the bipolar lead.
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Affiliation(s)
- Ajay Raj
- Department of Cardiology, ABVIMS & Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Ajay Pratap Singh
- Department of Cardiology, ABVIMS & Dr. Ram Manohar Lohia Hospital, New Delhi, India.
| | - Ranjit Kumar Nath
- Department of Cardiology, ABVIMS & Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Neeraj Pandit
- Department of Cardiology, ABVIMS & Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Puneet Aggarwal
- Department of Cardiology, ABVIMS & Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Ashok Kumar Thakur
- Department of Cardiology, ABVIMS & Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Rajeev Bharadwaj
- Department of Cardiology, ABVIMS & Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Vinod Kumar
- Department of Cardiology, ABVIMS & Dr. Ram Manohar Lohia Hospital, New Delhi, India
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Non-infective left ventricular lead complications requiring re-intervention following cardiac resynchronization therapy: prevalence, causes and outcomes. J Interv Card Electrophysiol 2021; 63:69-75. [PMID: 33523328 DOI: 10.1007/s10840-021-00947-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Left ventricular (LV) lead complications in cardiac resynchronization therapy are challenging and poorly reported. We aimed to establish prevalence, causes and outcomes of LV lead complications requiring re-intervention. METHODS We analysed the rate of complications in 2551 consecutive patients who received a transvenous de novo LV lead as part of a cardiac resynchronization therapy device between 2000 and 2018. LV lead complications requiring re-intervention were identified; those due to infection were excluded. Patient, procedural and device characteristics, and outcomes were examined for non-infective LV lead complications requiring re-intervention. RESULTS During a median of 4.7 years, 142 (5.6%) patients required re-intervention for non-infective LV lead complications with a decrease from 10.7% between 2000 and 2004, 8.7% between 2005 and 2009, 3.2% between 2010 and 2014 to 3.2% after 2014. The most common complications were LV lead displacement (50%), high pacing threshold (28%) and phrenic nerve stimulation (15%). Of the complications, 79 (56%) occurred within 90 days post-implant and 63 (44%) later. At the end of the study period, 132/142 patients (93%) had a functional LV lead. Lead re-intervention was associated with higher risk of complications (20%), but no increase in mortality (P = 0.19). Quadripolar leads had longer longevity and lower risk of complications compared with unipolar and bipolar LV leads. CONCLUSIONS A small but significant proportion of patients required LV lead re-intervention for complications following de novo implant. Lead displacement accounted for half of the re-interventions. Re-intervention was associated with a higher complication rate, but 92% of these patients had functional LV leads at the end of follow-up.
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Behon A, Schwertner WR, Merkel ED, Kovács A, Lakatos BK, Zima E, Gellér L, Kutyifa V, Kosztin A, Merkely B. Lateral left ventricular lead position is superior to posterior position in long-term outcome of patients who underwent cardiac resynchronization therapy. ESC Heart Fail 2020; 7:3374-3382. [PMID: 33089662 PMCID: PMC7754922 DOI: 10.1002/ehf2.13066] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/08/2020] [Accepted: 09/24/2020] [Indexed: 11/15/2022] Open
Abstract
Aims Preferring side branch of coronary sinus during cardiac resynchronization therapy (CRT) implantation has been empirical due to the limited data on the association of left ventricular (LV) lead position and long‐term clinical outcome. We evaluated the long‐term all‐cause mortality by LV lead non‐apical positions and further characterized them by interlead electrical delay (IED). Methods and results In our retrospective database, 2087 patients who underwent CRT implantation were registered between 2000 and 2018. Those with non‐apical LV lead locations were classified into anterior (n = 108), posterior (n = 643), and lateral (n = 1336) groups. All‐cause mortality was assessed by Kaplan–Meier and Cox analyses. Echocardiographic response was measured 6 months after CRT implantation. During the median follow‐up time of 3.7 years, 1150 (55.1%) patients died—710 (53.1%) with lateral, 78 (72.2%) with anterior, and 362 (56.3%) with posterior positions. When we investigated the risk of all‐cause mortality, there was a significantly lower rate of death in patients with lateral LV lead location when compared with those with an anterior (P < 0.01) or posterior (P < 0.01) position. Multivariate analysis after adjustment for relevant clinical covariates such as age, sex, ischaemic aetiology, left bundle branch block morphology, atrial fibrillation, and device type revealed consistent results that lateral position is associated with a significant risk reduction of all‐cause mortality when compared with anterior [hazard ratio 0.69; 95% confidence interval (CI) 0.55–0.87; P < 0.01] or posterior (hazard ratio 0.84; 95% CI 0.74–0.96; P < 0.01) position. When echocardiographic response was evaluated within the lateral group, patients with an IED longer than 110 ms (area under the receiver operating characteristic curve, 0.63; 95% CI 0.53–0.73; P = 0.012) showed 2.1 times higher odds of improvement in echocardiographic response 6 months after the implantation. Conclusions In this study, we proved in a real‐world patient population that after CRT implantation, lateral LV lead location was associated with long‐term mortality benefit and is superior to both anterior and posterior positions. Moreover, patients with this position showed the greatest echocardiographic response over 110 ms IED.
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Affiliation(s)
- Anett Behon
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, Budapest, H-1122, Hungary
| | | | - Eperke Dóra Merkel
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, Budapest, H-1122, Hungary
| | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, Budapest, H-1122, Hungary
| | - Bálint Károly Lakatos
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, Budapest, H-1122, Hungary
| | - Endre Zima
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, Budapest, H-1122, Hungary
| | - László Gellér
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, Budapest, H-1122, Hungary
| | - Valentina Kutyifa
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, Budapest, H-1122, Hungary.,Cardiology Division, University of Rochester Medical Center, Rochester, NY, USA
| | - Annamária Kosztin
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, Budapest, H-1122, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, Budapest, H-1122, Hungary
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Marques P, Nunes‐Ferreira A, António PS, Aguiar‐Ricardo I, Lima da Silva G, Guimarães T, Bernardes A, Santos I, Pinto FJ, Sousa J. Modified snare technique improves left ventricular lead implant success for cardiac resynchronization therapy. J Cardiovasc Electrophysiol 2020; 31:2954-2963. [DOI: 10.1111/jce.14750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/28/2020] [Accepted: 09/04/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Pedro Marques
- Cardiology Department Centro Hospitalar Universitário Lisboa Norte Lisboa Portugal
- Cardiac Rhythm Abnormalities, CAML, CCUL, Lisbon School of Medicine Universidade de Lisboa Lisboa Portugal
| | - Afonso Nunes‐Ferreira
- Cardiology Department Centro Hospitalar Universitário Lisboa Norte Lisboa Portugal
- Cardiac Rhythm Abnormalities, CAML, CCUL, Lisbon School of Medicine Universidade de Lisboa Lisboa Portugal
- Heart Failure and Cardiomyopathies, CAML, CCUL, Lisbon School of Medicine Universidade de Lisboa Portugal
| | - Pedro S. António
- Cardiology Department Centro Hospitalar Universitário Lisboa Norte Lisboa Portugal
| | - Inês Aguiar‐Ricardo
- Cardiology Department Centro Hospitalar Universitário Lisboa Norte Lisboa Portugal
- Heart Failure and Cardiomyopathies, CAML, CCUL, Lisbon School of Medicine Universidade de Lisboa Portugal
| | - Gustavo Lima da Silva
- Cardiology Department Centro Hospitalar Universitário Lisboa Norte Lisboa Portugal
- Cardiac Rhythm Abnormalities, CAML, CCUL, Lisbon School of Medicine Universidade de Lisboa Lisboa Portugal
| | - Tatiana Guimarães
- Cardiology Department Centro Hospitalar Universitário Lisboa Norte Lisboa Portugal
- Heart Failure and Cardiomyopathies, CAML, CCUL, Lisbon School of Medicine Universidade de Lisboa Portugal
| | - Ana Bernardes
- Cardiology Department Centro Hospitalar Universitário Lisboa Norte Lisboa Portugal
| | - Igor Santos
- Cardiology Department Centro Hospitalar Universitário Lisboa Norte Lisboa Portugal
| | - Fausto J. Pinto
- Cardiology Department Centro Hospitalar Universitário Lisboa Norte Lisboa Portugal
- Structural and Coronary Heart Disease, CAML, CCUL, Lisbon School of Medicine Universidade de Lisboa Portugal
| | - João Sousa
- Cardiology Department Centro Hospitalar Universitário Lisboa Norte Lisboa Portugal
- Cardiac Rhythm Abnormalities, CAML, CCUL, Lisbon School of Medicine Universidade de Lisboa Lisboa Portugal
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Tapias C, Muratore C, Tentori M, Lara S, Pérez F, Pérez A, Peterson B, Rodríguez DA. Evaluación del impacto de la terapia de resincronización cardiaca en pacientes de Latinoamérica. REVISTA COLOMBIANA DE CARDIOLOGÍA 2020. [DOI: 10.1016/j.rccar.2019.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Dauw J, Martens P, Mullens W. CRT Optimization: What Is New? What Is Necessary? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:45. [PMID: 31342198 DOI: 10.1007/s11936-019-0751-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cardiac resynchronization therapy (CRT) has proven to improve quality of life, reduce heart failure hospitalization, and prolong life in selected heart failure patients with reduced ejection fraction, on optimal medical therapy and with electrical dyssynchrony. To ensure maximal benefit for CRT patients, optimization of care should be implemented. This begins with appropriate referring as well as selecting patients, knowing that the presence of left bundle branch block and QRS ≥ 150 ms is associated with the greatest reverse remodeling. The LV lead, preferably quadripolar, is best targeted in a postero-lateral position. After implantation, optimal device programming should aim for maximal biventricular pacing and in selected cases further electrical delay optimization might be of use. Even as important, is the implementation of thorough multidisciplinary heart failure care with medication uptitration, remote monitoring, rehabilitation, and patient education. The role of newer pacing strategies as endocardial or His-bundle pacing remains the subject of ongoing investigation.
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Affiliation(s)
- Jeroen Dauw
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium.
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