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Braams NJ, Boon GJAM, de Man FS, van Es J, den Exter PL, Kroft LJM, Beenen LFM, Huisman MV, Nossent EJ, Boonstra A, Vonk Noordegraaf A, Ruigrok D, Klok FA, Bogaard HJ, Meijboom LJ. Evolution of CT findings after anticoagulant treatment for acute pulmonary embolism in patients with and without an ultimate diagnosis of chronic thromboembolic pulmonary hypertension. Eur Respir J 2021; 58:13993003.00699-2021. [PMID: 34112733 DOI: 10.1183/13993003.00699-2021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/13/2021] [Indexed: 01/18/2023]
Abstract
INTRODUCTION The pulmonary arterial morphology of patients with pulmonary embolism (PE) is diverse and it is unclear how the different vascular lesions evolve after initiation of anticoagulant treatment. A better understanding of the evolution of computed tomography pulmonary angiography (CTPA) findings after the start of anticoagulant treatment may help to better identify those PE patients prone to develop chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to assess the evolution of various thromboembolic lesions on CTPA over time after the initiation of adequate anticoagulant treatment in individual acute PE patients with and without an ultimate diagnosis of CTEPH. METHODS We analysed CTPA at diagnosis of acute PE (baseline) and at follow-up in 41 patients with CTEPH and 124 patients without an ultimate diagnosis of CTEPH, all receiving anticoagulant treatment. Central and segmental pulmonary arteries were scored by expert chest radiologists as normal or affected. Lesions were further subclassified as 1) central thrombus, 2) total thrombotic occlusion, 3) mural thrombus, 4) web or 5) tapered pulmonary artery. RESULTS Central thrombi resolved after anticoagulant treatment, while mural thrombi and total thrombotic occlusions either resolved or evolved into webs or tapered pulmonary arteries. Only patients with an ultimate diagnosis of CTEPH exhibited webs and tapered pulmonary arteries on the baseline scan. Moreover, such lesions always persisted after follow-up. CONCLUSIONS Webs and tapered pulmonary arteries at the time of PE diagnosis strongly indicate a state of chronic PE and should raise awareness for possible CTEPH, particularly in patients with persistent dyspnoea after anticoagulant treatment for acute PE.
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Affiliation(s)
- Natalia J Braams
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Gudula J A M Boon
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frances S de Man
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Josien van Es
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paul L den Exter
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J M Kroft
- Dept of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ludo F M Beenen
- Dept of Radiology, Amsterdam UMC, AMC, Amsterdam, The Netherlands
| | - Menno V Huisman
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther J Nossent
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anco Boonstra
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Dieuwertje Ruigrok
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Frederikus A Klok
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Harm Jan Bogaard
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands .,H.J. Bogaard and L.J. Meijboom are co-last authors and contributed equally to this work
| | - Lilian J Meijboom
- Dept of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,H.J. Bogaard and L.J. Meijboom are co-last authors and contributed equally to this work
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2
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Oikonomou EK, Kokkinidis DG, Kampaktsis PN, Amir EA, Marwick TH, Gupta D, Thavendiranathan P. Assessment of Prognostic Value of Left Ventricular Global Longitudinal Strain for Early Prediction of Chemotherapy-Induced Cardiotoxicity: A Systematic Review and Meta-analysis. JAMA Cardiol 2020; 4:1007-1018. [PMID: 31433450 DOI: 10.1001/jamacardio.2019.2952] [Citation(s) in RCA: 197] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Importance Echocardiographic left ventricular global longitudinal strain (GLS) detects early subclinical ventricular dysfunction and can be used in patients receiving potentially cardiotoxic chemotherapy. A meta-analysis of the prognostic value of GLS for cancer therapy-related cardiac dysfunction (CTRCD) has not been performed, to our knowledge. Objective To explore the prognostic value of GLS for the prediction of CTRCD. Data Sources Systematic search of the MEDLINE, Embase, Scopus, and the Cochrane Library databases from database inception to June 1, 2018. Study Selection Cohort studies assessing the prognostic or discriminatory performance of GLS before or during chemotherapy for subsequent CTRCD. Data Extraction and Synthesis Random-effects meta-analysis and hierarchical summary receiver operating characteristic curves (HSROCs) were used to summarize the prognostic and discriminatory performance of different GLS indices. Publication bias was assessed using the Egger test, and meta-regression was performed to assess sources of heterogeneity. Main Outcomes and Measures The primary outcome was CTRCD, defined as a clinically significant change in left ventricular ejection fraction with or without new-onset heart failure symptoms. Results Analysis included 21 studies comprising 1782 patients with cancer, including breast cancer, hematologic malignancies, or sarcomas, treated with anthracyclines with or without trastuzumab. The incidence of CTRCD ranged from 9.3% to 43.8% over a mean follow-up of 4.2 to 23.0 months (pooled incidence, 21.0%). For active treatment absolute GLS (9 studies), the high-risk cutoff values ranged from -21.0% to -13.8%, with worse GLS associated with a higher CTRCD risk (odds ratio, 12.27; 95% CI, 7.73-19.47; area under the HSROC, 0.86; 95% CI, 0.83-0.89). For relative changes vs a baseline value (9 studies), cutoff values ranged from 2.3% to 15.9%, with a greater decrease linked to a 16-fold higher risk of CTRCD (odds ratio, 15.82; 95% CI, 5.84-42.85; area under the HSROC, 0.86; 95% CI, 0.83-0.89). Both indices showed significant publication bias. Meta-regression identified differences in sample size and CTRCD definition but not GLS cutoff value as significant sources of interstudy heterogeneity. Conclusions and Relevance In this meta-analysis, measurement of GLS after initiation of potentially cardiotoxic chemotherapy with anthracyclines with or without trastuzumab had good prognostic performance for subsequent CTRCD. However, risk of bias in the original studies, publication bias, and limited data on the incremental value of GLS and its optimal cutoff values highlight the need for larger prospective multicenter studies.
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Affiliation(s)
- Evangelos K Oikonomou
- Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Damianos G Kokkinidis
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York
| | - Polydoros N Kampaktsis
- Department of Cardiology, New York Presbyterian Hospital, Weill Cornell Medical College, New York
| | - Eitan A Amir
- Division of Medical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Dipti Gupta
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paaladinesh Thavendiranathan
- Peter Munk Cardiac Centre, Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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3
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Marwick TH, Shah SJ, Thomas JD. Myocardial Strain in the Assessment of Patients With Heart Failure: A Review. JAMA Cardiol 2020; 4:287-294. [PMID: 30810702 DOI: 10.1001/jamacardio.2019.0052] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance The cornerstones of imaging in heart failure (HF) are the measurement of systolic and diastolic function and left ventricular (LV) filling pressure. Observations Ejection fraction and the assessment of LV filling pressure and diastolic dysfunction using the ratio of early transmitral flow and LV relaxation (E/e') are conventional imaging markers of LV function. Despite their extensive use in HF guidelines, both have significant detractions, especially in an era when HF with preserved ejection fraction is becoming the dominant presentation. In contrast, strain imaging has provided a new window into myocardial mechanics. Myocardial strain is now well validated, robust, and can easily be performed on most modern echocardiography machines. This Review summarizes the evidence in 9 situations across the stages of HF where LV global longitudinal strain and other strain parameters may provide information on risk prediction, diagnosis, assessment of treatment response, and follow-up. Conclusions and Relevance The evolution of myocardial deformation imaging from research tool to clinical practice will provide clinicians with a useful additional imaging parameter to facilitate the assessment and risk evaluation of patients with HF.
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Affiliation(s)
- Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Sanjiv J Shah
- Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois.,Associate Editor
| | - James D Thomas
- Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois
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4
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Ejection Fraction Pros and Cons. J Am Coll Cardiol 2018; 72:2360-2379. [DOI: 10.1016/j.jacc.2018.08.2162] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/06/2018] [Accepted: 08/09/2018] [Indexed: 12/18/2022]
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5
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Marwick TH, Poole J. Cardiac Resynchronization Therapy in the Absence of LV Mechanical Dyssynchrony. J Am Coll Cardiol 2018; 71:1334-1336. [DOI: 10.1016/j.jacc.2018.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 11/25/2022]
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6
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Höke U, Bax JJ, Delgado V, Ajmone Marsan N. Assessment of left ventricular dyssynchrony by three-dimensional echocardiography: Prognostic value in patients undergoing cardiac resynchronization therapy. J Cardiovasc Electrophysiol 2018; 29:780-787. [PMID: 29377419 DOI: 10.1111/jce.13445] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 01/10/2018] [Accepted: 01/22/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Systolic dyssynchrony index (SDI) using three-dimensional echocardiography (3DE) was shown to be a reliable measure of left ventricular (LV) dyssynchrony. However, the prognostic value of SDI on long-term outcomes after cardiac resynchronization therapy (CRT) remains unknown. METHODS AND RESULTS A total of 414 patients (mean age 67 ± 10 years, 60% ischemic etiology) with 3DE evaluation before CRT implantation were included. SDI was evaluated as continuous value and in quartiles. The study endpoint was combined all-cause mortality, heart transplantation, and LV assist device implantation. At baseline, median SDI was 8.0% (IQR 5.6-11.3%). During a median follow-up of 45 months (IQR 25-59 months), the endpoint was observed in 94 (23%) patients. SDI was independently associated with the endpoint together with ischemic etiology, diabetes, and renal function (HR 0.914, P = 0.003) after adjustment for age, atrial fibrillation, hemoglobin level, NYHA functional class, and posterolateral LV lead position. Patients from the 1st, 2nd, and 3rd SDI quartiles showed similar survival and superior as compared to the 4th quartile with the lowest SDI values (≤5.5%; χ²: 30.4, log-rank P < 0.001). From receiver operating characteristic curve analysis, the optimal SDI cut-off value associated with the endpoint was >6.8% (area under the curve 0.634). Finally, a subgroup analysis (293 patients) demonstrated that a more pronounced reduction in SDI immediately after CRT (resynchronization) was independently associated with superior survival (HR 0.461, P = 0.011) after adjustment for prognostic relevant parameters. CONCLUSION SDI is independently associated with long-term prognosis after CRT and might therefore be important to optimize risk-stratification in these patients.
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Affiliation(s)
- Ulas Höke
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands.,Interuniversity Cardiology Institute of The Netherlands, Utrecht, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
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7
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Rowe MK, Kaye GC. Advances in atrioventricular and interventricular optimization of cardiac resynchronization therapy - what's the gold standard? Expert Rev Cardiovasc Ther 2018; 16:183-196. [PMID: 29338475 DOI: 10.1080/14779072.2018.1427582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Cardiac resynchronization therapy (CRT) is one of the most important advances in heart failure management in the last twenty years. Approximately one-third of patients appear not to respond to therapy. Although there are a number of possible mechanisms for non-response, an important factor is suboptimal atrioventricular (AV) and interventricular (VV) timing intervals. There remains controversy over whether routinely optimizing intervals is necessary and there is no agreed gold standard methodology. Optimization has classically been performed using echocardiography which has limits related to resource use, time-cost and variable reproducibility. Newer optimization methods using device-based sensors and algorithms show promise in reducing heart-failure hospitalization compared with echocardiography. Areas covered: This review outlines the rationale for optimization, the principles of AV and VV optimization, the standard echocardiographic approach and newer device-based algorithms and the evidence base for their use. Expert commentary: The incremental gains of optimization are likely to be real, but small, compared to the overall improvement gained from cardiac resynchronization itself. At this time routine optimization may not be mandatory but should be performed where there is no response to CRT. Device-based optimization algorithms appear to be practical and in some cases, deliver superior clinical outcomes compared to echocardiography.
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Affiliation(s)
- Matthew K Rowe
- a Department of Cardiology , Princess Alexandra Hospital , Brisbane , Australia.,b Faculty of Medicine , The University of Queensland , Brisbane , Australia
| | - Gerald C Kaye
- a Department of Cardiology , Princess Alexandra Hospital , Brisbane , Australia.,b Faculty of Medicine , The University of Queensland , Brisbane , Australia
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8
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Cobb DB, Gold MR. The Role of Atrioventricular and Interventricular Optimization for Cardiac Resynchronization Therapy. Heart Fail Clin 2017; 13:209-223. [DOI: 10.1016/j.hfc.2016.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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9
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Marek J, Gandalovičová J, Kejřová E, Pšenička M, Linhart A, Paleček T. Echocardiography and cardiac resynchronization therapy. COR ET VASA 2016. [DOI: 10.1016/j.crvasa.2015.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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10
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Khan SG, Klettas D, Kapetanakis S, Monaghan MJ. Clinical utility of speckle-tracking echocardiography in cardiac resynchronisation therapy. Echo Res Pract 2016; 3:R1-R11. [PMID: 27249816 PMCID: PMC5402657 DOI: 10.1530/erp-15-0032] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 03/08/2016] [Indexed: 11/08/2022] Open
Abstract
Cardiac resynchronisation therapy (CRT) can profoundly improve outcome in selected patients with heart failure; however, response is difficult to predict and can be absent in up to one in three patients. There has been a substantial amount of interest in the echocardiographic assessment of left ventricular dyssynchrony, with the ultimate aim of reliably identifying patients who will respond to CRT. The measurement of myocardial deformation (strain) has conventionally been assessed using tissue Doppler imaging (TDI), which is limited by its angle dependence and ability to measure in a single plane. Two-dimensional speckle-tracking echocardiography is a technique that provides measurements of strain in three planes, by tracking patterns of ultrasound interference ('speckles') in the myocardial wall throughout the cardiac cycle. Since its initial use over 15 years ago, it has emerged as a tool that provides more robust, reproducible and sensitive markers of dyssynchrony than TDI. This article reviews the use of two-dimensional and three-dimensional speckle-tracking echocardiography in the assessment of dyssynchrony, including the identification of echocardiographic parameters that may hold predictive potential for the response to CRT. It also reviews the application of these techniques in guiding optimal LV lead placement pre-implant, with promising results in clinical improvement post-CRT.
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Affiliation(s)
- Sitara G Khan
- King's College London British Heart Foundation Centre, London, UK Department of Cardiology, King's College Hospital, London, UK
| | | | | | - Mark J Monaghan
- King's College London British Heart Foundation Centre, London, UK Department of Cardiology, King's College Hospital, London, UK
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11
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Claridge S, Chen Z, Jackson T, De Silva K, Behar J, Sohal M, Webb J, Hyde E, Lumley M, Asrress K, Williams R, Bostock J, Ali M, Gill J, O'Neill M, Razavi R, Niederer S, Perera D, Rinaldi CA. Effects of Epicardial and Endocardial Cardiac Resynchronization Therapy on Coronary Flow: Insights From Wave Intensity Analysis. J Am Heart Assoc 2015; 4:JAHA.115.002626. [PMID: 26679935 PMCID: PMC4845290 DOI: 10.1161/jaha.115.002626] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background The increase in global coronary flow seen with conventional biventricular pacing is mediated by an increase in the dominant backward expansion wave (BEW). Little is known about the determinants of flow in the left‐sided epicardial coronary arteries beyond this or the effect of endocardial pacing stimulation on coronary physiology. Methods and Results Eleven patients with a chronically implanted biventricular pacemaker underwent an acute hemodynamic and electrophysiological study. Five of 11 patients also took part in a left ventricular endocardial pacing protocol at the same time. Conventional biventricular pacing, delivered epicardially from the coronary sinus, resulted in a 9% increase in flow (average peak velocity) in the left anterior descending artery (LAD), mediated by a 13% increase in the area under the BEW (P=0.004). Endocardial pacing resulted in a 27% increase in LAD flow, mediated by a 112% increase in the area under the forward compression wave (FCW) and a 43% increase in the area under the BEW (P=0.048 and P=0.036, respectively). There were no significant changes in circumflex parameters. Conventional biventricular pacing resulted in homogenization of timing of coronary flow compared with baseline (mean difference in time to peak in the LAD versus circumflex artery: FCW 39 ms [baseline] versus 3 ms [conventional biventricular pacing], P=0.008; BEW 47 ms [baseline] versus 8 ms [conventional biventricular pacing], P=0.004). Conclusions Epicardial and endocardial pacing result in increased coronary flow in the left anterior descending artery and homogenization of the timing of waves that determine flow in the LAD and the circumflex artery. The increase in both the FCW and the BEW with endocardial pacing may be the result of a more physiological activation pattern than that of epicardial pacing, which resulted in an increase of only the BEW.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Motin Ali
- Guy's and St Thomas’ Hospital TrustLondonUK
| | - Jaswinder Gill
- Guy's and St Thomas’ Hospital Trust and King's CollegeLondonUK
| | - Mark O'Neill
- Guy's and St Thomas’ Hospital Trust and King's CollegeLondonUK
| | - Reza Razavi
- Guy's and St Thomas’ Hospital Trust and King's CollegeLondonUK
| | | | - Divaka Perera
- Guy's and St Thomas’ Hospital Trust and King's CollegeLondonUK
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12
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Cobb DB, Gold MR. The Role of Atrioventricular and Interventricular Optimization for Cardiac Resynchronization Therapy. Card Electrophysiol Clin 2015; 7:765-779. [PMID: 26596818 DOI: 10.1016/j.ccep.2015.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Many patients with left ventricular systolic dysfunction may benefit from cardiac resynchronization therapy; however, approximately 30% of patients do not experience significant clinical improvement with this treatment. AV and VV delay optimization techniques have included echocardiography, device-based algorithms, and several other novel noninvasive techniques. Using these techniques to optimize device settings has been shown to improve hemodynamic function acutely; however, the long-term clinical benefit is limited. In most cases, an empiric AV delay with simultaneous biventricular or left ventricular pacing is adequate. The value of optimization of these intervals in "nonresponders" still requires further investigation.
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Affiliation(s)
- Daniel B Cobb
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Michael R Gold
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
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13
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Cole GD, Nowbar AN, Mielewczik M, Shun-Shin MJ, Francis DP. Frequency of discrepancies in retracted clinical trial reports versus unretracted reports: blinded case-control study. BMJ 2015; 351:h4708. [PMID: 26387520 PMCID: PMC4575810 DOI: 10.1136/bmj.h4708] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To compare the frequency of discrepancies in retracted reports of clinical trials with those in adjacent unretracted reports in the same journal. DESIGN Blinded case-control study. SETTING Journals in PubMed. POPULATION 50 manuscripts, classified on PubMed as retracted clinical trials, paired with 50 adjacent unretracted manuscripts from the same journals. Reports were randomly selected from PubMed in December 2012, with no restriction on publication date. Controls were the preceding unretracted clinical trial published in the same journal. All traces of retraction were removed. Three scientists, blinded to the retraction status of individual reports, reviewed all 100 trial reports for discrepancies. Discrepancies were pooled and cross checked before being counted into prespecified categories. Only then was the retraction status unblinded for analysis. MAIN OUTCOME MEASURE Total number of discrepancies (defined as mathematically or logically contradictory statements) in each clinical trial report. RESULTS Of 479 discrepancies found in the 100 trial reports, 348 were in the 50 retracted reports and 131 in the 50 unretracted reports. On average, individual retracted reports had a greater number of discrepancies than unretracted reports (median 4 (interquartile range 2-8.75) v 0 (0-5); P<0.001). Papers with a discrepancy were significantly more likely to be retracted than those without a discrepancy (odds ratio 5.7 (95% confidence interval 2.2 to 14.5); P<0.001). In particular, three types of discrepancy arose significantly more frequently in retracted than unretracted reports: factual discrepancies (P=0.002), arithmetical errors (P=0.01), and missed P values (P=0.02). Results from a retrospective analysis indicated that citations and journal impact factor were unlikely to affect the result. CONCLUSIONS Discrepancies in published trial reports should no longer be assumed to be unimportant. Scientists, blinded to retraction status and with no specialist skill in the field, identify significantly more discrepancies in retracted than unretracted reports of clinical trials. Discrepancies could be an early and accessible signal of unreliability in clinical trial reports.
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Affiliation(s)
- Graham D Cole
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London W2 1LA, UK
| | - Alexandra N Nowbar
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London W2 1LA, UK
| | - Michael Mielewczik
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London W2 1LA, UK
| | - Matthew J Shun-Shin
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London W2 1LA, UK
| | - Darrel P Francis
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London W2 1LA, UK
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Abstract
Cardiac resynchronisation therapy (CRT) is an effective intervention for appropriately selected patients with heart failure, but exactly how it works is uncertain. Recent data suggest that much, or perhaps most, of the benefits of CRT are not delivered by re-coordinating left ventricular dyssynchrony. Atrio-ventricular resynchronization, reduction in mitral regurgitation and prevention of bradycardia are other potential mechanisms of benefit that will vary from one patient to the next and over time. Because there is no single therapeutic target, it is unlikely that any single measure will accurately predict benefit. The only clinical characteristic that appears to be a useful predictor of the benefits of CRT is a QRS duration of >140 ms. Many new approaches are being developed to try to improve the effectiveness of and extend the indications for CRT. These include smart pacing algorithms, better pacing-site targeting, new sensors, multipoint pacing, remote device monitoring and leadless endocardial pacing. Whether CRT is effective in patients with atrial fibrillation or whether adding a defibrillator function to CRT improves prognosis awaits further evidence.
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15
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Cole GD, Shun-Shin MJ, Nowbar AN, Buell KG, Al-Mayahi F, Zargaran D, Mahmood S, Singh B, Mielewczik M, Francis DP. Difficulty in detecting discrepancies in a clinical trial report: 260-reader evaluation. Int J Epidemiol 2015; 44:862-9. [PMID: 26174517 PMCID: PMC4521134 DOI: 10.1093/ije/dyv114] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2015] [Indexed: 01/09/2023] Open
Abstract
Background: Scientific literature can contain errors. Discrepancies, defined as two or more statements or results that cannot both be true, may be a signal of problems with a trial report. In this study, we report how many discrepancies are detected by a large panel of readers examining a trial report containing a large number of discrepancies. Methods: We approached a convenience sample of 343 journal readers in seven countries, and invited them in person to participate in a study. They were asked to examine the tables and figures of one published article for discrepancies. 260 participants agreed, ranging from medical students to professors. The discrepancies they identified were tabulated and counted. There were 39 different discrepancies identified. We evaluated the probability of discrepancy identification, and whether more time spent or greater participant experience as academic authors improved the ability to detect discrepancies. Results: Overall, 95.3% of discrepancies were missed. Most participants (62%) were unable to find any discrepancies. Only 11.5% noticed more than 10% of the discrepancies. More discrepancies were noted by participants who spent more time on the task (Spearman’s ρ = 0.22, P < 0.01), and those with more experience of publishing papers (Spearman’s ρ = 0.13 with number of publications, P = 0.04). Conclusions: Noticing discrepancies is difficult. Most readers miss most discrepancies even when asked specifically to look for them. The probability of a discrepancy evading an individual sensitized reader is 95%, making it important that, when problems are identified after publication, readers are able to communicate with each other. When made aware of discrepancies, the majority of readers support editorial action to correct the scientific record.
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Affiliation(s)
| | | | | | - Kevin G Buell
- School of Medicine, Imperial College London, London, UK
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16
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Cole GD, Dhutia NM, Shun-Shin MJ, Willson K, Harrison J, Raphael CE, Zolgharni M, Mayet J, Francis DP. Defining the real-world reproducibility of visual grading of left ventricular function and visual estimation of left ventricular ejection fraction: impact of image quality, experience and accreditation. Int J Cardiovasc Imaging 2015; 31:1303-14. [PMID: 26141526 PMCID: PMC4572050 DOI: 10.1007/s10554-015-0659-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 04/08/2015] [Indexed: 12/04/2022]
Abstract
Left ventricular function can be evaluated by qualitative grading and by eyeball estimation of ejection fraction (EF). We sought to define the reproducibility of these techniques, and how they are affected by image quality, experience and accreditation. Twenty apical four-chamber echocardiographic cine loops (Online Resource 1–20) of varying image quality and left ventricular function were anonymized and presented to 35 operators. Operators were asked to provide (1) a one-phrase grading of global systolic function (2) an “eyeball” EF estimate and (3) an image quality rating on a 0–100 visual analogue scale. Each observer viewed every loop twice unknowingly, a total of 1400 viewings. When grading LV function into five categories, an operator’s chance of agreement with another operator was 50 % and with themself on blinded re-presentation was 68 %. Blinded eyeball LVEF re-estimates by the same operator had standard deviation (SD) of difference of 7.6 EF units, with the SD across operators averaging 8.3 EF units. Image quality, defined as the average of all operators’ assessments, correlated with EF estimate variability (r = −0.616, p < 0.01) and visual grading agreement (r = 0.58, p < 0.01). However, operators’ own single quality assessments were not a useful forewarning of their estimate being an outlier, partly because individual quality assessments had poor within-operator reproducibility (SD of difference 17.8). Reproducibility of visual grading of LV function and LVEF estimation is dependent on image quality, but individuals cannot themselves identify when poor image quality is disrupting their LV function estimate. Clinicians should not assume that patients changing in grade or in visually estimated EF have had a genuine clinical change.
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Affiliation(s)
- Graham D Cole
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London, W2 1LA, UK.
| | - Niti M Dhutia
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London, W2 1LA, UK
| | - Matthew J Shun-Shin
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London, W2 1LA, UK
| | - Keith Willson
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London, W2 1LA, UK
| | - James Harrison
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | | | - Massoud Zolgharni
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London, W2 1LA, UK
| | - Jamil Mayet
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London, W2 1LA, UK
| | - Darrel P Francis
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London, W2 1LA, UK
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Jackson T, Claridge S, Behar J, Sammut E, Webb J, Carr-White G, Razavi R, Rinaldi CA. Narrow QRS systolic heart failure: is there a target for cardiac resynchronization? Expert Rev Cardiovasc Ther 2015; 13:783-97. [PMID: 26048215 DOI: 10.1586/14779072.2015.1049945] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cardiac resynchronization therapy has revolutionized the management of systolic heart failure in patients with prolonged QRS during the past 20 years. Initially, the use of this treatment in patients with shorter QRS durations showed promising results, which have since been opposed by larger randomized controlled trials. Despite this, some questions remain, such as, whether correction of mechanical dyssynchrony is the therapeutic target by which biventricular pacing may confer benefit in this group, or are there other mechanisms that need consideration? In addition, novel techniques of cardiac resynchronization therapy delivery such as endocardial and multisite pacing may reduce potential detrimental effects of biventricular pacing, thereby improving the benefit/harm balance of this therapy in some patients.
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Affiliation(s)
- Tom Jackson
- Department of Cardiovascular Imaging, 4th Floor Lambeth Wing, St Thomas' Hospital, London, SE1 7EH, UK
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Sohaib SMA, Kyriacou A, Jones S, Manisty CH, Mayet J, Kanagaratnam P, Peters NS, Hughes AD, Whinnett ZI, Francis DP. Evidence that conflict regarding size of haemodynamic response to interventricular delay optimization of cardiac resynchronization therapy may arise from differences in how atrioventricular delay is kept constant. Europace 2015; 17:1823-33. [PMID: 25855674 PMCID: PMC4700730 DOI: 10.1093/europace/euu374] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 12/01/2014] [Indexed: 01/21/2023] Open
Abstract
Aims Whether adjusting interventricular (VV) delay changes haemodynamic efficacy of cardiac resynchronization therapy (CRT) is controversial, with conflicting results. This study addresses whether the convention for keeping atrioventricular (AV) delay constant during VV optimization might explain these conflicts. Method and results Twenty-two patients in sinus rhythm with existing CRT underwent VV optimization using non-invasive systolic blood pressure. Interventricular optimization was performed with four methods for keeping the AV delay constant: (i) atrium and left ventricle delay kept constant, (ii) atrium and right ventricle delay kept constant, (iii) time to the first-activated ventricle kept constant, and (iv) time to the second-activated ventricle kept constant. In 11 patients this was performed with AV delay of 120 ms, and in 11 at AV optimum. At AV 120 ms, time to the first ventricular lead (left or right) was the overwhelming determinant of haemodynamics (13.75 mmHg at ±80 ms, P < 0.001) with no significant effect of time to second lead (0.47 mmHg, P = 0.50), P < 0.001 for difference. At AV optimum, time to first ventricular lead again had a larger effect (5.03 mmHg, P < 0.001) than time to second (2.92 mmHg, P = 0.001), P = 0.02 for difference. Conclusion Time to first ventricular activation is the overwhelming determinant of circulatory function, regardless of whether this is the left or right ventricular lead. If this is kept constant, the effect of changing time to the second ventricle is small or nil, and is not beneficial. In practice, it may be advisable to leave VV delay at zero. Specifying how AV delay is kept fixed might make future VV delay research more enlightening.
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Affiliation(s)
- S M Afzal Sohaib
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Andreas Kyriacou
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Siana Jones
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Charlotte H Manisty
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Jamil Mayet
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Prapa Kanagaratnam
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Nicholas S Peters
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Alun D Hughes
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Zachary I Whinnett
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Darrel P Francis
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
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Sohaib SA, Finegold JA, Nijjer SS, Hossain R, Linde C, Levy WC, Sutton R, Kanagaratnam P, Francis DP, Whinnett ZI. Opportunity to Increase Life Span in Narrow QRS Cardiac Resynchronization Therapy Recipients by Deactivating Ventricular Pacing. JACC-HEART FAILURE 2015; 3:327-36. [DOI: 10.1016/j.jchf.2014.11.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 11/12/2014] [Accepted: 11/14/2014] [Indexed: 01/14/2023]
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Jabbour RJ, Shun-Shin MJ, Finegold JA, Afzal Sohaib SM, Cook C, Nijjer SS, Whinnett ZI, Manisty CH, Brugada J, Francis DP. Effect of study design on the reported effect of cardiac resynchronization therapy (CRT) on quantitative physiological measures: stratified meta-analysis in narrow-QRS heart failure and implications for planning future studies. J Am Heart Assoc 2015; 4:e000896. [PMID: 25564370 PMCID: PMC4330047 DOI: 10.1161/jaha.114.000896] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [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 Biventricular pacing (CRT) shows clear benefits in heart failure with wide QRS, but results in narrow QRS have appeared conflicting. We tested the hypothesis that study design might have influenced findings. Method and Results We identified all reports of CRT‐P/D therapy in subjects with narrow QRS reporting effects on continuous physiological variables. Twelve studies (2074 patients) met these criteria. Studies were stratified by presence of bias‐resistance steps: the presence of a randomized control arm over a single arm, and blinded outcome measurement. Change in each endpoint was quantified using a standardized effect size (Cohen's d). We conducted separate meta‐analyses for each variable in turn, stratified by trial quality. In non‐randomized, non‐blinded studies, the majority of variables (10 of 12, 83%) showed significant improvement, ranging from a standardized mean effect size of +1.57 (95%CI +0.43 to +2.7) for ejection fraction to +2.87 (+1.78 to +3.95) for NYHA class. In the randomized, non‐blinded study, only 3 out of 6 variables (50%) showed improvement. For the randomized blinded studies, 0 out of 9 variables (0%) showed benefit, ranging from −0.04 (−0.31 to +0.22) for ejection fraction to −0.1 (−0.73 to +0.53) for 6‐minute walk test. Conclusions Differences in degrees of resistance to bias, rather than choice of endpoint, explain the variation between studies of CRT in narrow‐QRS heart failure addressing physiological variables. When bias‐resistance features are implemented, it becomes clear that these patients do not improve in any tested physiological variable. Guidance from studies without careful planning to resist bias may be far less useful than commonly perceived.
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Affiliation(s)
- Richard J Jabbour
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Matthew J Shun-Shin
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Judith A Finegold
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - S M Afzal Sohaib
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Christopher Cook
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Sukhjinder S Nijjer
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Zachary I Whinnett
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Charlotte H Manisty
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Josep Brugada
- Hospital Clinic, University of Barcelona, Barcelona, Spain (J.B.)
| | - Darrel P Francis
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
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Claridge S, Chen Z, Jackson T, Sammut E, Sohal M, Behar J, Razavi R, Niederer S, Rinaldi CA. Current concepts relating coronary flow, myocardial perfusion and metabolism in left bundle branch block and cardiac resynchronisation therapy. Int J Cardiol 2014; 181:65-72. [PMID: 25482281 DOI: 10.1016/j.ijcard.2014.11.194] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 11/18/2014] [Accepted: 11/24/2014] [Indexed: 11/16/2022]
Abstract
Cardiac resynchronisation therapy (CRT) improves mortality and symptoms in heart failure patients with electromechanically dyssynchronous ventricles. There is a 50% non-response rate and reproducible biomarkers to predict non-response have not been forthcoming. Therefore, there has been increasing interest in the pathophysiological effects of dyssynchrony particularly focusing on coronary flow, myocardial perfusion and metabolism. Studies suggest that dyssynchronous electrical activation effects coronary flow throughout the coronary vasculature from the epicardial arteries to the microvascular bed and that these changes can be corrected by CRT. The effect of both electrical and mechanical dyssynchrony on myocardial perfusion is unclear with some studies suggesting there is a reduction in septal perfusion whilst others propose that there is an increase in lateral perfusion. Better understanding of these effects offers the possibility for better prediction of non-response. CRT appears to improve homogeneity in myocardial perfusion where heterogeneity is described in the initial substrate. Novel approaches to the identification of non-responders via metabolic phenotyping both invasively and non-invasively have been encouraging. There remains a need for further research to clarify the interaction of coronary flow with perfusion and metabolism in patients who undergo CRT.
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Affiliation(s)
- Simon Claridge
- Guy's and St Thomas' Hospital, UK; King's College London, UK.
| | | | | | | | | | - Jonathan Behar
- Guy's and St Thomas' Hospital, UK; King's College London, UK
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22
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Selection for cardiac resynchronization therapy: all in a flash? JACC Cardiovasc Imaging 2014; 7:980-2. [PMID: 25323161 DOI: 10.1016/j.jcmg.2014.04.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 04/11/2014] [Indexed: 11/24/2022]
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24
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Doltra A, Bijnens B, Tolosana JM, Borràs R, Khatib M, Penela D, De Caralt TM, Castel MÁ, Berruezo A, Brugada J, Mont L, Sitges M. Mechanical abnormalities detected with conventional echocardiography are associated with response and midterm survival in CRT. JACC Cardiovasc Imaging 2014; 7:969-79. [PMID: 25240452 DOI: 10.1016/j.jcmg.2014.03.022] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 03/05/2014] [Accepted: 03/06/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Our aim was to identify "correctable abnormalities" using conventional grayscale and blood-pool Doppler echocardiography and evaluate their ability to predict both response and midterm survival. BACKGROUND Identification of mechanical abnormalities that may be corrected with cardiac resynchronization therapy (CRT) is useful for predicting echocardiographic response at 1-year follow-up. METHODS A total of 200 CRT patients were included. Clinical evaluation and echocardiography were performed before and after CRT to assess the presence of the mechanical abnormalities of interest (septal flash, abnormal ventricular filling, or exaggerated interventricular dependence). Response to CRT was defined as a reduction in left ventricular (LV) end-systolic volume (ESV) ≥15%. Four subgroups of extent of response were defined: LVESV reduction >26.68% (extensive remodeling); LVESV reduction 6.8% to 26.68% (slight remodeling); LVESV reduction <6.8% (no remodeling) and clinical response; and LVESV reduction <6.8% without clinical response or the occurrence of death or heart transplantation. Midterm cardiovascular survival was evaluated (mean follow-up 38 ± 19 months). RESULTS The presence of a correctable abnormality was independently associated with a better rate (odds ratio: 0.03 [95% confidence interval (CI): 0.01 to 0.10], p < 0.001) and extent of response to CRT (n = 59 [96.7%] for the extensive remodeling subgroup vs. n = 53 [85.5%] for the slight remodeling subgroup vs. n = 19 [47.5%] for the no remodeling with clinical response subgroup vs. n = 17 [45.9%] for the no remodeling without clinical response subgroup, p = 0.0001), as well as with increased midterm survival (hazard ratio: 0.11 [95% CI: 0.2 to 0.6]). Other independent predictors included creatinine level and LV end-systolic diameter for response; New York Heart Association functional class IV, creatinine, LV end-systolic diameter, and transmurality index for extent of response; and New York Heart Association functional class IV for cardiovascular mortality. CONCLUSIONS The presence of a correctable abnormality evaluated by conventional echocardiography is associated with LV reverse remodeling and better survival at midterm follow-up. Clinical characteristics and myocardial viability also have an influence.
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Affiliation(s)
- Adelina Doltra
- Thorax Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain.
| | - Bart Bijnens
- ICREA, Universitat Pompeu Fabra, Barcelona, Spain
| | - José M Tolosana
- Thorax Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Roger Borràs
- Thorax Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Malek Khatib
- Thorax Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Diego Penela
- Thorax Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Teresa Maria De Caralt
- Thorax Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - María Ángeles Castel
- Thorax Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Antonio Berruezo
- Thorax Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Josep Brugada
- Thorax Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Lluís Mont
- Thorax Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Marta Sitges
- Thorax Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
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Nowbar AN, Mielewczik M, Karavassilis M, Dehbi HM, Shun-Shin MJ, Jones S, Howard JP, Cole GD, Francis DP. Discrepancies in autologous bone marrow stem cell trials and enhancement of ejection fraction (DAMASCENE): weighted regression and meta-analysis. BMJ 2014; 348:g2688. [PMID: 24778175 PMCID: PMC4002982 DOI: 10.1136/bmj.g2688] [Citation(s) in RCA: 169] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To investigate whether discrepancies in trials of use of bone marrow stem cells in patients with heart disease account for the variation in reported effect size in improvement of left ventricular function. DESIGN Identification and counting of factual discrepancies in trial reports, and sample size weighted regression against therapeutic effect size. Meta-analysis of trials that provided sufficient information. DATA SOURCES PubMed and Embase from inception to April 2013. ELIGIBILITY FOR SELECTING STUDIES Randomised controlled trials evaluating the effect of autologous bone marrow stem cells for heart disease on mean left ventricular ejection fraction. RESULTS There were over 600 discrepancies in 133 reports from 49 trials. There was a significant association between the number of discrepancies and the reported increment in EF with bone marrow stem cell therapy (Spearman's r=0.4, P=0.005). Trials with no discrepancies were a small minority (five trials) and showed a mean EF effect size of -0.4%. The 24 trials with 1-10 discrepancies showed a mean effect size of 2.1%. The 12 with 11-20 discrepancies showed a mean effect of size 3.0%. The three with 21-30 discrepancies showed a mean effect size of 5.7%. The high discrepancy group, comprising five trials with over 30 discrepancies each, showed a mean effect size of 7.7%. CONCLUSIONS Avoiding discrepancies is difficult but is important because discrepancy count is related to effect size. The mechanism is unknown but should be explored in the design of future trials because in the five trials without discrepancies the effect of bone marrow stem cell therapy on ejection fraction is zero.
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Affiliation(s)
- Alexandra N Nowbar
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London W2 1LA, UK
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Barron A, Dhutia N, Mayet J, Hughes AD, Francis DP, Wensel R. Response to editorial ‘Reproducibility of cardiopulmonary exercise test variables: getting into an additional strength of the test’. Eur J Prev Cardiol 2014; 21:454-5. [DOI: 10.1177/2047487314526683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- A Barron
- International Centre for Circulatory Health, Imperial College, UK
| | - N Dhutia
- International Centre for Circulatory Health, Imperial College, UK
| | - J Mayet
- International Centre for Circulatory Health, Imperial College, UK
| | - AD Hughes
- International Centre for Circulatory Health, Imperial College, UK
| | - DP Francis
- International Centre for Circulatory Health, Imperial College, UK
| | - R Wensel
- International Centre for Circulatory Health, Imperial College, UK
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Boriani G, Ziacchi M, Diemberger I, Valzania C, Biffi M, Martignani C. Cardiac resynchronization therapy. J Cardiovasc Med (Hagerstown) 2014; 15:269-72. [DOI: 10.2459/jcm.0000000000000022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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28
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Howard JP, Cole GD, Sievert H, Bhatt DL, Papademetriou V, Kandzari DE, Davies JE, Francis DP. Unintentional overestimation of an expected antihypertensive effect in drug and device trials: Mechanisms and solutions. Int J Cardiol 2014; 172:29-35. [DOI: 10.1016/j.ijcard.2013.12.183] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 12/28/2013] [Indexed: 11/30/2022]
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29
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Meta-analysis of symptomatic response attributable to the pacing component of cardiac resynchronization therapy. Eur J Heart Fail 2014; 15:1419-28. [DOI: 10.1093/eurjhf/hft139] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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International RCT-based guidelines for use of preoperative stress testing and perioperative beta-blockers and statins in non-cardiac surgery. Int J Cardiol 2014; 172:138-43. [PMID: 24486062 DOI: 10.1016/j.ijcard.2013.12.309] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 12/31/2013] [Indexed: 01/09/2023]
Abstract
BACKGROUND Cardiologists frequently advise on perioperative care for non-cardiac surgery and require guidance based on randomised controlled trials that are not discredited by misconduct or misreporting. Regional political bodies currently do not provide this. We therefore examined the credible randomised controlled trial (RCT) evidence on key cardiac perioperative questions which currently have 14 recommendations. METHODS Three aspects of perioperative measures were considered: perioperative statins, preoperative stress-testing and perioperative beta-blockade. One author searched PubMed for RCTs considering these topics. All authors independently assessed the RCTs and then collaboratively composed guidelines. RESULTS Perioperative statin therapy has been examined by three RCTs, DECREASE III and IV, which are discredited and a third containing serious inconsistencies undermining its validity. Preoperative stress testing has been examined by two RCTs: one discredited trial, DECREASE II, and a second which found no benefit. Perioperative beta-blockade has been examined by eleven RCTs, two of which are discredited. The nine remaining trials together suggest that perioperative beta-blockade increases mortality. CONCLUSIONS When the non-credible RCTs are omitted, the evidence base on these three subjects is much smaller than previously believed: 14 recommendations can be replaced by 3. Current guideline arrangements collectively paralyse the numerous signatories from making urgent amendments after initial publication, even when important new information comes to light. Clinicians simply have to wait for the routine five-year expiry. We present a concise scientifically based guideline and commit to updating it responsibly.
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Cleland JG, Abraham WT, Linde C, Gold MR, Young JB, Claude Daubert J, Sherfesee L, Wells GA, Tang AS. An individual patient meta-analysis of five randomized trials assessing the effects of cardiac resynchronization therapy on morbidity and mortality in patients with symptomatic heart failure. Eur Heart J 2013; 34:3547-56. [PMID: 23900696 PMCID: PMC3855551 DOI: 10.1093/eurheartj/eht290] [Citation(s) in RCA: 380] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 06/24/2013] [Accepted: 07/04/2013] [Indexed: 12/25/2022] Open
Abstract
AIMS Cardiac resynchronization therapy (CRT) with or without a defibrillator reduces morbidity and mortality in selected patients with heart failure (HF) but response can be variable. We sought to identify pre-implantation variables that predict the response to CRT in a meta-analysis using individual patient-data. METHODS AND RESULTS An individual patient meta-analysis of five randomized trials, funded by Medtronic, comparing CRT either with no active device or with a defibrillator was conducted, including the following baseline variables: age, sex, New York Heart Association class, aetiology, QRS morphology, QRS duration, left ventricular ejection fraction (LVEF), and systolic blood pressure. Outcomes were all-cause mortality and first hospitalization for HF or death. Of 3782 patients in sinus rhythm, median (inter-quartile range) age was 66 (58-73) years, QRS duration was 160 (146-176) ms, LVEF was 24 (20-28)%, and 78% had left bundle branch block. A multivariable model suggested that only QRS duration predicted the magnitude of the effect of CRT on outcomes. Further analysis produced estimated hazard ratios for the effect of CRT on all-cause mortality and on the composite of first hospitalization for HF or death that suggested increasing benefit with increasing QRS duration, the 95% confidence bounds excluding 1.0 at ∼140 ms for each endpoint, suggesting a high probability of substantial benefit from CRT when QRS duration exceeds this value. CONCLUSION QRS duration is a powerful predictor of the effects of CRT on morbidity and mortality in patients with symptomatic HF and left ventricular systolic dysfunction who are in sinus rhythm. QRS morphology did not provide additional information about clinical response. CLINICALTRIALSGOV NUMBERS NCT00170300, NCT00271154, NCT00251251.
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Affiliation(s)
- John G. Cleland
- National Heart and Lung Institute, Imperial College London (Royal Brompton & Harefield Hospitals) and Department of Cardiology, Castle Hill Hospital, University of Hull, Kingston-upon-Hull, UK
| | - William T. Abraham
- Division of Cardiovascular Medicine and the Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA
| | - Cecilia Linde
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | | | - James B. Young
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | | | | | | | - Anthony S.L. Tang
- The Island Medical Program, University of British Columbia, Vancouver, Canada
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A Review of JACC Articles on the Topic of Heart Rhythm Disorders: 2011–2012. J Am Coll Cardiol 2013; 62:e451-e519. [DOI: 10.1016/j.jacc.2013.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Howard JP, Nowbar AN, Francis DP. Size of blood pressure reduction from renal denervation: insights from meta-analysis of antihypertensive drug trials of 4,121 patients with focus on trial design: the CONVERGE report. Heart 2013; 99:1579-87. [PMID: 24038167 DOI: 10.1136/heartjnl-2013-304238] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE 30 mm Hg drops in office systolic blood pressure are reported in trials of renal denervation, but ambulatory reductions are much smaller. This disparity is assumed to have a physiological basis and also be present with antihypertensive drugs. DESIGN We examine this office-ambulatory discrepancy through meta-analysis of drug and denervation trials, categorising by trial design. PATIENTS (STUDIES) 31 drug trials enrolling 4121 patients and 23 renal denervation trials enrolling 720 patients met the criteria. RESULTS In drug trials without randomisation or blinding, pressure reductions are 5.6 mm Hg (95% CI 2.98 to 8.22 mm Hg) larger on office measurements than ambulatory blood pressure monitoring (p<0.0001). By contrast, with randomisation and blinding, office reductions are identical to ambulatory reductions (difference -0.88 mm Hg, 95% CI -3.18 to 1.43, p=0.45). For renal denervation, there are no randomised blinded trial results. In unblinded trials, office pressure drops were 27.6 mm Hg versus pretreatment, and 26.6 mm Hg versus unintervened controls. By contrast, ambulatory pressure drops averaged 15.7 mm Hg across all trials. Among those where the baseline ambulatory pressure was not the deciding factor for enrolment (avoiding regression to the mean), ambulatory drops averaged only 11.9 mm Hg. CONCLUSIONS Discrepancies in drug trials between office and ambulatory blood pressure reductions disappear once double-blinded placebo control is implemented. Renal denervation trials may also undergo similar evolution. We predict that as denervation trial designs gradually improve in bias-resistance, office and ambulatory pressure drops will converge. We predict that it is the office drops that will move to match the ambulatory drops, that is, not 30, but nearer 13.
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Affiliation(s)
- James P Howard
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, , London, UK
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Kyriacou A, Pabari PA, Mayet J, Peters NS, Davies DW, Lim PB, Lefroy D, Hughes AD, Kanagaratnam P, Francis DP, Whinnett ZI. Cardiac resynchronization therapy and AV optimization increase myocardial oxygen consumption, but increase cardiac function more than proportionally. Int J Cardiol 2013; 171:144-52. [PMID: 24332598 PMCID: PMC3919205 DOI: 10.1016/j.ijcard.2013.10.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 09/08/2013] [Accepted: 10/07/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND The mechanoenergetic effects of atrioventricular delay optimization during biventricular pacing ("cardiac resynchronization therapy", CRT) are unknown. METHODS Eleven patients with heart failure and left bundle branch block (LBBB) underwent invasive measurements of left ventricular (LV) developed pressure, aortic flow velocity-time-integral (VTI) and myocardial oxygen consumption (MVO2) at 4 pacing states: biventricular pacing (with VV 0 ms) at AVD 40 ms (AV-40), AVD 120 ms (AV-120, a common nominal AV delay), at their pre-identified individualised haemodynamic optimum (AV-Opt); and intrinsic conduction (LBBB). RESULTS AV-120, relative to LBBB, increased LV developed pressure by a mean of 11(SEM 2)%, p=0.001, and aortic VTI by 11(SEM 3)%, p=0.002, but also increased MVO2 by 11(SEM 5)%, p=0.04. AV-Opt further increased LV developed pressure by a mean of 2(SEM 1)%, p=0.035 and aortic VTI by 4(SEM 1)%, p=0.017. MVO2 trended further up by 7(SEM 5)%, p=0.22. Mechanoenergetics at AV-40 were no different from LBBB. The 4 states lay on a straight line for Δexternal work (ΔLV developed pressure × Δaortic VTI) against ΔMVO2, with slope 1.80, significantly >1 (p=0.02). CONCLUSIONS Biventricular pacing and atrioventricular delay optimization increased external cardiac work done but also myocardial oxygen consumption. Nevertheless, the increase in cardiac work was ~80% greater than the increase in oxygen consumption, signifying an improvement in cardiac mechanoenergetics. Finally, the incremental effect of optimization on external work was approximately one-third beyond that of nominal AV pacing, along the same favourable efficiency trajectory, suggesting that AV delay dominates the biventricular pacing effect - which may therefore not be mainly "resynchronization".
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Affiliation(s)
- Andreas Kyriacou
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - Punam A Pabari
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - Jamil Mayet
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - Nicholas S Peters
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - D Wyn Davies
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - P Boon Lim
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - David Lefroy
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - Alun D Hughes
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - Prapa Kanagaratnam
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - Darrel P Francis
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK.
| | - Zachary I Whinnett
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
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Francis DP, Mielewczik M, Zargaran D, Cole GD. Autologous bone marrow-derived stem cell therapy in heart disease: discrepancies and contradictions. Int J Cardiol 2013; 168:3381-403. [PMID: 23830344 DOI: 10.1016/j.ijcard.2013.04.152] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 04/11/2013] [Accepted: 04/12/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Autologous bone marrow stem cell therapy is the greatest advance in the treatment of heart disease for a generation according to pioneering reports. In response to an unanswered letter regarding one of the largest and most promising trials, we attempted to summarise the findings from the most innovative and prolific laboratory. METHOD AND RESULTS Amongst 48 reports from the group, there appeared to be 5 actual clinical studies ("families" of reports). Duplicate or overlapping reports were common, with contradictory experimental design, recruitment and results. Readers cannot always tell whether a study is randomised versus not, open-controlled or blinded placebo-controlled, or lacking a control group. There were conflicts in recruitment dates, criteria, sample sizes, million-fold differences in cell counts, sex reclassification, fractional numbers of patients and conflation of competitors' studies with authors' own. Contradictory results were also common. These included arithmetical miscalculations, statistical errors, suppression of significant changes, exaggerated description of own findings, possible silent patient deletions, fractional numbers of coronary arteries, identical results with contradictory sample sizes, contradictory results with identical sample sizes, misrepresented survival graphs and a patient with a negative NYHA class. We tabulate over 200 discrepancies amongst the reports. The 5 family-flagship papers (Strauer 2002, STAR, IACT, ABCD, BALANCE) have had 2665 citations. Of these, 291 citations were to the pivotal STAR or IACT-JACC papers, but 97% of their eligible citing papers did not mention any discrepancies. Five meta-analyses or systematic reviews covered these studies, but none described any discrepancies and all resolved uncertainties by undisclosed methods, in mutually contradictory ways. Meta-analysts disagreed whether some studies were randomised or "accepter-versus-rejecter". Our experience of presenting the discrepancies to journals is that readers may remain unaware of such problems. CONCLUSIONS Modern reporting of clinical research can still be imperfect. The scientific literature absorbs such reports largely uncritically. Even meta-analyses seem to resolve contradictions haphazardly. Discrepancies communicated to journals are not guaranteed to reach the scientific community. Journals could consider prioritising systematic reporting of queries even if seemingly minor, and establishing a policy of "habeas data".
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Applicability of the iterative technique for cardiac resynchronization therapy optimization: full-disclosure, 50-sequential-patient dataset of transmitral Doppler traces, with implications for future research design and guidelines. ACTA ACUST UNITED AC 2013; 16:541-50. [DOI: 10.1093/europace/eut257] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Jones DG, Haldar SK, Hussain W, Sharma R, Francis DP, Rahman-Haley SL, McDonagh TA, Underwood SR, Markides V, Wong T. A Randomized Trial to Assess Catheter Ablation Versus Rate Control in the Management of Persistent Atrial Fibrillation in Heart Failure. J Am Coll Cardiol 2013; 61:1894-903. [DOI: 10.1016/j.jacc.2013.01.069] [Citation(s) in RCA: 311] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2012] [Revised: 12/27/2012] [Accepted: 01/23/2013] [Indexed: 01/09/2023]
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Yingchoncharoen T, Agarwal S, Popović ZB, Marwick TH. Normal ranges of left ventricular strain: a meta-analysis. J Am Soc Echocardiogr 2012; 26:185-91. [PMID: 23218891 DOI: 10.1016/j.echo.2012.10.008] [Citation(s) in RCA: 615] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Indexed: 12/26/2022]
Abstract
BACKGROUND The definition of normal values of left ventricular global longitudinal strain (GLS), global circumferential strain, and global radial strain is of critical importance to the clinical application of this modality. The investigators performed a meta-analysis of normal ranges and sought to identify factors that contribute to reported variations. METHODS MEDLINE, Embase, and the Cochrane Library database were searched through August 2011 using the key terms "strain," "speckle tracking," "left ventricle," and "echocardiography" and related phrases. Studies were included if the articles reported left ventricular strain using two-dimensional speckle-tracking echocardiography in healthy normal subjects, either in the control group or as a primary objective of the study. Data were combined using a random-effects model, and effects of demographic, hemodynamic, and equipment variables were sought in a meta-regression. RESULTS The search identified 2,597 subjects from 24 studies. Reported normal values of GLS varied from -15.9% to -22.1% (mean, -19.7%; 95% CI, -20.4% to -18.9%). Normal global circumferential strain varied from -20.9% to -27.8% (mean, -23.3%; 95% CI, -24.6% to -22.1%). Global radial strain ranged from 35.1% to 59.0% (mean, 47.3%; 95% CI, 43.6% to 51.0%). There was significant between-study heterogeneity and inconsistency. The source of variation was sought between studies using meta-regression. Blood pressure, but not age, gender, frame rate, or equipment, was associated with variation in normal GLS values. CONCLUSIONS The narrowest confidence intervals from this meta-analysis were for GLS and global circumferential strain, but individual studies have shown a broad range of strain in apparently normal subjects. Variations between different normal ranges seem to be associated with differences in systolic blood pressure, emphasizing that this should be considered in the interpretation of strain.
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Marwick TH, Narula J. Dyssynchrony Measurements to Predict Functional Recovery After CRT: Too Good to Be True? JACC Cardiovasc Imaging 2012; 5:1075-7. [DOI: 10.1016/j.jcmg.2012.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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