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Bertelli M, Ziacchi M, van Slochteren F, Rondanina E, Lazzeri M, Carecci A, Biffi M. LV cathode position in CRT recipients: How can we benefit from CMR? Int J Cardiol 2024; 412:132321. [PMID: 38977225 DOI: 10.1016/j.ijcard.2024.132321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/24/2024] [Accepted: 07/01/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Left ventricular lead positioning represents a key step in CRT optimization. However, evidence for its guidance based on specific topographical factors and related imaging techniques is sparse. OBJECTIVE To analyze reverse remodeling (RR) and clinical events in CRT recipients based on LV cathode (LVC) position relative to latest mechanical activation (LMA) and scar as determined by cardiac magnetic resonance (CMR). METHODS This is a retrospective single-center study of 68 consecutive Q-LV-guided CRT-D and CRT-P recipients. Through CMR-based 3D reconstructions overlayed on fluoroscopy images, LVCs were stratified as concordant, adjacent, or discordant to LMA (3 segments with latest and greatest radial strain) and scar (segments with >50% scar transmurality). The primary endpoint of RR (expressed as percentage ESV change) and secondary composite endpoint of HF hospitalizations, LVAD/heart transplant, or cardiovascular death were compared across categories. RESULTS LVC proximity to LMA was associated with a progressive increase in RR (percentage ESV change: concordant -47.0 ± 5.9%, adjacent -31.4 ± 3.1%, discordant +0.4 ± 3.7%), while proximity to scar was associated with sharply decreasing RR (concordant +10.7 ± 12.9%, adjacent +0.3 ± 5.3%, discordant -31.3 ± 4.4%, no scar -35.4 ± 4.8%). 4 integrated classes of LVC position demonstrated a significant positive RR gradient the more optimal the category (class I -47.0 ± 5.9%, class II -34.9 ± 2.8%, class III -5.5 ± 4.3%, class IV + 3.4 ± 5.2%). Freedom from composite secondary endpoint of HF hospitalization, LVAD/heart transplant, or cardiovascular death confirmed these trends demonstrating significant differences across both integrated as well as individual LMA and scar categories. CONCLUSION Integrated CMR-determined LVC position relative to LMA and scar stratifies response to CRT.
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Affiliation(s)
- Michele Bertelli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Cardiology, 40122 Bologna, Italy.
| | - Matteo Ziacchi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Cardiology, 40122 Bologna, Italy
| | | | | | - Mirco Lazzeri
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Cardiology, 40122 Bologna, Italy
| | - Alessandro Carecci
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Cardiology, 40122 Bologna, Italy
| | - Mauro Biffi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Cardiology, 40122 Bologna, Italy
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Ziacchi M, Anselmino M, Palmisano P, Casella M, Pelargonio G, Russo V, D'Onofrio A, Massaro G, Vilotta M, Lauretti M, Themistoclakis S, Boriani G, De Ponti R. Selection of candidates for cardiac resynchronization therapy and implantation management: an Italian survey promoted by the Italian Association of Arrhythmology and Cardiac Pacing. J Cardiovasc Med (Hagerstown) 2024; 25:601-608. [PMID: 38949147 DOI: 10.2459/jcm.0000000000001650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) represents an effective heart failure treatment, associated with reduction in mortality and heart failure hospitalizations. This Italian survey aimed to address relevant CRT issues. METHODS An online survey was administered to AIAC members. RESULTS One hundred and five electrophysiologists participated, with a median of 40 (23-70) CRT implantations/year (33% in high-volume centres). Forty-five percent of respondents (especially working in high-volume centres) reported an increase in CRT implantations in the last 2 years, in 16% a decrease, and in 38% CRT remained stable. Seventy-five percent of respondents implanted CRT only in patients with European Heart Rhythm Association (EHRA) class I indications. All operators collected ECG and echocardiography before implantation. Eighty-five percent of respondents selected coronary sinus target vein empirically, whereas 10% used mechanical and/or electrical delay techniques. Physicians working in high-volume centres reported a lower failure rate compared with others (16 vs. 34%; P = 0.03). If the coronary sinus lead could not be positioned in the target branch, 80% placed it in another vein, whereas 16% opted for a surgical approach or for conduction system pacing (CSP). Eighty percent accomplished CRT optimization in all patients, 17% only in nonresponders. Regarding anticoagulation, high agreement with EHRA guidelines emerged. CONCLUSION CRT represents a valid therapeutic option in heart failure treatment. Nowadays, CRT implantations remain stable and are mainly performed in patients with class I indications. ECG remains the preferred tool for patient selection, whereas imaging is increasingly used to determine the left pacing target area. In most patients, the left ventricular lead can be successfully positioned in the target vein, but in some cases, the result can be unsatisfactory; however, the decision to explore alternative resynchronization approaches is rarely pursued.
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Affiliation(s)
- Matteo Ziacchi
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Dipartimento Cardio-toraco-vascolare, Bologna
| | - Matteo Anselmino
- Cardiology Division, 'Città della Salute e della Scienza di Torino' Hospital, Department of Medical Sciences, University of Turin, Turin
| | | | - Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital 'Azienda Ospedaliero-Universitaria delle Marche'
- Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona
| | - Gemma Pelargonio
- Institute of Cardiology, Catholic University of Sacred Heart
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome
| | - Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli
| | - Antonio D'Onofrio
- Departmental Unit of Electrophysiology, Evaluation and Treatment of Arrhythmias, Monaldi Hospital, Naples
| | - Giulia Massaro
- Institute of Cardiology, Department of Medical and Surgical Sciences, University of Bologna, Policlinico S.Orsola-Malpighi, Bologna
| | - Manola Vilotta
- Department of Medicine and Surgery, University of Insubria
- Cardiology Unit, Ospedale di Circolo, ASST Settelaghi, Varese
| | | | | | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Roberto De Ponti
- Department of Medicine and Surgery, University of Insubria
- Cardiology Unit, Ospedale di Circolo, ASST Settelaghi, Varese
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König S, Hilbert S, Bode K. Conduction System Pacing: Hope, Challenges, and the Journey Forward. Curr Cardiol Rep 2024; 26:801-814. [PMID: 38976199 DOI: 10.1007/s11886-024-02085-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 07/09/2024]
Abstract
PURPOSE OF THE REVIEW Cardiac pacing has evolved in recent years currently culminating in the specific stimulation of the cardiac conduction system (conduction system pacing, CSP). This review aims to provide a comprehensive overview of the available literature on CSP, focusing on a critical classification of studies comparing CSP with standard treatment in the two fields of pacing for bradycardia and cardiac resynchronization therapy in patients with heart failure. The article will also elaborate specific benefits and limitations associated with CSP modalities of His bundle pacing (HBP) and left bundle branch area pacing (LBBAP). RECENT FINDINGS Based on a growing number of observational studies for different indications of pacing therapy, both CSP modalities investigated are advantageous over standard treatment in terms of narrowing the paced QRS complex and preserving or improving left ventricular systolic function. Less consistent evidence exists with regard to the improvement of heart failure-related rehospitalization rates or mortality, and effect sizes vary between HBP and LBBAP. LBBAP is superior over HBP in terms of lead measurements and procedural duration. With regard to all reported outcomes, evidence from large scale randomized controlled clinical trials (RCT) is still scarce. CSP has the potential to sustainably improve patient care in cardiac pacing therapy if patients are appropriately selected and limitations are considered. With this review, we offer not only a summary of existing data, but also an outlook on probable future developments in the field, as well as a detailed summary of upcoming RCTs that provide insights into how the journey of CSP continues.
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Affiliation(s)
- S König
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany.
- Helios Health Institute, Real World Evidence and Health Technology Assessment, Berlin, Germany.
| | - S Hilbert
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - K Bode
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
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Gold MR, Zhou J, Higuera L, Lanctin DP, Chung ES. Association Between use of an Adaptive Cardiac Resynchronization Therapy Algorithm and Healthcare Utilization and Cost. J Card Fail 2024:S1071-9164(24)00225-2. [PMID: 38977056 DOI: 10.1016/j.cardfail.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/20/2024] [Accepted: 06/04/2024] [Indexed: 07/10/2024]
Abstract
OBJECTIVES To assess the association between use of adaptive pacing on clinical and economic outcomes of CRT recipients in a real-world analysis. BACKGROUND The AdaptivCRTTM algorithm was shown in prior subgroup analyses of prospective trials to achieve clinical benefits, but a large prospective trial showed nonsignificant changes in the endpoint of mortality or heart failure hospitalizations. METHODS CRT-implanted patients from the Optum Clinformatics® database with ≥90 days of follow-up were included. Remote monitoring data was used to classify patients based on CRT setting - adaptive biventricular and left ventricular pacing (aCRT) vs. standard biventricular pacing (Standard CRT). Inverse probability of treatment weighting was used to adjust for baseline differences between groups. Mortality, 30-day readmissions, healthcare utilization, and payer and patient costs were evaluated post-implantation. RESULTS This study included 2,412 aCRT and 1,638 Standard CRT patients (mean follow-up: 2.4 ± 1.4 years), with balanced baseline characteristics after adjustment. The aCRT group was associated with lower all-cause mortality (adjusted hazard ratio = 0.88 [95% confidence interval (CI):0.80, 0.96]), fewer all-cause 30-day readmissions (adjusted incidence rate ratio = 0.87 [CI:0.81, 0.94]), and fewer all-cause and HF-related inpatient, outpatient, and emergency department (ED) visits. The aCRT cohort was also associated with lower all-cause outpatient payer-paid amounts and lower all-cause and HF-related inpatient and ED patient-paid amounts. CONCLUSIONS In this retrospective analysis of a large real-world cohort, use of an adaptive CRT algorithm was associated with lower mortality, reduced healthcare resource utilization, and lower payer and patient costs. LAY SUMMARY While cardiac resynchronization therapy (CRT) improves quality of life and clinical outcomes for certain heart failure patients, some patients do not respond to this therapy. Adaptive CRT algorithms (aCRT), such as AdaptivCRTTM, have been developed with the goal of improving effectiveness of CRT, and consequently, clinical and economic outcomes. This research study used a large database of administrative claims data - which contains information on patient demographics, diagnoses, healthcare services received, mortality, and cost data - to compare clinical and economic outcomes between CRT patients with the aCRT algorithm turned on (aCRT group) and CRT patients with the aCRT algorithm turned off (standard CRT group). Statistical methods were used to adjust for baseline differences between the aCRT group and standard CRT groups. Ultimately, the aCRT group was found to have a lower risk of all-cause mortality, fewer all-cause 30-day readmissions, fewer hospital visits (including inpatient, outpatient, and emergency department visits), and lower costs to payers and patients for specific types of costs.
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Affiliation(s)
- Michael R Gold
- Medical University of South Carolina, Charleston, SC, USA.
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Chyou JY, Qin H, Butler J, Voors AA, Lam CSP. Sex-related similarities and differences in responses to heart failure therapies. Nat Rev Cardiol 2024; 21:498-516. [PMID: 38459252 DOI: 10.1038/s41569-024-00996-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2024] [Indexed: 03/10/2024]
Abstract
Although sex-related differences in the epidemiology, risk factors, clinical characteristics and outcomes of heart failure are well known, investigations in the past decade have shed light on an often overlooked aspect of heart failure: the influence of sex on treatment response. Sex-related differences in anatomy, physiology, pharmacokinetics, pharmacodynamics and psychosocial factors might influence the response to pharmacological agents, device therapy and cardiac rehabilitation in patients with heart failure. In this Review, we discuss the similarities between men and women in their response to heart failure therapies, as well as the sex-related differences in treatment benefits, dose-response relationships, and tolerability and safety of guideline-directed medical therapy, device therapy and cardiac rehabilitation. We provide insights into the unique challenges faced by men and women with heart failure, highlight potential avenues for tailored therapeutic approaches and call for sex-specific evaluation of treatment efficacy and safety in future research.
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Affiliation(s)
- Janice Y Chyou
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hailun Qin
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-NUS Medical School, Singapore, Singapore.
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Savage P, Cox B, Shahmohammadi M, Kelly B, Menown I. Advances in Clinical Cardiology 2023: A Summary of Key Clinical Trials. Adv Ther 2024; 41:2606-2634. [PMID: 38743242 PMCID: PMC11213809 DOI: 10.1007/s12325-024-02877-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/16/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Over the course of 2023, numerous key clinical trials with valuable contributions to clinical cardiology were published or presented at major international conferences. This review seeks to summarise these trials and reflect on their clinical context. METHODS The authors collated and reviewed clinical trials presented at major cardiology conferences during 2023 including the American College of Cardiology (ACC), European Association for Percutaneous Cardiovascular Interventions (EuroPCR), European Society of Cardiology (ESC), Transcatheter Cardiovascular Therapeutics (TCT), American Heart Association (AHA), European Heart Rhythm Association (EHRA), Society for Cardiovascular Angiography and Interventions (SCAI), TVT-The Heart Summit (TVT) and Cardiovascular Research Technologies (CRT). Trials with a broad relevance to the cardiology community and those with potential to change current practice were included. RESULTS A total of 80 key cardiology clinical trials were identified for inclusion. Key trials in acute coronary syndrome (ACS) and antiplatelet management such as HOST-IDEA, T-PASS and STOP-DAPT3 were included in addition to several pivotal interventional trials such as ORBITA 2, MULTISTARS-AMI, ILUMIEN-IV, OCTIVUS and OCTOBER. Additionally, several trials evaluated new stent design and technology such as BIOSTEMI, PARTHENOPE and TRANSFORM. Structural intervention trials included long-term data from PARTNER 3, new data on the durability of transcatheter aortic valve intervention (TAVI), in addition to major new trials regarding transcatheter tricuspid valve intervention from TRISCEND II. Heart failure (HF) and prevention covered several key studies including DAPA-MI, STEP-HF, ADVOR, DICTATE HF and CAMEO-DAPA. In cardiac devices and electrophysiology, several trial exploring novel ablation strategies in atrial fibrillation (AF) such as PULSED AF and ADVENT were presented with further data evaluating the efficacy of anticoagulation in subclinical AF in NOAH-AFNET 6, FRAIL AF and AZALEA-TIMI 71. CONCLUSION This article presents a summary of key clinical cardiology trials published and presented during the past year and should be of interest to both practising clinicians and researchers.
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Affiliation(s)
- Patrick Savage
- Craigavon Cardiology Department, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK.
| | - Brian Cox
- Craigavon Cardiology Department, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK
| | - Michael Shahmohammadi
- Craigavon Cardiology Department, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK
| | - Bronagh Kelly
- Craigavon Cardiology Department, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK
| | - Ian Menown
- Craigavon Cardiology Department, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK
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Filippatos G, Gold MR, Mullens W, Kusano K, Hersi AS, Birnie D, Gerritse B, Leclercq C. Clinical outcomes of the AdaptResponse trial - Authors' reply. Lancet 2024; 403:2484-2485. [PMID: 38851281 DOI: 10.1016/s0140-6736(24)00866-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/22/2024] [Indexed: 06/10/2024]
Affiliation(s)
- Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens 124 61, Greece.
| | - Michael R Gold
- Medical University of South Carolina, Charleston, SC, USA
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Hasselt University, Hasselt, Belgium
| | - Kengo Kusano
- National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Ahmad S Hersi
- King Saud University, Faculty of Medicine, Riyadh, Saudi Arabia
| | - David Birnie
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Bart Gerritse
- Medtronic Bakken Research Center, Maastricht, Netherlands
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Komamura K, Iwase M. Clinical outcomes of the AdaptResponse trial. Lancet 2024; 403:2484. [PMID: 38851282 DOI: 10.1016/s0140-6736(24)00867-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 04/22/2024] [Indexed: 06/10/2024]
Affiliation(s)
- Kazuo Komamura
- Toyota Memorial Hospital, 1-1, Heiwa-cho, Toyota, Aichi 471-8513, Japan.
| | - Mitsunori Iwase
- Toyota Memorial Hospital, 1-1, Heiwa-cho, Toyota, Aichi 471-8513, Japan
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Ollitrault P, Font J, Ferchaud V, Al Khoury M, Pellissier A, Milliez P, Champ-Rigot L. A highly symptomatic loss of CRT: What is the mechanism? Pacing Clin Electrophysiol 2024; 47:786-788. [PMID: 38646809 DOI: 10.1111/pace.14978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/12/2024] [Accepted: 03/15/2024] [Indexed: 04/23/2024]
Affiliation(s)
- Pierre Ollitrault
- Electrophysiology Unit, Department of Cardiology, Centre Hospitalier Régional et Universitaire, Caen, France
| | - Jonaz Font
- Electrophysiology Unit, Department of Cardiology, Centre Hospitalier Régional et Universitaire, Caen, France
| | - Virginie Ferchaud
- Electrophysiology Unit, Department of Cardiology, Centre Hospitalier Régional et Universitaire, Caen, France
| | - Mayane Al Khoury
- Electrophysiology Unit, Department of Cardiology, Centre Hospitalier Régional et Universitaire, Caen, France
| | - Arnaud Pellissier
- Electrophysiology Unit, Department of Cardiology, Centre Hospitalier Régional et Universitaire, Caen, France
| | - Paul Milliez
- Electrophysiology Unit, Department of Cardiology, Centre Hospitalier Régional et Universitaire, Caen, France
- Pôle de Formation et de Recherche en Santé, Rue des Rochambelles, Caen, France
| | - Laure Champ-Rigot
- Electrophysiology Unit, Department of Cardiology, Centre Hospitalier Régional et Universitaire, Caen, France
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Plaisted J, Christensen E, Kowalsky M, Rooke D, Clendenen N. Year in Review 2023: Noteworthy Literature in Cardiac Anesthesiology. Semin Cardiothorac Vasc Anesth 2024; 28:80-90. [PMID: 38593818 DOI: 10.1177/10892532241246431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
Notable clinical research published in 2023 related to cardiac anesthesia included studies focused on resuscitation and pharmacology, regional anesthesia, technological advances, and novel gene therapies. We reviewed 241 articles to identify 25 noteworthy studies that represent the most significant research related to cardiac anesthesia from the past year. Overall, improvements in clinical practice have enabled decreased morbidity and mortality with a renewed focus on mechanical circulatory support and transplantation.
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Affiliation(s)
- Jacob Plaisted
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Markus Kowalsky
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Douglas Rooke
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Scarà A, Palamà Z, Robles AG, Dei LL, Borrelli A, Zanin F, Pignalosa L, Romano S, Sciarra L. Non-Pharmacological Treatment of Heart Failure-From Physical Activity to Electrical Therapies: A Literature Review. J Cardiovasc Dev Dis 2024; 11:122. [PMID: 38667740 PMCID: PMC11050051 DOI: 10.3390/jcdd11040122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/11/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Heart failure (HF) represents a significant global health challenge that is still responsible for increasing morbidity and mortality despite advancements in pharmacological treatments. This review investigates the effectiveness of non-pharmacological interventions in the management of HF, examining lifestyle measures, physical activity, and the role of some electrical therapies such as catheter ablation, cardiac resynchronization therapy (CRT), and cardiac contractility modulation (CCM). Structured exercise training is a cornerstone in this field, demonstrating terrific improvements in functional status, quality of life, and mortality risk reduction, particularly in patients with HF with reduced ejection fraction (HFrEF). Catheter ablation for atrial fibrillation, premature ventricular beats, and ventricular tachycardia aids in improving left ventricular function by reducing arrhythmic burden. CRT remains a key intervention for selected HF patients, helping achieve left ventricular reverse remodeling and improving symptoms. Additionally, the emerging therapy of CCM provides a novel opportunity for patients who do not meet CRT criteria or are non-responders. Integrating non-pharmacological interventions such as digital health alongside specific medications is key for optimizing outcomes in HF management. It is imperative to tailor approaches to individual patients in this diverse patient population to maximize benefits. Further research is warranted to improve treatment strategies and enhance patient outcomes in HF management.
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Affiliation(s)
- Antonio Scarà
- San Carlo di Nancy Hospital—GVM, 00165 Roma, Italy; (A.B.); (F.Z.); (L.P.)
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
| | - Zefferino Palamà
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
- Electrophysiology Unit “Casa di Cura Villa Verde”, 74121 Taranto, Italy
| | - Antonio Gianluca Robles
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
- Electrophysiology Unit “Casa di Cura Villa Verde”, 74121 Taranto, Italy
- Department of Cardiology, “L. Bonomo” Hospital, 76123 Andria, Italy
| | - Lorenzo-Lupo Dei
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
| | - Alessio Borrelli
- San Carlo di Nancy Hospital—GVM, 00165 Roma, Italy; (A.B.); (F.Z.); (L.P.)
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
| | - Federico Zanin
- San Carlo di Nancy Hospital—GVM, 00165 Roma, Italy; (A.B.); (F.Z.); (L.P.)
| | - Leonardo Pignalosa
- San Carlo di Nancy Hospital—GVM, 00165 Roma, Italy; (A.B.); (F.Z.); (L.P.)
| | - Silvio Romano
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
| | - Luigi Sciarra
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
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12
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Gold MR, Auricchio A, Leclercq C, Wold N, Stein KM, Ellenbogen KA. Atrioventricular optimization improves cardiac resynchronization response in patients with long interventricular electrical delays: A pooled analysis of the SMART-AV and SMART-CRT trials. Heart Rhythm 2024:S1547-5271(24)02277-X. [PMID: 38604592 DOI: 10.1016/j.hrthm.2024.03.1783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND The utility of atrioventricular (AV) optimization (AVO) algorithms remains in question. A substudy of the SMART-AV trial found that patients with prolonged interventricular delays ≥70 ms were more likely to benefit from cardiac resynchronization therapy (CRT) with AVO. The SMART-CRT trial evaluated AVO on the basis of these results, but the study was underpowered. OBJECTIVE To increase statistical power, data from SMART-AV patients meeting the inclusion criterion of interventricular delay ≥70 ms were pooled with data from SMART-CRT to reassess AVO. METHODS SMART-CRT and SMART-AV were prospective, randomized, multicenter clinical trials. Patients in both studies were randomized to be programmed with an AVO algorithm (SmartDelay) or fixed AV delay (120 ms). Paired echocardiograms obtained at baseline and 6 months were compared, with CRT response defined as ≥15% reduction in left ventricular end-systolic volume. RESULTS A total of 451 complete patient data sets were pooled and analyzed. The baseline demographics between studies did not differ statistically in terms of age, sex, left ventricular ejection fraction, or left ventricular end-systolic volume. The AVO group had a greater proportion of CRT responders (SmartDelay, 73.9%; fixed, 63.1%; P = .014) and greater changes in measures of reverse remodeling. SmartDelay patients with a recommended sensed AV delay outside the nominal range (100-120 ms) had 2.3 greater odds of CRT response than fixed AV delay patients. CONCLUSION Greater CRT response and measures of reverse remodeling were observed in patients with SmartDelay enabled vs a fixed AV delay. This study supports the use of SmartDelay in patients with a CRT indication and interventricular delay ≥70 ms. CLINICALTRIALS GOV REGISTRATION NCT00677014 and NCT03089281.
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Affiliation(s)
- Michael R Gold
- Medical University of South Carolina, Charleston, South Carolina.
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13
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Maigrot JLA, Weiss AJ, Wazni O, Starling RC. Multidisciplinary approach to long-standing left bundle branch block with dyssynchrony and aortic stenosis: case report. Eur Heart J Case Rep 2024; 8:ytae127. [PMID: 38567275 PMCID: PMC10986398 DOI: 10.1093/ehjcr/ytae127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/20/2024] [Accepted: 03/08/2024] [Indexed: 04/04/2024]
Abstract
Background Cardiac resynchronization therapy (CRT) is recommended for patients with symptomatic heart failure in sinus rhythm with left ventricular ejection fraction (LVEF) ≤ 35%, QRS duration ≥ 150 ms, and left bundle branch block (LBBB) morphology. However, when severe left ventricular dysfunction and cardiogenic shock are present, treatment paradigms are often limited to palliative medical therapy or advanced therapies with durable left ventricular assist device or heart transplant as the functional and survival benefit of CRT in these patients remains uncertain. Case summary A 77-year-old white man with long-standing LBBB with dyssynchrony, severely reduced LVEF of 4%, and severe bicuspid aortic stenosis (AS) presented with worsening heart failure symptoms. After multidisciplinary heart team evaluation and pre-operative optimization, the patient underwent a surgical aortic valve replacement with simultaneous intraoperative initiation of CRT with pacemaker (CRT-P) and temporary mechanical circulatory support. Echocardiography at 44 days and 201 days post-discharge showed an LVEF of 29% and 40%, respectively. Discussion This case demonstrates that reverse remodelling and native heart recovery were successfully achieved in a patient with advanced structural heart disease, presenting with cardiogenic shock, through an early and aggressive approach involving multidisciplinary heart team evaluation, treatment of severe AS with surgical aortic valve replacement, prophylactic intraoperative initiation of temporary mechanical circulatory support, and early initiation of CRT-P.
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Affiliation(s)
- Jean-Luc A Maigrot
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Aaron J Weiss
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Oussama Wazni
- Department of Cardiovascular Medicine, Section of Cardiac Electrophysiology and Pacing, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Randall C Starling
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH 44195, USA
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14
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Ito R, Kondo Y, Nakano M, Kajiyama T, Nakano M, Kitagawa M, Sugawara M, Chiba T, Kobayashi Y. Interaction of left ventricular size with the outcome of cardiac resynchronization therapy in Japanese patients. Clin Cardiol 2024; 47:e24267. [PMID: 38619004 PMCID: PMC11017297 DOI: 10.1002/clc.24267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/08/2024] [Accepted: 03/28/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND We analyzed the influence of the QRS duration (QRSd) to LV end-diastolic volume (LVEDV) ratio on cardiac resynchronization therapy (CRT) outcomes in heart failure patients classified as III/IV per the New York Heart Association (NYHA) and with small body size. HYPOTHESIS We proposed the hypothesis that the QRSd/LV size ratio is a better index of the CRT substrate. METHODS We enrolled 114 patients with advanced heart failure (NYHA class III/IV, and LV ejection fraction >35%) who received a CRT device, including those with left bundle branch block (LBBB) and QRSd ≥120 milliseconds (n = 60), non-LBBB and QRSd ≥150 milliseconds (n = 30) and non-LBBB and QRSd of 120-149 milliseconds (n = 24). RESULTS Over a mean follow-up period of 65 ± 58 months, the incidence of the primary endpoint, a composite of all-cause death and hospitalization for heart failure, showed no significant intergroup difference (43.3% vs. 50.0% vs. 37.5%, respectively, p = .72). Similarly, among 104 patients with QRSd/LVEDV ≥ 0.67 (n = 54) and QRSd/LVEDV < 0.67 (n = 52), no significant differences were observed in the incidence of the primary endpoint (35.1% vs. 51.9%, p = .49). Nevertheless, patients with QRSd/LVEDV ≥ 0.67 showed better survival than those with QRSd/LVEDV < 0.67 (14.8% vs. 34.6%, p = .0024). CONCLUSION Advanced HF patients with a higher QRSd/LVEDV ratio showed better survival in this small-body-size population. Thus, the risk is concentrated among those with a larger QRSd, and patients with a relatively smaller left ventricular size appeared to benefit from CRT.
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Affiliation(s)
- Ryo Ito
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Yusuke Kondo
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Masahiro Nakano
- Department of Advanced Cardiorhythm TherapeuticsChiba University Graduate School of MedicineChibaJapan
| | - Takatsugu Kajiyama
- Department of Advanced Cardiorhythm TherapeuticsChiba University Graduate School of MedicineChibaJapan
| | - Miyo Nakano
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Mari Kitagawa
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Masafumi Sugawara
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Toshinori Chiba
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Yoshio Kobayashi
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
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15
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Ueda N, Oka S, Ishibashi K, Kitai T, Izumi C, Kusano K. Pitfalls of the AdaptivCRT algorithm for effective pacing: Optimization using the EffectivCRT algorithm data. HeartRhythm Case Rep 2024; 10:297-301. [PMID: 38766613 PMCID: PMC11096432 DOI: 10.1016/j.hrcr.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Affiliation(s)
- Nobuhiko Ueda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Oka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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16
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Wisnoskey B, Varma N. Balancing right ventricular paced and right bundle branch activation to electrically optimize cardiac resynchronization therapy: triple-fusion pacing. Europace 2024; 26:euae084. [PMID: 38651191 PMCID: PMC11036018 DOI: 10.1093/europace/euae084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 04/02/2024] [Indexed: 04/25/2024] Open
Abstract
Abstract
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Affiliation(s)
- Brian Wisnoskey
- Cardiac Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Niraj Varma
- Cardiac Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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17
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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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18
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Biffi M, Statuto G, Carecci A, Lazzeri M, Bertelli M, Ziacchi M. Reply to the Editor-The time has come to rethink our approach to heart failure with right bundle branch block. HeartRhythm Case Rep 2024; 10:171-172. [PMID: 38404979 PMCID: PMC10885720 DOI: 10.1016/j.hrcr.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Affiliation(s)
- Mauro Biffi
- Cardiology Unit, Azienda Ospedaliero Universitaria di Bologna, Policlinico di S. Orsola, Bologna, Italy
| | - Giovanni Statuto
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Alessandro Carecci
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Mirco Lazzeri
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Michele Bertelli
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Matteo Ziacchi
- Cardiology Unit, Azienda Ospedaliero Universitaria di Bologna, Policlinico di S. Orsola, Bologna, Italy
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19
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Linde C. Will the results from the AdaptResponse trial boost CRT use? Lancet 2023; 402:1110-1112. [PMID: 37634522 DOI: 10.1016/s0140-6736(23)01313-2] [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: 05/19/2023] [Accepted: 06/22/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Cecilia Linde
- Heart, Vascular and Neurology Theme, Karolinska University Hospital, Stockholm, Sweden; Karolinska Institutet, 171 77 Stockholm, Sweden.
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20
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Ellenbogen KA, Auricchio A, Burri H, Gold MR, Leclercq C, Leyva F, Linde C, Jastrzebski M, Prinzen F, Vernooy K. The evolving state of cardiac resynchronization therapy and conduction system pacing: 25 years of research at EP Europace journal. Europace 2023; 25:euad168. [PMID: 37622580 PMCID: PMC10450796 DOI: 10.1093/europace/euad168] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 06/12/2023] [Indexed: 08/26/2023] Open
Abstract
Cardiac resynchronization therapy (CRT) was proposed in the 1990s as a new therapy for patients with heart failure and wide QRS with depressed left ventricular ejection fraction despite optimal medical treatment. This review is aimed first to describe the rationale and the physiologic effects of CRT. The journey of the landmark randomized trials leading to the adoption of CRT in the guidelines since 2005 is also reported showing the high level of evidence for CRT. Different alternative pacing modalities of CRT to conventional left ventricular pacing through the coronary sinus have been proposed to increase the response rate to CRT such as multisite pacing and endocardial pacing. A new emerging alternative technique to conventional biventricular pacing, conduction system pacing (CSP), is a promising therapy. The different modalities of CSP are described (Hirs pacing and left bundle branch area pacing). This new technique has to be evaluated in clinical randomized trials before implementation in the guidelines with a high level of evidence.
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Affiliation(s)
- Kenneth A Ellenbogen
- Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Angelo Auricchio
- Division of Cardiology, Università della Svizzera Italiana and Istituto Cardiocentro Ticino, Lugano, Switzerland
| | - Haran Burri
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Michael R Gold
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | | | - Francisco Leyva
- Aston University, Birmingham NHS Trust at Queen Elizabeth Hospital, Birmingham, UK
| | - Cecilia Linde
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Marek Jastrzebski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Frits Prinzen
- Physiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC), Maastricht, the Netherlands
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