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The Primary Alteration of Ventricular Myocardium Conduction: The Significant Determinant of Left Bundle Branch Block Pattern. Cardiol Res Pract 2022; 2022:3438603. [PMID: 36589707 PMCID: PMC9800102 DOI: 10.1155/2022/3438603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022] Open
Abstract
Intraventricular conduction disturbances (IVCD) are currently generally accepted as ECG diagnostic categories. They are characterized by defined QRS complex patterns that reflect the abnormalities in the intraventricular sequence of activation that can be caused by pathology in the His-Purkinje conduction system (HP) or ventricular myocardium. However, the current understanding of the IVCD's underlying mechanism is mostly attributed to HP structural or functional alterations. The involvement of the working ventricular myocardium is only marginally mentioned or not considered. This opinion paper is focused on the alterations of the ventricular working myocardium leading to the most frequent IVCD pattern-the left bundle branch block pattern (LBBB). Recognizing the underlying mechanisms of the LBBB patterns and the involvement of the ventricular working myocardium is of utmost clinical importance, considering a patient's prognosis and indication for cardiac resynchronization therapy.
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Syed FF, DeSimone CV, Ebrille E, Gaba P, Ladewig DJ, Mikell SB, Suddendorf SH, Gilles EJ, Danielsen AJ, Lukášová M, Wolf J, Leinveber P, Novák M, Stárek Z, Kara T, Bruce CJ, Friedman PA, Asirvatham SJ. Percutaneous Epicardial Pacing using a Novel Insulated Multi-electrode Lead. JACC Clin Electrophysiol 2015; 1:273-283. [PMID: 27547832 DOI: 10.1016/j.jacep.2015.04.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Epicardial cardiac resynchronization therapy (CRT) permits unrestricted electrode positioning. However, this requires surgical placement of device leads and the risk of unwanted phrenic nerve stimulation. We hypothesized that shielded electrodes can capture myocardium without extracardiac stimulation. METHODS In 6 dog and 5 swine experiments, we used a percutaneous approach to access the epicardial surface of the heart, and deploy novel leads housing multiple electrodes with selective insulation. Bipolar pacing thresholds at prespecified sites were tested compare electrode threshold data both facing towards and away from the epicardial surface. RESULTS In 151 paired electrode recordings (70 in 6 dogs; 81 in 5 swine), thresholds facing myocardium were lower than facing away (median [IQR] mA: dogs 0.9 [0.4-1.6] vs 4.6 [2.1 to >10], p<0.0001; swine 0.5 [0.2-1] vs 2.5 [0.5-6.8], p<0.0001). Myocardial capture was feasible without extracardiac stimulation at all tested sites, with mean ± SE threshold margin 3.6±0.7 mA at sites of high output extracardiac stimulation (p=0.004). CONCLUSION Selective electrode insulation confers directional pacing to a multielectrode epicardial pacing lead. This device has the potential for a novel percutaneous epicardial resynchronization therapy that permits placement at an optimal pacing site, irrespective of the anatomy of the coronary veins or phrenic nerves.
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Affiliation(s)
- Faisal F Syed
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Christopher V DeSimone
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Elisa Ebrille
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | - Markéta Lukášová
- ICRC - Department of Cardiovascular Diseases, St Anne's University Hospital, Brno, Czech Republic
| | - Jiří Wolf
- ICRC - Department of Cardiovascular Diseases, St Anne's University Hospital, Brno, Czech Republic
| | - Pavel Leinveber
- ICRC - Department of Cardiovascular Diseases, St Anne's University Hospital, Brno, Czech Republic
| | - Miroslav Novák
- ICRC - Department of Cardiovascular Diseases, St Anne's University Hospital, Brno, Czech Republic
| | - Zdeněk Stárek
- ICRC - Department of Cardiovascular Diseases, St Anne's University Hospital, Brno, Czech Republic
| | - Tomas Kara
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN; ICRC - Department of Cardiovascular Diseases, St Anne's University Hospital, Brno, Czech Republic
| | - Charles J Bruce
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Paul A Friedman
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN; Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
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Varma N, Ploux S, Ritter P, Wilkoff B, Eschalier R, Bordachar P. Noninvasive mapping of electrical dyssynchrony in heart failure and cardiac resynchronization therapy. Card Electrophysiol Clin 2015; 7:125-134. [PMID: 25784029 DOI: 10.1016/j.ccep.2014.11.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Causes for diverse effects of cardiac resynchronization therapy (CRT) are poorly understood. Because CRT is an electrical therapy, it may be best understood by detailed characterization of electrical substrate and its interaction with pacing. Electrocardiogram (ECG) features affect CRT outcomes. However, the surface ECG reports rudimentary electrical data. In contrast, noninvasive electrocardiographic imaging provides high-resolution single-beat ventricular mapping. Several complex characteristics of electrical substrate, not decipherable from the 12-lead ECG, are linked to CRT effect. CRT response may be improved by candidate selection and left ventricular lead placement directed by more precise electrical evaluation, on an individual patient basis.
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Affiliation(s)
- Niraj Varma
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | - Sylvain Ploux
- CHU Bordeaux, Liryc Institute Bordeaux, Université de Bordeaux, France
| | - Philippe Ritter
- CHU Bordeaux, Liryc Institute Bordeaux, Université de Bordeaux, France
| | - Bruce Wilkoff
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Romain Eschalier
- CHU Bordeaux, Liryc Institute Bordeaux, Université de Bordeaux, France
| | - Pierre Bordachar
- CHU Bordeaux, Liryc Institute Bordeaux, Université de Bordeaux, France
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Varma N. Left ventricular electrical activation during right ventricular pacing in heart failure patients with LBBB: Visualization by electrocardiographic imaging and implications for cardiac resynchronization therapy. J Electrocardiol 2015; 48:53-61. [DOI: 10.1016/j.jelectrocard.2014.09.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Indexed: 11/16/2022]
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5
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Sweeney MO, Hellkamp AS, van Bommel RJ, Schalij MJ, Jan Willem Borleffs C, Bax JJ. QRS fusion complex analysis using wave interference to predict reverse remodeling during cardiac resynchronization therapy. Heart Rhythm 2014; 11:806-13. [DOI: 10.1016/j.hrthm.2014.01.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Indexed: 11/29/2022]
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6
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Response or nonresponse to cardiac resynchronization therapy in heart failure: Lessons from the real world. Heart Rhythm 2014; 11:417-8. [DOI: 10.1016/j.hrthm.2013.12.016] [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: 12/04/2013] [Indexed: 11/17/2022]
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7
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Suever JD, Hartlage GR, Magrath III RP, Iravanian S, Lloyd MS, Oshinski JN. Relationship between mechanical dyssynchrony and intra-operative electrical delay times in patients undergoing cardiac resynchronization therapy. J Cardiovasc Magn Reson 2014; 16:4. [PMID: 24393383 PMCID: PMC3895745 DOI: 10.1186/1532-429x-16-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 12/27/2013] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND It is important to understand the relationship between electrical and mechanical ventricular activation in CRT patients. By measuring local electrical activation at multiple locations within the coronary veins and myocardial contraction at the same locations in the left ventricle, we determined the relationship between electrical and mechanical activation at potential left ventricular pacing locations. METHODS In this study, mechanical contraction times were computed using high temporal resolution cine cardiovascular magnetic resonance (CMR) data, while electrical activation times were derived from intra-procedural local electrograms. RESULTS In our cohort, there was a strong correlation between electrical and mechanical delay times within each patient (R2=0.78 ± 0.23). Additionally, the latest electrically activated location corresponded with the latest mechanically contracting location in 91% of patients. CONCLUSIONS This study provides initial evidence that our method of obtaining non-invasive mechanical activation patterns accurately reflects the underlying electromechanical substrate of intraventricular dyssynchrony.
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Affiliation(s)
- Jonathan D Suever
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology / Emory University, 1364 Clifton Road, Suite AG30, Atlanta, GA 30322, USA
| | - Gregory R Hartlage
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - R Patrick Magrath III
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology / Emory University, 1364 Clifton Road, Suite AG30, Atlanta, GA 30322, USA
| | - Shahriar Iravanian
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael S Lloyd
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - John N Oshinski
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology / Emory University, 1364 Clifton Road, Suite AG30, Atlanta, GA 30322, USA
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
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FUJIWARA RYUDO, YOSHIDA AKIHIRO, FUKUZAWA KOJI, TAKEI ASUMI, KIUCHI KUNIHIKO, ITOH MITSUAKI, IMAMURA KIMITAKE, SUZUKI ATSUSHI, NAKANISHI TOMOYUKI, YAMASHITA SOICHIRO, MATSUMOTO AKINORI, TANAKA HIDEKAZU, HIRATA KENICHI. Discrepancy between Electrical and Mechanical Dyssynchrony in Patients with Heart Failure and an Electrical Disturbance. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2013; 37:576-84. [DOI: 10.1111/pace.12326] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 09/27/2013] [Accepted: 10/20/2013] [Indexed: 11/30/2022]
Affiliation(s)
- RYUDO FUJIWARA
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - AKIHIRO YOSHIDA
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - KOJI FUKUZAWA
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - ASUMI TAKEI
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - KUNIHIKO KIUCHI
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - MITSUAKI ITOH
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - KIMITAKE IMAMURA
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - ATSUSHI SUZUKI
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - TOMOYUKI NAKANISHI
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - SOICHIRO YAMASHITA
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - AKINORI MATSUMOTO
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - HIDEKAZU TANAKA
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - KEN-ICHI HIRATA
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
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Scharf C, Krasniqi N, Hellermann J, Rahn M, Sütsch G, Brunckhorst C, Duru F. Electrical activation in the coronary sinus branches as a guide to cardiac resynchronisation therapy: rationale for a coordinate system. PLoS One 2011; 6:e19914. [PMID: 21857896 PMCID: PMC3152548 DOI: 10.1371/journal.pone.0019914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Accepted: 04/20/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND For successful cardiac resynchronisation therapy (CRT) a spatial and electrical separation of right and left ventricular electrodes is essential. The spatial distribution of electrical delays within the coronary sinus (CS) tributaries has not yet been identified. OBJECTIVE Electrical delays within the CS are described during sinus rhythm (SR) and right ventricular pacing (RVP). A coordinate system grading the mitral ring from 0° to 360° and three vertical segments is proposed to define the lead positions irrespective of individual CS branch orientation. METHODS In 13 patients undergoing implantation of a CRT device 6±2.5, (median 5) lead positions within the CS were mapped during SR and RVP. The delay to the onset and the peak of the local signal was measured from the earliest QRS activation or the pacing spike. Fluoroscopic positions were compared to localizations on a nonfluoroscopic electrode imaging system. RESULTS During SR, electrical delays in the CS were inhomogenous in patients with or without left bundle branch block (LBBB). During RVP, the delays increased by 44±32 ms (signal onset from 36±33 ms to 95±30 ms; p<0.001, signal peak from 105±44 ms to 156±30 ms; p<0.001). The activation pattern during RVP was homogeneous and predictable by taking the grading on the CS ring into account: (% QRS) = 78-0.002 (grade-162)(2), p<0.0001. This indicates that 78% of the QRS duration can be expected as a maximum peak delay at 162° on the CS ring. CONCLUSION Electrical delays within the CS vary during SR, but prolong and become predictable during RVP. A coordinate system helps predicting the local delays and facilitates interindividual comparison of lead positions irrespective of CS branch anatomy.
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Affiliation(s)
- Christoph Scharf
- Division of Pacing and Electrophysiology, Clinic for Cardiology, Cardiovascular Center, University Hospital Zurich, Zurich, Switzerland.
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10
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Tsvetkova AS, Kibler NA, Nuzhny VP, Shmakov DN, Azarov JE. Acute effects of pacing site on repolarization and haemodynamics of the canine ventricles. Europace 2011; 13:889-96. [PMID: 21421575 DOI: 10.1093/europace/eur053] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
AIMS To determine the repolarization duration gradients in different ventricular regions at atrial and ventricular pacing and to test the hypothesis that acute haemodynamic response to ventricular pacing is related to the lead position with respect to repolarization gradients. METHODS AND RESULTS Repolarization durations estimated as activation-recovery intervals (ARIs) were measured from unipolar electrograms recorded in the subepicardial (Epi), mid-myocardial (Mid), and subendocardial (Endo) layers of the apical and basal parts of the right ventricle (RV) and left ventricle (LV) of 15 healthy dogs under atrial and ventricular pacing. Cardiac haemodynamic variables were measured as well. At atrial pacing, ARIs were shorter in Epi than in the innermost layers (P< 0.05) in the RV apex and LV base, but not in the LV apex and RV base. Activation-recovery intervals increased from apex to base and from base to apex in RV and LV, respectively (P ≤ 0.05). At apical or basal pacing of RV and LV, repolarization gradients decayed. The dispersion of repolarization increased at LV apical pacing and preserved at RV apical pacing. The pump function of a ventricle was altered dramatically at pacing of the area with the shorter ARIs and to a lesser degree at pacing of the area with the longer ARIs (P ≤ 0.051). CONCLUSION The transmural and apicobasal differences in repolarization durations were heterogeneously distributed at atrial pacing. The acute haemodynamic response of the individual ventricle was better with pacing of the region with the longest repolarization suggesting a promising criterion for the lead position selection on the basis of ARIs measurements.
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Affiliation(s)
- Alena S Tsvetkova
- Laboratory of Cardiac Physiology, Institute of Physiology, Komi Science Center, Ural Division, Russian Academy of Sciences, 50 Pervomayskaya St., Syktyvkar, 167982 Russia
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11
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Fatemi M, Le Gal G, Blanc JJ, Mansourati J, Etienne Y. The use of epicardial electrogram as a simple guide to select the optimal site of left ventricular pacing in cardiac resynchronization therapy. Cardiol Res Pract 2011; 2011:956062. [PMID: 21403903 PMCID: PMC3043300 DOI: 10.4061/2011/956062] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 12/23/2010] [Accepted: 01/04/2011] [Indexed: 11/23/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) has been demonstrated to improve symptoms and survival in patients with left ventricular (LV) systolic dysfunction and dyssynchrony. To achieve this goal, the LV lead should be positioned in a region of delayed contraction. We hypothesized that pacing at the site of late electrical activation was also associated with long-term response to CRT. We conducted a retrospective study on 72 CRT patients. For each patient, we determined the electrical delay (ED) from the onset of QRS to the epicardial EGM and the ratio of ED to QRS duration (ED/QRS duration). After a followup of 30 ± 20 months, 47 patients responded to CRT. Responders had a significantly longer ED and greater ratio of ED/QRS duration than nonresponders. An ED/QRS duration ≥0.38 predicted a response to CRT with 89% specificity and 53% sensitivity.
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Affiliation(s)
- Marjaneh Fatemi
- Department of Cardiology, Brest University Hospital, 29609, Brest Cedex, France
| | - Grégoire Le Gal
- Department of Cardiology, Brest University Hospital, 29609, Brest Cedex, France
| | - Jean-Jacques Blanc
- Department of Cardiology, Brest University Hospital, 29609, Brest Cedex, France
| | - Jacques Mansourati
- Department of Cardiology, Brest University Hospital, 29609, Brest Cedex, France
| | - Yves Etienne
- Department of Cardiology, Brest University Hospital, 29609, Brest Cedex, France
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FAHEEM OSMAN, PADALA ARUN, KLUGER JEFFREY, ZWEIBEL STEVEN, CLYNE CHRISTOPHERA. Coronary Sinus Shocking Lead As Salvage In Patients with Advanced CHF and High Defibrillation Thresholds. Pacing Clin Electrophysiol 2010; 33:967-72. [DOI: 10.1111/j.1540-8159.2010.02726.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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13
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Zanon F, Aggio S, Baracca E, Pastore G, Corbucci G, Boaretto G, Braggion G, Piergentili C, Rigatelli G, Roncon L. Ventricular-arterial coupling in patients with heart failure treated with cardiac resynchronization therapy: may we predict the long-term clinical response? EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2009; 10:106-11. [DOI: 10.1093/ejechocard/jen184] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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14
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Kautzner J, Peichl P. Selecting CRT candidates: the value of intracardiac mapping. Europace 2008; 10 Suppl 3:iii106-9. [DOI: 10.1093/europace/eun224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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15
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Riedlbauchová L, Brunken R, Jaber WA, Popová L, Patel D, Lánská V, Civello K, Cummings J, Burkhardt JD, Saliba W, Martin D, Schweikert R, Wilkoff BL, Grimm R, Natale A. The impact of myocardial viability on the clinical outcome of cardiac resynchronization therapy. J Cardiovasc Electrophysiol 2008; 20:50-7. [PMID: 18803571 DOI: 10.1111/j.1540-8167.2008.01294.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Around 30% of patients do not respond to cardiac resynchronization therapy (CRT). Nonischemic cardiomyopathy has been identified as an independent predictor of response to CRT, probably due to the absence of compact scar. METHODS AND RESULTS The relationship between cardiac scar, ischemia, and hibernation (both at the left-ventricular pacing site and as a total burden) and response to CRT was studied in patients with ischemic cardiomyopathy using the perfusion-viability positron emission tomography (PET) test. Sixty-six patients with ischemic cardiomyopathy and traditional criteria for CRT were included. All patients underwent PET scan prior to CRT. Using PET, the amount and location of scarred, ischemic, and hibernating myocardium were characterized. No revascularization was indicated. Responders were defined by an improvement of left-ventricular ejection fraction (LVEF) >or= 5% and/or New York Heart Association (NYHA) class >or= 1 degree. During a mean follow-up of 26.2 +/- 22.2 months, there was a significant improvement in NYHA class and reverse remodeling in patients with the LV lead inserted remotely from the scar. However, reverse remodeling of a similar degree was present also in patients with extensive scarring including the lateral wall. The presence of ischemia, hibernation, or nontransmural scar at the pacing-site did not significantly modify the outcome of CRT as compared with viable myocardium. There were only 38% of CRT-nonresponders. Neither the extent of scar, ischemia, hibernation, or viability predicted outcome or mortality. Twenty patients died during the follow-up, one patient underwent heart transplant. CONCLUSIONS At follow-up, response to CRT is observed regardless of the presence of extensive scarring. Left ventricular (LV) pacing at sites with ischemia, hibernation, or nontransmural scar does not appear to modify the effect of CRT as compared to viable tissue.
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Affiliation(s)
- Lucie Riedlbauchová
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA.
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Tuccillo B, Muto C, Iengo R, Accadia M, Rumolo S, Canciello M, Carreras G, Calvanese R, Celentano E, Davinelli M, Valsecchi S, Ascione L. Presence of left ventricular contractile reserve, evaluated by means of dobutamine stress-echo test, is able to predict response to cardiac resynchronization therapy. J Interv Card Electrophysiol 2008; 23:121-6. [DOI: 10.1007/s10840-008-9255-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2008] [Accepted: 03/25/2008] [Indexed: 11/29/2022]
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17
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Varma N. Left Ventricular Conduction Delays Induced by Right Ventricular Apical Pacing: Effect of Left Ventricular Dysfunction and Bundle Branch Block. J Cardiovasc Electrophysiol 2008; 19:114-22. [PMID: 17971145 DOI: 10.1111/j.1540-8167.2007.00995.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Niraj Varma
- Cardiac Electrophysiology Laboratory, University Hospitals/Case Western Reserve University, Cleveland, Ohio, USA.
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Auricchio A, Sorgente A, Singh JP, Faletra F, Conca C, Pedrazzini GB, Pasotti E, Siclari F, Moccetti T. Role of multislice computed tomography for preprocedural evaluation before revision of a chronically implanted transvenous left ventricular lead. Am J Cardiol 2007; 100:1566-70. [PMID: 17996521 DOI: 10.1016/j.amjcard.2007.06.065] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2007] [Revised: 06/14/2007] [Accepted: 06/14/2007] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to determine the feasibility of multislice computed tomography (MSCT) to assess the coronary sinus (CS) and its tributaries in patients who are undergoing cardiac resynchronization therapy and need a left ventricular (LV) lead revision. Preprocedural imaging modality, which may enable delineation of the cardiac venous anatomy in patients who need LV lead replacement, has not yet been evaluated. Ten patients with heart failure with previously implanted cardiac resynchronization therapy devices, who presented with worsening heart failure, were studied with MSCT and tissue Doppler imaging echocardiography before LV lead replacement. MSCT was performed to evaluate patency of the CS and coronary veins, and tissue Doppler imaging echocardiography assessed the region and the magnitude of mechanical dyssynchrony. An excellent concordance in the vein diameter, location, and status between MSCT and angiography was found. Apart from the need to perform a venoplasty in 1 patient and an unsuccessful lead explantation in another patient, all other anatomic issues were correctly predicted by MSCT. CS or vein occlusion were present in 4 patients, and in 3 of them surgical LV lead replacement was performed. Identification of a patent venous system enabling successful transvenous lead implantation was possible in 2 patients. Direct visualization of the proximity of the target vein to the phrenic nerve and the diaphragm guided lead selection and position in 4 patients. In conclusion, MSCT may be used to delineate the coronary venous anatomy in patients in whom LV lead replacement is needed to help strategize whether a transvenous or transthoracic approach may be preferred for LV lead revision.
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Affiliation(s)
- Angelo Auricchio
- Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland.
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Varma N, Jia P, Rudy Y. Electrocardiographic imaging of patients with heart failure with left bundle branch block and response to cardiac resynchronization therapy. J Electrocardiol 2007; 40:S174-8. [DOI: 10.1016/j.jelectrocard.2007.06.017] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Accepted: 06/07/2007] [Indexed: 11/26/2022]
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20
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Gold MR, Niazi I, Giudici M, Leman RB, Sturdivant JL, Kim MH, Yu Y, Ding J, Waggoner AD. A prospective comparison of AV delay programming methods for hemodynamic optimization during cardiac resynchronization therapy. J Cardiovasc Electrophysiol 2007; 18:490-6. [PMID: 17313533 DOI: 10.1111/j.1540-8167.2007.00770.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION There are several methods for programming the optimal AV delay (AVD) during cardiac resynchronization therapy (CRT). These include Doppler echocardiographic measurements of mitral inflow or aortic outflow velocities, an arbitrarily fixed AVD, and calculations based on intracardiac electrogram (EGM) intervals. The present study was designed to compare the acute effects of AVD programming methods during CRT. METHODS AND RESULTS We studied 28 patients at CRT implant with invasive measurements of LV dP/dt to determine the effect of AVD during atrial sensed (AS) and atrial paced (AP) modes. The optimal AVD, defined as that resulting in the maximal LV dP/dt, was then compared with that predicted by several noninvasive methods. CRT increased LV dP/dt 11% +/- 11% during AS (heart rate: 73 +/- 14 bpm) and 17% +/- 12% during AP (heart rate: 86 +/- 12 bpm) (P < 0.001 vs AS). There was an excellent correlation between the EGM method and the maximum achievable LV dP/dt (AS: R2 = 0.99, P < 0.0001, AP: R2 = 0.96, P < 0.0001) and this method performed better than other techniques. CONCLUSIONS An electrogram-based optimization method accurately predicts the optimal AVD among patients over a wide range of QRS intervals during CRT in both AS and AP modes. This simple technique may obviate the need for echocardiography for AVD programming.
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Affiliation(s)
- Michael R Gold
- Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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21
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White JA, Yee R, Yuan X, Krahn A, Skanes A, Parker M, Klein G, Drangova M. Delayed Enhancement Magnetic Resonance Imaging Predicts Response to Cardiac Resynchronization Therapy in Patients With Intraventricular Dyssynchrony. J Am Coll Cardiol 2006; 48:1953-60. [PMID: 17112984 DOI: 10.1016/j.jacc.2006.07.046] [Citation(s) in RCA: 270] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2006] [Revised: 05/22/2006] [Accepted: 07/10/2006] [Indexed: 12/30/2022]
Abstract
OBJECTIVES We evaluated the ability of delayed enhancement magnetic resonance imaging (DE-MRI) to predict clinical response to cardiac resynchronization therapy (CRT). BACKGROUND Cardiac resynchronization therapy reduces morbidity and mortality in selected heart failure patients. However, up to 30% of patients do not have a response. We hypothesized that scar burden on DE-MRI predicts response to CRT. METHODS The DE-MRI was performed on 28 heart failure patients undergoing CRT. Patients with QRS > or =120 ms, left ventricular ejection fraction < or =35%, New York Heart Association functional class II to IV, and dyssynchrony > or =60 ms were studied. Baseline and 3-month clinical follow-up, wall motion, 6-min walk, and quality of life assessment were performed. The DE-MRI was performed 10 min after 0.20 mmol/kg intravenous gadolinium. Scar measured by planimetry was correlated with response criteria. RESULTS Twenty-three patients completed the protocol (mean age 64.9 +/- 11.7 years), with 12 (52%) having a history of myocardial infarction. Thirteen (57%) patients met response criteria. Percent total scar was significantly higher in the nonresponse versus response group (median and interquartile range of 24.7% [18.1 to 48.7] vs. 1.0% [0.0 to 8.7], p = 0.0022) and predicted nonresponse by receiver-operating characteristic analysis (area = 0.94). At a cutoff value of 15%, percent total scar provided a sensitivity and specificity of 85% and 90%, respectively, for clinical response to CRT. Similarly, septal scar < or =40% provided a 100% sensitivity and specificity for response. Regression analysis showed linear correlations between percent total scar and change in each of the individual response criteria. CONCLUSIONS The DE-MRI accurately predicted clinical response to CRT. This technique offers unique information in the assessment of patients referred for CRT.
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Affiliation(s)
- James A White
- Division of Cardiology, Department of Medicine, University of Western Ontario, London, Ontario, Canada
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22
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Jia P, Ramanathan C, Ghanem RN, Ryu K, Varma N, Rudy Y. Electrocardiographic imaging of cardiac resynchronization therapy in heart failure: observation of variable electrophysiologic responses. Heart Rhythm 2006; 3:296-310. [PMID: 16500302 PMCID: PMC2030622 DOI: 10.1016/j.hrthm.2005.11.025] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2005] [Accepted: 11/22/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) for congestive heart failure patients with delayed left ventricular (LV) conduction is clinically beneficial in approximately 70% of patients. Unresolved issues include patient selection, lead placement, and efficacy of LV pacing alone. Being an electrical approach, detailed electrical information during CRT is critical to resolving these issues. However, electrical data from patients have been limited because of the requirement for invasive mapping. OBJECTIVES The purpose of this study was to provide observations and insights on the variable electrophysiologic responses of the heart to CRT using electrocardiographic imaging (ECGI). METHODS ECGI is a novel modality for noninvasive epicardial mapping. ECGI was conducted in eight patients undergoing CRT during native rhythm and various pacing modes. RESULTS In native rhythm (six patients), ventricular activation was heterogeneous, with latest activation in the lateral LV base in three patients and in the anterolateral, midlateral, or inferior LV in the remainder of patients. Anterior LV was susceptible to block and slow conduction. Right ventricular pacing improved electrical synchrony in two of six patients. LV pacing in three of four patients involved fusion with intrinsic excitation resulting in electrical resynchronization similar to biventricular pacing. Although generally electrical synchrony improved significantly with biventricular pacing, it was not always accompanied by clinical benefit. CONCLUSION Results suggest that (1) when accompanied by fusion, LV pacing alone can be as effective as biventricular pacing for electrical resynchronization; (2) right ventricular pacing is not effective for resynchronization; and (3) efficacy of CRT depends strongly on the patient-specific electrophysiologic substrate.
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Affiliation(s)
- Ping Jia
- Cardiac Bioelectricity Research and Training Center, Case Western Reserve University, Cleveland, Ohio
| | - Charulatha Ramanathan
- Cardiac Bioelectricity Research and Training Center, Case Western Reserve University, Cleveland, Ohio
| | - Raja N. Ghanem
- Cardiac Bioelectricity Research and Training Center, Case Western Reserve University, Cleveland, Ohio
| | - Kyungmoo Ryu
- Cardiac Bioelectricity Research and Training Center, Case Western Reserve University, Cleveland, Ohio
| | - Niraj Varma
- Cardiac Bioelectricity Research and Training Center, Case Western Reserve University, Cleveland, Ohio
- University Hospitals of Cleveland, Cleveland, Ohio
| | - Yoram Rudy
- Cardiac Bioelectricity and Arrhythmia Center, Washington University in St. Louis, St. Louis, Missouri
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